This document discusses modifying the Atlanta classification system for acute pancreatitis. It summarizes the history of classifications, limitations of the Atlanta system, and proposals for revisions. The Atlanta system only divides pancreatitis into mild and severe groups. The revised classification adds a third category - moderately severe acute pancreatitis (MSAP) - for patients with local complications but transient organ failure who require ICU care. The document presents results of a study validating the MSAP subgroup and comparing outcomes between mild, MSAP and severe pancreatitis. The study found MSAP to have higher morbidity than mild but lower mortality than severe pancreatitis.

1. Do we need to modify Atlanta
Classification?
Mahesh Khakurel FRCS,FCPS, FNAMS,
FAICS, Professor of Surgery and Clinical
Director, Kist Medical College,
Kathmandu, Nepal
Paleswan Lakhey, MS, McH, Associate
Professor of Surgery, TU University
Teaching Hospital, Kathmandu, Nepal

2. Lord Moynihan, 1925
*“…………………….acute pancreatitis is the
most terrible of all the calamities occurring
in conjunction with the abdominal viscera.”
*Arch.surgery 1925 81, 132;42

3. Background
• Acute inflammatory disease of pancreas with
wide clinical variation and outcome varies
according to the severity
• Categorization of severity – one of the key
elements of the classification
• First attempt to classify severity of
pancreatitis – Reginald Fitz in 1889
considering morphological component in the
classification

4. Atlanta Classification
• A clinically based classification system for acute
pancreatitis. Summary of the International
Symposium on Acute Pancreatitis. Atlanta, Ga,
September 11 through 13, 1992 (46 international
authority from 6 discipline)
• Attempted to create an ideal classification
system for acute pancreatitis that would be
simple, objective, quantitative, noninvasive and
accurate
Bradley EL, Arch Surgery, 1993, May, 128(5):586-90

5. Atlanta Classification (AF)
• Remained gold standard for nearly 16
years
• Confusion aroused because of different
guideline within AC with new guideline
such as UK guideline, American guide line
and similar guide line from other countries
• Terminologies are defined differently by
different group

6. Limitation of AC
• It divides acute pancreatitis into two group only
with mild (no organ failure) severe (with local
complications and persistent organ failure and
high mortality) requiring intervention and ICU
care.
• Does not cover transient organ failure who
requires ICU care and some form of intervention
• Many of the definition proved confusing

7. Limitations of Atlanta classification
• Broad definition of severe acute pancreatitis
• Lack of differentiation between transient and persistent
organ failure
• Criteria for organ failure defined in Atlanta not used
uniformly
• Definition of local complications not uniform
• GI bleeding is not common occurrence
• Banks PA et al, Am J Gastroenterol
2006;101:2379-2400
Vege SS et al, Gastroenterology 2005;128:113
– Pandol SJ et al, Gastroenterology 2007;132:1127-51

8. Acute pancreatitis classification
working group
• Revision of Atlanta classification and definitions
of collections associated with AP has been
proposed by Acute Pancreatitis Classification
Working Group in 2007
• 3rd revision based on worldwide
review/suggestions published in 2009
» WWW.pancreas club/com resourses/Atlana classification.pdf

9. The goal of the group
The goal of new classification is to update
AC, clarify previous areas of confusion,
improve clinical assessment and
management, and standardized means of
data collection for future studies to allow
objective evaluation of new therapies

11. Clinical features of mild, moderately
severe, and severe pancreatitis
Feature Mild (MAP) Moderate
(MSAP)
Severe
(SAP)
Structural
alterations
Interstitial Interstitial,
necrotizing, or
local
complications,
Interstitial,
necrotizing, or
local
complications
Functional
effects
No organ failure No organ
failure, or tran.
Persistent organ
failure
Morbidity Low High High
Mortality No Low High

12. Rationale of the study
• Tertiary care hospital
• No such study has been conducted in the past
as the concept is being investigated recently
• This study has been carried out to see whether
the classification system is feasible in our set up.

