ArticlesEarly prediction of severity in acute pancreatitis by urinary trypsinogen activation peptide: a multicentre study
Introduction
Acute pancreatitis affects around 40 per 100 000 of the general population, and 20–30% of attacks are severe, with a mortality of about 30–50%.1 Improved outcome is based on early recognition of disease severity to allow high-dependency or intensive treatment2 and, in the case of gallstone-linked disease, emergency endoscopic sphincterotomy.3, 4 About 50% of deaths occur within 1 week of the attack, mostly from multiorgan dysfunction syndrome.5
It is hard to identify severe cases within 2–3 days of symptom onset, by which time the network of pathophysiological mechanisms leading to multiorgan dysfunction syndrome is established. An ideal prognostic system would be based on a single test and have a high negative predictive value. To date, few prospective studies have analysed prognostic markers or systems from the time of symptom onset, which undermines their value. The APACHE II,6 Ranson,7 and Imrie8 clinicobiochemical systems have similar accuracy 48 h after hospital admission but, although used in randomised controlled trials, are not used routinely in most hospitals because they are complex.9 Only the APACHE II score has useful accuracy on admission, but it is the most complicated system.6 Single markers are not used routinely because they are useful only at 48 h or more after onset of symptoms, have not been rigorously tested or had initial reports confirmed, or laboratory measurement is difficult.10, 11, 12, 13, 14, 15
Measurement of trypsinogen activation peptide (TAP), released on activation of trypsinogen to trypsin, has promising predictive value since it is a single marker specifically related to the onset of acute pancreatitis.13 Accurate measurement of TAP has been difficult because of unavailability of a validated assay. We investigated, in a prospective multicentre study, the predictive value of a TAP assay compared with C-reactive protein10 and clinicobiochemical scoring systems.
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Study population
Consecutive patients were recruited for 6–12 months from July, 1997, to July, 1998, at the Royal Liverpool University Hospital, Liverpool, UK, Helsinki University Central Hospital, Helsinki, Finland, Ulm University Hospital, Ulm, Germany, and the Mater Misericordiae Hospital, Dublin, Ireland. The time of onset of acute abdominal pain was determined prospectively. Eligible patients were those admitted from the community with a diagnosis of acute pancreatitis. We excluded patients who had had
Results
303 individuals were enrolled, of whom 57 were excluded because they did not meet all the eligibility criteria. 246 eligible patients were included, of whom 172 had acute pancreatitis and 74 were controls. 35 (20%) patients with acute pancreatitis had severe disease (Atlanta classification16). Sex, age, admission delay, and duration of hospital stay in relation to clinical severity and cause of acute pancreatitis are shown in table 1. Median admission delay for patients with acute pancreatitis
Discussion
Measurement of urinary TAP proved a valuable early marker of severity in acute pancreatitis, with advantages over all other available prognostic systems.6, 7, 8, 10, 11, 12, 13, 14 The use of TAP measurement for severity assessment is appealing, since activation of trysinogen to trypsin, leading to the release of TAP, precedes all other systemic and clinical events in severe acute pancreatitis.13, 20 Optimum supportive care with limited health-care resources,1, 2 as well as the application of
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