Clinical characteristics and outcomes of acute pancreatitis at St. Paul’s Hospital Millennium Medical College: A five-year retrospective study.

doi:10.21203/rs.3.rs-5218816/v1

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Clinical characteristics and outcomes of acute pancreatitis at St. Paul’s Hospital Millennium Medical College: A five-year retrospective study.

https://doi.org/10.21203/rs.3.rs-5218816/v1

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Background: Acute pancreatitis is characterized by excessive upper abdominal pain, nausea, vomiting, or a systemic inflammatory response syndrome characterized by fever, low blood pressure, and, in some cases progression to organ failure. It is one of the most prevalent gastrointestinal diseases requiring hospital admission. Because of the scarcity of data in Ethiopia, it is necessary to understand the clinical profile and outcome of acute pancreatitis for better management and intervention.

Methods: this was an institutional-based cross-sectional study design in which all patients admitted with a diagnosis of acute pancreatitis who fulfilled the inclusion criteria were included. The study involved a review of complete and documented records of these patients, using a structured format to collect data on various sociodemographic variables, clinical presentations, imaging findings, biochemical profile patterns, and outcomes. The data were cleaned and analyzed via SPSS version 26.

Results: The mean age at presentation was 36.89 ± 10.4 years and females accounted for 51.1% of the sample. The most common etiology was gallstones (57.8%), followed by alcoholic pancreatitis (26.7%). Only 3 patients died, and the majority of patients were discharged alive. The severity of pancreatitis and the presence of complications are associated with the outcome of acute pancreatitis.

Conclusion: Females are more affected by acute pancreatitis, in our study area, with the majority being affected by biliary stones and alcohol.

Surgery

Acute pancreatitis

gallstone pancreatitis

severe pancreatitis

prognosis.

Background

Acute pancreatitis (AP) is characterized by active pancreatic inflammation and injury, which can cause exceptional upper abdominal pain, nausea, vomiting, improper release of pancreatic juice, or systemic inflammatory response syndrome with fever, low blood pressure, and in some cases organ failure.(1) In many parts of the world, including Europe, Asia, and North America, acute pancreatitis has become one of the most significant acute gastrointestinal illnesses.

Although this varies across nations and regions, gallstones and alcohol are often the two main etiologies of acute pancreatitis, accounting for 60 to 80% of all cases. (2) Hypertriglyceridemia and hypercalcemia can lead to acute pancreatitis, which is triggered by damage to acinar cells. Acute pancreatitis with extrapancreatic organ failure is associated with systemic inflammatory response syndrome (SIRS). (3)

Two of the following three characteristics are necessary for the diagnosis of acute pancreatitis: 1- Abdominal pain that is consistent with acute pancreatitis. 2- Serum lipase or amylase activity that is at least three times higher than the upper limit of normal and 3- Characteristic findings of acute pancreatitis on CECT, MRI, or transabdominal ultrasonography. (4)

Over the past 20 years, the incidence and hospitalization rates of acute pancreatitis have increased in adults. Increases in metabolic syndrome and obesity may be linked to an increase in acute pancreatitis. The average annual percent change (AAPC) in biliary and alcohol-induced pancreatitis has increased significantly over time. The overall incidence of acute pancreatitis has increased by 3.07% per year, contributing to an increasing burden on healthcare systems.

There are also regional variations in the distribution of the population; alcohol-related pancreatitis is more prevalent in the West and Japan. Both genders experience AP in roughly equal amounts. The risk of AP gradually increases with age. Age and sex distributions vary according to etiology. The majority of male AP cases are caused by alcohol. Comparison of black and white populations revealed that the risk of pancreatitis is two to three times greater in the former. (11)

Overall, there is a paucity of data from African populations. (8) One study from Ethiopia showed that the incidence of AP accounts for 0.23% of all emergency visits, but a study in a high-volume center such as Saint Paul's Hospital Millennium Medical College (SPHMMC) is necessary to build on existing knowledge and inform policymakers on the significance of the disease burden. (13)

Knowing the pattern of illness, including etiology, severity outcomes, and associated factors in a given population, is important for planning the management and delivery of care for acute pancreatitis patients, as well.

OBJECTIVES

General Objective

To assess the clinical characteristics, outcomes, and associated factors of acute pancreatitisin SPHMMC Addis Ababa, Ethiopia from May 2018 to June 2023.

Specific Objectives

To assess the clinical presentation of acute pancreatitis.
To determine the early outcomes of the management of acute pancreatitis.
To identify factors associated with acute pancreatitis outcomes.