13. Aims and Objectives
• To describe the demographics, etiology and
severity predictors in acute pancreatitis
• To determine the proportion of MSAP and to
validate this subgroup in patients with acute
pancreatitis

14. Study design
• Prospective observational study
• Carried out in patients admitted with the diagnosis of acute
pancreatitis from Sept 2008 to March 2010
• Surgical Gastroenterology units of Department of Surgery, Tribhuvan
University Teaching Hospital, Kathmandu, Nepal.
• Informed consent
• Ethical clearance

15. Inclusion/Exclusion criteria
• Inclusion criteria
 All patients ≥ 18 years with two of the following
diagnostic criteria
• Abdominal pain suggestive of pancreatic origin
• Serum amylase and/ or lipase ≥3 times normal
• Radiological findings compatible with acute pancreatitis
UK guidelines for management of acute pancreatitis 2005
• Exclusion criteria
 Alternative diagnosis
 Those patients that left against medical advise

16. Data collection
• Data regarding
– Need for ICU care, length of ICU stay, length of
hospital stay, need for surgical intervention, death
(Primary outcome variables)
– Patient demographics, diagnostic criteria, predicted
severity according to Ranson’s criteria, etiology, local
and systemic complications (Secondary outcome
variables)

17. Study procedure
• Patients with OF (transient/persistent) admitted in
ICU, rest in the ward
• Aggressive medical management
• Need for intervention defined as need for
endotracheal intubation, ionotropic support,
hemodialysis and minimally invasive and surgical
intervention for the local complications
• Development of local complications or organ failure

18. Study procedure
• Patients divided into 3 groups depending upon
the presence of organ failure and local
complications
– Mild acute pancreatitis (MAP)
– Moderately severe acute pancreatitis (MSAP)
– Severe acute pancreatitis (SAP)
• Comparison was made between the three
groups

19. Statistical analysis
• SPSS version 11.5
• Continuous variables expressed as mean ±
standard deviation and categorical variables as
frequency and percentage
• Independent t-test and Chi square tests
• Confidence interval 95%
• p value < 0.05 taken as statistically significant

20. Demography
Variables Frequency (n=172) Percentag
e
Age, year, mean ± SD 42.7 ± 16.5
Male 95 55.2
Female 77 44.8
Etiology
Gall stones
Alcohol
Hypertriglyceridemia
Drugs
Idiopathic
104
64
1
3
38
60.5
37.2
0.6
1.7
22.1
Predicted severity 72 41.9
Local complications 68 39.5
Organ failure 12 7
Mortality 4 2.3

21. Local complications (n=68)

22. Persistent organ failure according to
Marshall Scoring system (n=12)*
* 50% of patients had ≥ 2 organ failure

23. Outcome patients with OF

24. Clinical characteristics of patients who
died
Age/Se
x
Etiology Local
complicatio
ns
No of
organ
failure
Death
48/M Idiopathic - 2(ARDS/Shoc
k)
Day 3
41/F Idiopathic Fluid collection 2(ARDS/Shoc
k)
Day 4
65/F Biliary Fluid collection 1(ARDS) Day 7
72/F Biliary Fluid +
Necrosis <30%
1(ARDS) Day 7

25. Atlanta classification vs New

26. Patient demography according to new
groups
Variable MAP
(n=103)
MSAP
(n= 57)
SAP
(n=12)
P
value
Age(mean±SD) 41.8±16.6 43±16.2 49.7±17.6 0.29
Male, n(%)
Female, n(%)
49 (47.6)
54 (52.4)
39 (68.4)
18 (31.6)
7 (58.3)
5 (41.7) 0.04
Etiology n(%)
Gall stones
Alcohol
Hypertriglyceridemia
Drugs
Idiopathic
57 (55.3)
33 (32)
0 (0)
3 (2.9)
23 (22.3)
39 (68.4)
25 (43.9)
1 (1.8)
0 (0)
12 (21.1)
8 (66.7)
6 (50)
0 (0)
0 (0)
3 (7.9)
0.24
0.21
0.36
0.36
0.95

