The Importance of Standard Definitions

Francisco Jose Morera-Ocon
Department of General Surgery, Hospital de Requena. Valencia, Spain
Dear Sir:
Sanjay et al. [1] assessed compliance with the revised
guidelines for the management of acute pancreatitis
published by the work group of the British Society of
Gastroenterology in 2005 [2].
This article is valuable in reminding us of the standards
of care in this disease but there are some points which
may require comments and questions. First, a
distinction between severe acute pancreatitis, defined
by the presence of complications, and predicted severe
acute pancreatitis as determined by multiple score
systems should be encouraged. The recommendation of
the guidelines for the definition of severity is that the
Atlanta criteria should be used. Nevertheless, the
authors use C-reactive protein level, Glasgow score
and Acute Physiology and Chronic Health Evaluation
II (APACHE II) score to determine the severity and,
based on these, 46% of their patients had severe
pancreatitis and 54% had mild pancreatitis. Those
results are far from those published regarding severity
distribution in acute pancreatitis [2].
One-hundred patients with acute biliary pancreatitis
were included in the trial, and pancreatitis was
established secondary to gallstones in 92 patients.
What was the etiology in the remaining 8 patients?
In this series, 4 patients underwent early endoscopic
retrograde cholangiopancreatography. What were the
criteria used to perform this procedure in some patients
with biochemical evidence of obstructive jaundice and
not the others?
Mortality was zero in that cohort of 100 patients.
However, of the 46 cases of severe pancreatitis, only 6
patients were managed in the intensive care unit. The
authors did not specify the incidence of organ failure,
one of the most important prognostic factors in the
acute pancreatitis mortality rate [3].
In addition to that, this study has a gross patient
classification bias in that the authors chose prognostic
score criteria for the definition of severity and not the
Atlanta classification. Probably that bias resulted in a
falsely high rate of severe pancreatitis and low (zero)
mortality. Those results contrast strongly with the
current data published on acute pancreatitis [2, 3, 4].
Conflict of interest The authors have no potential
conflicts of interest
References
1. Sanjay P, Yeeting S, Whigham C, Judson HK, Kulli C,
Polignano FM, Tait IS. Management guidelines for gallstone
pancreatitis. Are the targets achievable? JOP. J Pancreas (Online)
2009; 10(1):43-7. [PMID 19129614]
2. Working Party of the British Society of Gastroenterology;
Association of Surgeons of Great Britain and Ireland; Pancreatic
Society of Great Britain and Ireland; Association of Upper GI
Surgeons of Great Britain and Ireland. UK guidelines for the
management of acute pancreatitis. Gut 2005; 54(Suppl 3):1-9. [PMID
15831893]
3. Carnovale A, Rabitti PG, Manes G, Esposito P, Pacelli L, Uomo
G. Mortality in acute pancreatitis: is it an early or a late event? JOP. J
Pancreas (Online) 2005; 6(5):438-44. [PMID 16186665]
4. De Campos T, Cerqueira C, Kuryura L, Parreira JG, Soldá S,
Perlingeiro JA, et al. Morbidity indicators in severe acute
pancreatitis. JOP. J Pancreas (Online) 2008; 9(6):690-7. [PMID
1898154

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