Study Area and Period

The study was conducted at SPHMMC, the largest governmental tertiary care hospital, which is located in Addis Ababa, Ethiopia. It is a medical center for a catchment area of more than 10 million people.

Study Design

An institution-based cross-sectional study was employed.

Source Population

All patients with acute pancreatitis were admitted to SPHMMC from May 2018 to June 2023.

Study Population

Patients with a diagnosis of acute pancreatitis who were admitted to the SPHMMC fulfilling the inclusion criteria during the study period.

Inclusion Criteria

All adult patients were admitted with a diagnosis of acute pancreatitis with a complete chart and investigation.

Exclusion Criteria

Age < 15 yrs
Incomplete documentation

Sampling Technique and Sample Size

All patients admitted with a diagnosis of acute pancreatitis to the SPHMMC during the study period of May 2018 – June 2023who fulfilled the inclusion criteria wereincluded in the study.

Data Collection Procedure

The data were collected via a structured questionnaire. The patient’s card was identified from the patient's archive. Using the questionnaire, data were retrieved from the patients’ chart. The charts were reviewed for completeness.

Data Quality Control

Records of the study population were assessed for completeness before data entry, and the entered data were checked daily by the data supervisor for any incompleteness and/or inconsistency.

Data Processing and Analysis

The data were analyzed via the Statistical Package of Social Sciences (SPSS) version 26.0. Continuous data are expressed in the form of means and standard deviations, and nominal data are expressed as frequencies and percentages. Moreover, relationship between categorical variables were assessed via Chi-square test. Statistical significance was accepted at a P-value < 0.05.The results were presented via of charts, tables, and text. Microsoft Excel 2019 was used to make graphs and charts. Then summarization was performed.

Ethical Consideration

Ethical clearance was obtained from the Institutional Review Board of St. Paul’s Hospital Millennium Medical College. The collected information was only used for this particular study and was kept confidential.

Dependent Variable

Clinical characteristics and outcomes of acute pancreatitis patients.

Independent Variable

Demography
Risk factors for pancreatitis
Comorbidities
Presence of complications

Operational Definition

The severity of acute pancreatitis: utilization of Atlanta classification criteria for stratification of severity.
Complete chart: Patient charts with complete history, physical examination, and investigation for acute pancreatitis.
Respiratory complications: Patients who had pneumonia, pleural effusion, or lung atelectasis.
GI complications:Patients who hadascites, GI bleeding, orileus.
Renal complications:Patients whose creatinine level is >2 mg/dl.

Sociodemographic Data and Clinical Data

Among the 55 patients with a diagnosis of AP identified in the log books of surgical wards and the ICU, only 45 charts were completed for review resulting in a retrieval rate of 82%.

The diagnosis of acute pancreatitis reached by clinical and laboratory parameters was made in forty-four patients (97.8%), and one patient (2.2%) was diagnosed intraoperatively. The mean age of the patients was 36.89 ± 10.428 years, with a range between 22 and 60 years, and 31 patients (68.9%) were within the age range of 20–40 years. Among the studied patients, 22 (48.9%) were males and 23 (51.1%) were females. On imaging, 16 patients (35.6%) had cholelithiasis, 11 patients (24.4%) had edematous pancreases, 8 (17.8%) patients had pancreatic fluid collections, 2(4.4%) patients had choledocholithiasis, 1 (2.2%) patient had dilated bowel loops, and 7(15.6%) patients had normal findings. Patients with Comorbidities accounted for 7 (15.6%) patients. Abdominal pain was present in 100% of the cases, and 37 patients (82.2%) experienced nausea and vomiting, followed by abdominal tenderness in 30 (66.7%) patients. Seventeen (37.8%) and 13 (28.9%) patients had a fever and abdominal guarding, respectively.

