급성 췌장염의 분류, Classification of acute pancreatitis

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개정된 Atlanta classification system은 급성 췌장염을 2개로 넓은 범부로 구분합니다 (테이블에서 1-2).

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1) Interstitial edematous acute pancreatitis

: characterized by acute inflammation of the pancreatic parenchyma and peripancreatic tissues, but without recognizable tissue necrosis

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2) Necrotizing acute pancreatitis

: characterized by inflammation associated with pancreatic parenchymal necrosis and/or peripancreatic necrosis

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Revised definitions of morphological features of acute pancreatitis

1. Interstitial edematous pancreatitis

Acute inflammation of the pancreatic parenchyma and peripancreatic tissues, but without recognizable tissue necrosis Contrast-enhanced computed tomography criteria: Pancreatic parenchyma enhancement by intravenous contrast agent No findings of peripancreatic necrosis

2. Necrotizing pancreatitis

Inflammation associated with pancreatic parenchymal necrosis and/or peripancreatic necrosis Contrast-enhanced computed tomography criteria: Lack of pancreatic parenchymal enhancement by intravenous contrast agent, and/or Presence of findings of peripancreatic necrosis (see below—acute peripancreatic fluid collection and walled off necrosis)

3. Acute peripancreatic fluid collection (APFC)

Peripancreatic fluid associated with interstitial edematous pancreatitis with no associated peripancreatic necrosis. This term applies only to areas of peripancreatic fluid seen within the first four weeks after onset of interstitial edematous pancreatitis and without the features of a pseudocyst. Contrast-enhanced computed tomography criteria: Occurs in the setting of interstitial edematous pancreatitis Homogeneous collection with fluid density Confined by normal peripancreatic fascial planes No definable wall encapsulating the collection Adjacent to pancreas (no intrapancreatic extension)

4. Pancreatic pseudocyst

An encapsulated collection of fluid with a well defined inflammatory wall usually outside the pancreas with minimal or no necrosis. This entity usually occurs more than four weeks after onset of interstitial edematous pancreatitis to mature. Contrast-enhanced computed tomography criteria: Well circumscribed, usually round or oval Homogeneous fluid density No non-liquid component Well defined wall (ie, completely encapsulated) Maturation usually requires >4 weeks after onset of acute pancreatitis; occurs after interstitial edematous pancreatitis

5. Acute necrotic collection (ANC)

A collection containing variable amounts of both fluid and necrosis associated with necrotizing pancreatitis; the necrosis can involve the pancreatic parenchyma and/or the peripancreatic tissues Contrast-enhanced computed tomography criteria: Occurs only in the setting of acute necrotizing pancreatitis Heterogeneous and non-liquid density of varying degrees in different locations (some appear homogeneous early in their course) No definable wall encapsulating the collection Location—intrapancreatic and/or extrapancreatic

6. Walled-off necrosis (WON)

A mature, encapsulated collection of pancreatic and/or peripancreatic necrosis that has developed a well defined inflammatory wall. WON usually occurs >4 weeks after onset of necrotizing pancreatitis. Contrast-enhanced computed tomography criteria: Heterogeneous with liquid and non-liquid density with varying degrees of loculations (some may appear homogeneous) Well defined wall, that is, completely encapsulated Location—intrapancreatic and/or extrapancreatic Maturation usually requires four weeks after onset of acute necrotizing pancreatitis

Reproduced with permission from: Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis - 2012: revisions of the Atlanta classification and definitions by international consensus. Gut 2013; 62:102.

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중증도에 따라, 급성 췌장염은 다음과 같이 나뉩니다.

1) Mild acute pancreatitis

: characterized by the absence of organ failure and local or systemic complications

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2) Moderately severe acute pancreatitis

: characterized by transient organ failure (resolves within 48 hours) and/or local or systemic complications without persistent organ failure (>48 hours)

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3) Severe acute pancreatitis

: characterized by persistent organ failure that may involve one or multiple organs

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급성 췌장염의 국소 합병증으로는 acute peripancreatic fluid collection, pancreatic pseudocyst, acute necrotic collection, walled-off necrosis가 있습니다 (Table에서 3-6).

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Organ failure는 modified Marshall scoring system를 사용하여 3개 기관계 (respiratory, cardiovascular, renal) 중에 어느 하나라도 2점 이상으로 정의합니다.

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Modified Marshall scoring system for organ dysfunction

Organ system	Score
	0	1	2	3	4
Respiratory (PaO2/FiO2)	>400	301-400	201-300	101-200	≤101
Renal*
(serum creatinine, micromol/L)	≤134	134-169	170-310	311-439	>439
(serum creatinine, mg/dL)	<1.4	1.4-1.8	1.9-3.6	3.6-4.9	>4.9
Cardiovascular (systolic blood pressure, mmHg)¶	>90	<90, fluid responsive	<90, not fluid responsive	<90, pH <7.3	<90, pH <7.2
For nonventilated patients, the FiO2 can be estimated from below:
Supplemental oxygen (L/min)	FiO2 (percent)
Room air	21
2	25
4	30
6-8	40
9-10	50

A score of 2 or more in any system defines the presence of organ failure.

* A score for patients with pre-existing chronic renal failure depends on the extent of further deterioration of baseline renal function. No formal correction exists for a baseline serum creatinine ≥134 micromol/L or ≥1.4 mg/dL.

¶ Off inotropic support.

Reproduced with permission from: Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis - 2012: revisions of the Atlanta classification and definitions by international consensus. Gut 2013; 62:102. BMJ

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REF. UpToDate 2021.04.25