Discrepancy between the extent of pancreatic necrosis and multiple organ failure score in severe acute pancreatitis.

backgroundWhether pancreatic necrosis is a prerequisite for the development of multiorgan failure (MOF) in severe acute pancreatitis (AP) is not clear and has implications for the rational design of translational therapies. This study was designed to investigate the magnitude of any association between MOF and radiologically evident pancreatic or extrapancreatic complications of AP.

methodsData regarding 276 patients with AP were analyzed retrospectively with regard to clinical presentation, MOF severity, computerized tomography (CT) evidence of pancreatic necrosis, and modified CT severity index (MCTSI).

resultsAgreement between the presence of necrosis and MOF status was seen in 160 of 276 patient episodes (58%; 95% confidence intervals (CI), 52.1-63.8%). In 116 of 276 episodes, the MCTSI and MOF scores disagreed (42%; 95% CI, 36.2-47.9%). CT evidence of pancreatic necrosis was present in 21 of 104 (20.2%) patients without any evidence of MOF, and there was no evidence of necrosis on CT scan in 95 of 176 (54%) patients with MOF. Full-factorial univariate analysis suggested that extrapancreatic complications seen on CT, in particular intra-abdominal fluid collections (effect size = 0.02; P = 0.016) and abnormal liver enhancement (effect size = 0.035; P = 0.031) were associated with severity of MOF, and exerted an even greater effect when they occurred synchronously.

conclusionsThe discrepancy between the presence of necrosis and the occurrence of MOF favors association but not cause in AP. A complex, systems-based, pleiotropic inflammatory network with a common root, in which the extent of pancreatic necrosis influences the severity of MOF in certain individuals and MOF exacerbates the development of pancreatic necrosis in others, seems more likely.