Table 1

Demographic data and clinical characteristics
Demographic and baseline laboratory data N = 45
Age(years) Range		36.69 ± 10.428 22–60
Sex Male Female		22 (48.9%) 23 (51.1%)
Comorbidity Yes No		7 (15.6%) 38 (84.4%)
Complete blood count Hemoglobin gm/dl White cell count/mm³ Platelet		15.1 ± 2.5 13.6 ± 6.3 259.9 ± 100.6
Liver function test Aspartate aminotransferase IU/L Alanine aminotransferase IU/L Alkaline phosphatase IU/L		138.3 ± 1343.5 146.1 ± 172.7 164.4 ± 116.9
Renal function test Creatinine Blood urea nitrogen		1.1 ± 1.1 24.2 ± 20.7
Amylase		1064.5 ± 956.5
Lipase		1203.7 ± 932.9
Intraoperative diagnosis Yes No		1 (2.2%) 44 (97.8%)
Abdominal pain Yes No		45 (100%) 0
Nausea and vomiting Yes No		37 (82.2%) 8 (17.8%)
Fever Yes No		17 (37.8%) 28 (62.2%)
Abdominal tenderness Yes No		30 (66.7%) 15 (33.3%)
Abdominal guarding Yes No		13 (28.9%) 32 (71.1%)
Random blood sugar		127.8 ± 23.4
Antibiotics given Yes No		17 (37.8%) 28 (62.2%)

Etiology

A total of 57.8% of patients had acute pancreatitis secondary to gall bladder stones, and 12 (26.7%) patients and 2 (4.4%) patients had alcohol abuse and trauma, respectively. In 5 (11.1%) patients, the etiology was not identified.

Severity of Pancreatitis

A total of 37 (80%) patients had mild acute pancreatitis, 3 (8.9%) patients had moderate acute pancreatitis, and 5 (11.1%) patients had severe acute pancreatitis.

Table 2

Severity of pancreatitis
N = 45
Severity	Frequency
Mild	36	80.0%
Moderate	4	8.9%
Severe	5	11.1%
Total	45	100.0%

The Average Length of Hospital Stay and Outcome

The mean hospital stay was 7.56 ± 6.927 days, the minimum hospital stay was 2, and the maximum hospital stay was 30 days. The majority of 42 (93.3%) patients improved, while 3 (6.7%) died. With respect to complications, sepsis or infection accounted for the majority (35.6%) of patients, 8 (17.8%) patients developed acute pancreatic collection, 6(13.3%) patients developed pulmonary complications, 7 (15.6%) patients developed renal complications, and 6 (13.3%) patients developed GI complications.

Table 3

Outcomes and Complications
		N = 45
Hospital stays (days)		7.56 ± 6.927
Outcomes Alive Died		42 (93.3%) 3 (6.7%)
Complications Respiratory complication Renal failure GI complication Sepsis (infection) Acute pancreatic collection		7 (15.6%) 6 (13.3%) 6 (13.3%) 16(35.6%) 8 (17.8%)

Variables associated with outcomes of acute pancreatitis

GI complications (X² = 7.92, P = 0.005), renal complications (X² = 20.893, P = 0.000), pulmonary complications (X² = 6.392, P = 0.011), severity of pancreatitis (X² = 13.661, P = 0.001), and sepsis or infection (X² = 5.286, 0.016), were correlated. Whereas, comorbidities, hyperglycemia, leucocytosis > 15000, and ALT > 45 IU/ul were not correlated with acute pancreatitis outcomes in our study.

Table 4

Cross tabulation for correlation
No	Variable	Outcome		Chi-square	P- value
No	Variable	Alive	Died	Chi-square	P- value
1.	Renal complication
	Yes	3	3	20.893	0.000
	No	32	0	20.893	0.000
2.	GI complication
	Yes	4	2	7.912	0.005
	No	38	1	7.912	0.005
3.	Respiratory complication
	Yes	5	2	6.392	0.011
	No	37	1	6.392	0.011
4.	Severity of pancreatitis
	Mild	36	0	13.661	0.001
	Moderate	3	1
	Severe	3	2
5.	Leukocytosis more than 15000/mm³
	Yes	26	2	0.027	0.869
	No	16	1	0.027	0.869
6.	Sepsis or infection
	Yes	13	3	5.286	0.016
	No	29	0	5.286	0.016
7.	Comorbidity
	Yes	7	0	0.592	0.442
	No	35	3	0.592	0.442
8.	RBS more than 180 g/dl
	Yes	1	0
	No	33	0
9	ALT more than 45IU/L
	Yes	19	2	0.309	0.578
	No	19	1	0.309	0.578

Acute pancreatitis has a variety of causes, from which 75–85% of patients can be identified. In developed nations, alcohol abuse (36 percent) and obstruction of the common bile duct by stones (38 percent) are the two leading causes of acute pancreatitis. The pancreatic duct, the bile duct, or both can be obstructed. (3) In this study of 45 patients with clinical characteristics and outcomes of pancreatitis, gallstones accounted for 26 (57.8%) patients and alcohol accounted for 12 (26.7%) patients. Two (4.4%) patients had trauma, and in 5 (11.1%) patients the etiology was not documented. This is similar to studies reported from Turkey and China. (16)(14)

