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David X. Jin1,2, Peter A. Banks1,2, and Julia McNabb‐Baltar1,2

1Brigham and Women’s Hospital

2 Harvard Medical School, Boston, MA, USA

The clinical severity and complications of acute pancreatitis (AP) can be highly variable. While the majority of patients develop a mild course, 5–15% develop severe disease, with mortality approaching 50% in some cases [1–8]. This clinical variability led to a need for accepted definitions of severity and complications to aid study and guide management.

The 1992 Atlanta Classification (AC) offered the first universally accepted set of definitions for AP ( Table 3.1) [9]. AP was defined as an acute inflammatory process of the pancreas that may also involve regional tissue or remote organ systems. Severe AP was broadly defined as the presence of (i) organ failure (shock, pulmonary insufficiency, renal failure, gastrointestinal bleeding) and/or (ii) local complications (especially pancreatic necrosis, but also abscess or pseudocyst). Early predictors of severity included three or more of Ranson’s criteria or an Acute Physiology, Age, and Chronic Health Evaluation (APACHE)‐II score of 8 or more. Additional terms, including mild AP, acute fluid collections, pancreatic necrosis, acute pseudocyst, and pancreatic abscess, were defined.

The AC served as the first clinically based classification system and provided the framework for how AP is defined today. However, some of the definitions proved ambiguous and were used inconsistently, for example (i) a uniform serum lipase and/or amylase threshold for diagnosis was not established; (ii) transient and persistent organ failure were not differentiated; and (iii) a heterogeneous group of patients with varying severity and mortality were combined into a single severe AP category [10]. These limitations led to large variability in the interpretation of organ failure and local complications [10,11].

With better understanding of the pathophysiology of organ failure and pancreatic necrosis, two widely adopted classification systems were subsequently derived: the Revised Atlanta Classification (RAC) and Determinant‐Based Classification (DBC) [12,13].

The RAC was derived through an iterative consultation process, ultimately generating consensus recommendations from the members of 11 international pancreatic societies [12]. The RAC provides a comprehensive classification of AP, including definitions of diagnosis, type (interstitial edematous versus necrotizing pancreatitis), clinical phase (early versus late), complications (local and systemic), and severity (mild, moderately severe, or severe). The scope of this chapter focuses on individual complications and definitions of severity.

Persistent organ failure is the primary determinant of outcomes and accounts for nearly all the mortality in AP [14–16]. Established risk factors include older age, comorbid conditions, obesity, elevated triglyceride levels, and certain etiologies (alcohol) [17–20]. Organ failure according to RAC is defined as a score of 2 or above for at least one of three organ systems using the modified Marshall scoring system ( Table 3.2) [21]. Persistent organ failure is defined as organ failure which lasts more than 48 hours while transient organ failure lasts less than 48 hours.

Table 3.1 Comparison of Atlanta Classification, Revised Atlanta Classification, and Determinant‐Based Classification.

Source: adapted from Bradley [9].

Local complications typically refer to a variety of pancreatic and peripancreatic fluid collections that differ in both composition and time to development. Other local complications include gastric outlet dysfunction, splanchnic vein thrombosis, and colonic necrosis. Local complications should be suspected when there is persistence or recurrence of pain, organ dysfunction, fever, or leukocytosis. High‐resolution contrast‐enhanced computed tomography (CECT) is often the diagnostic test of choice. In the RAC, local complications do not by themselves constitute severe AP.