27. Comparison of morbidity and mortality
among new group
Variable MAP
(n=103)
MSAP
(n=57)
SAP
(n=12)
P value
Need for ICU stay, n
(%)
0 11 (19.3) 12 (100) <0.001
Need for intervention, n
(%)
0 0 10 (83.3) <0.001
Length of ICU stay,
mean±SD, days
0 1 9.8±4.6 <0.001
Length of hospital stay,
mean±SD, days
4.9±2.1 8.7±3.7 16.8±8.1 <0.001
Death, n (%) 0 0 4 (33.3) <0.001

28. Comparison between MAP and MSAP
Variable MAP
(n=103)
MSAP
(n=57)
P value
Need for ICU stay, n (%) 0 11 (19.2) 0.001
Need for intervention, n (%) 0 0 NS
Length of ICU stay,
mean±SD, days
0 1 0.001
Length of hospital stay,
mean±SD, days
4.87±2.1 8.6±3.7 <0.001
Death, n (%) 0 0 NS

29. Comparison between MSAP and SAP
Variable MSAP
(n=57)
SAP
(n=12)
P value
Need for ICU stay, n (%) 11 (19.2) 12 (100) <0.001
Need for intervention, n
(%)
0 10 (83.3) <0.001
Length of ICU stay,
mean±SD, days
1 9.8±4.6 <0.001
Length of hospital stay,
mean±SD, days
8.6±3.7 16.6±8.1 <0.001
Death, n (%) 0 4 (33) <0.001

30. Discussion
• Call for revision of Atlanta classification in
various publications
• Major impetus for revision
– Recent significant advances in understanding
the pathophysiology of acute pancreatitis
– Role of organ failure
• Bollen TL et al: BJS 2008;95:6-21
• Petrov MS et al: Am J Gastroenterology 2010;105:74-76

31. Discussion

32. • Talukdar R et al. Moderately severe acute
pancreatitis: a prospective validation study of
this new subgroup of acute pancreatitis.
Pancreatology 2009;9:434.
• De-Madaria E et al. Update of the Atlanta
classification of severity of acute pancreatitis:
should a moderate category be included?
Pancreatology 2009;9:433–434.

33. Discussion
• Group from Mayo Clinic proposed new group MSAP
• High morbidity as SAP and low mortality as MAP
• Prospective validation done by the same group
• Total of 82 patients: MSAP – 12 (14.6%)
• This study, total 172 patients: MSAP – 57 (33.1%)
Talukdar R et al. Pancreatology 2009;9:434.

35. Comparison of results of this study
with other studies
Variable
(MSAP vs SAP)
Talukdar R et
al
(n=82)
De-Madaria E
(n=135)
This study
(n=172)
Need for ICU care 0% vs 71.4% 2.4% vs
62.3%
19.2% vs 100%
Need for
intervention
50% vs 35.7% 2.4% vs
45.5%
0% vs 83.3%
Length of hospital
stay, mean ± SD in
days
5.9 vs 17.5 21.2±11.5 vs
25±9.9
8.6±3.7 vs
16.6±8.1
Mortality 0% vs 28.6% 0% vs 45.5% 0% vs 33%

36. Discussion
• This study showed that MAP, MSAP, SAP as
classified according to the structural alterations
and functional effects, exist as different groups
in terms of need for ICU, need for intervention,
length of ICU stay, hospital stay and death.
• However, this study did not show that MSAP had
prolonged hospitalization as SAP as shown by
other studies.

37. Conclusion
• This study showed that MSAP having local
complications without OF exist as exclusive
entity different from MAP and SAP.
• We need to work closely with other groups to
validate in large number of patients and
recommend for inclusion of MSAP

38. THANK YOU