In contrast to the findings of most studies, our study revealed that females were more affected than males. Similar findings were documented in studies performed in Jamaica and California. (10)(18)

The mean age of patients affected with acute pancreatitis was 36.69 ± 10.428, and 68.9% of the patients were in the range of 20–40 years, which is similar to findings of other studies. (21)(13)(19) But it is in contrast to the findings of studies performed in Egypt and other European countries, which reported that the mean age was older. (3)

All patients experienced abdominal pain, and nausea and vomiting were experienced by 37 (82.2%) patients, followed by abdominal tenderness in 30 patients (66.7%). Thirteen (289%) and 17 (378%) patients experienced abdominal guarding, respectively, which is similar to the findings of studies performed in Bangladesh and our country-Ethiopia.(19)(21)

A chart review revealed that 37(80%) patients had mild acute pancreatitis, 3(8.9%) patients had moderate acute pancreatitis, and 5 (11.1%) patients had severe acute pancreatitis.

Forty-four (97.8%) patients had acute pancreatitis diagnosed by clinical and laboratory parameters, and one patient (2.2%) was diagnosed intraoperatively. All patients underwent abdominal ultrasounds scanning prior to decision. The laboratory biochemical profiles revealed increased serum levels of lipase and amylase, except for one patient, who had a normal level of serum amylase. The routine availability of abdominal ultrasound and biochemical tests decreased the number of patients requiring unnecessary operative intervention.(21)(13)

The average length of stay for the patients in the study was 7.56 ± 6.927 days, with a minimum of 2 days and a maximum of 30 days. A total of 42 (93.3%) patients improved, while 3 patients died.

In terms of complications, sepsis or infection affected the majority of patients which accounting for 35.6%, acute pancreatic fluid collection was diagnosed in 17.8%; respiratory complications affected 15.6%, and 13.3% had renal and GI complications.

Alkareemy et al. reported that the presence of coexisting conditions such as advanced age and the presence of complications were predictors of mortality in patients with acute pancreatitis. (3) Renal failure, significant leukocytosis, and high random blood sugar levels are associated with higher mortality rates in patients acute pancreatitis. (19) In contrast, in this study, GI complications, renal complications, pulmonary complications, and sepsis or infection were significantly correlated with acute pancreatitis outcomes. However, leucocytosis, high random blood sugar, high ALT, and the presence of comorbidities were not significantly associated with the outcomes of acute pancreatitis.

The mortality rate of acute pancreatitis in this study was 6.7%, which is much lower than those reported in previous studies; which was 20%. (21)

Females are more affected than males, and the majority of acute pancreatitis is caused by biliary stones followed by alcohol in our setup. Mortality was lower than that reported in the previous studies. The reason could be aggressive inpatient management of patients with acute pancreatitis and a reduction in the need for operative intervention in our setup.

Our study revealed that the presence of GI, renal, and respiratory complications, the development of sepsis, and the severity of pancreatitis affected the outcomes of pancreatitis. Whereas, hyperglycemia, leucocytosis, the presence of comorbidities, and elevated liver function test didn’t significantly influence to the outcome of acute pancreatitis.

recommendations

This study will serve as a baseline for a multicenter high-volume institutional study. This study recommends further studies that include more patients and more clinical and laboratory methods for the early diagnosis and detection of the causes of acute pancreatitis and its outcomes which are believed to provide insights for clinicians, decision-makers, and policymakers to pay appropriate attention to and perform appropriate procedures.

Limitations of the study

The small sample size and single institution-based nature of this study are limitations.

Acknowledgments

We would like to extend our heartfelt gratitude to SPHMMC, Department of Surgery for creating the opportunity to undertake this study, which is expected to impact clinical decision-making in acute pancreatitis patients.

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The authors declare no competing interests.

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Clinical characteristics and outcomes of acute pancreatitis at St. Paul’s Hospital Millennium Medical College: A five-year retrospective study.

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Abstract

INTRODUCTION

METHODOLOGIES

Results

Sociodemographic Data and Clinical Data

Etiology

Severity of Pancreatitis

The Average Length of Hospital Stay and Outcome

Variables associated with outcomes of acute pancreatitis

Discussion

Conclusion

Declarations

References

Additional Declarations

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