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Clasificación de Maxim Petrov
1. The American Journal of GASTROENTEROLOGY VOLUME 105 | JANUARY 2010 www.amjgastro.com
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CLINICAL REVIEWS
“Crude classifications and false generalizations are the
curse of organized life.”
—George Bernard Shaw
The Atlanta classification, the most widely used classification
of acute pancreatitis, was introduced in 1992 and defined mild
and severe categories of acute pancreatitis (1). However, its
limitations have been highlighted in a number of publications
over the past 5 years and a call for its revision has been made
(2–4). The major impetus to revision has been the recent signi-
ficant advances in understanding the pathophysiology of acute
pancreatitis and especially the role of systemic complications.
Whereas the original Atlanta classification assessed only the
presence or absence of organ failure (OF), it is now recognized
that the number of organs that fail, the timing of onset, the
change in OF in response to initial treatment, and the duration
of OF, all contribute to severity (5–7). Given that OF lasting
for >48h is associated with significantly increased mortality in
patients with acute pancreatitis (8,9), the proposed revision of
the Atlanta classification suggests that patients with persistent
OF should be defined as having severe acute pancreatitis (10).
This means that patients with transient OF are considered to
have mild acute pancreatitis, and that local (peri)pancreatic
complications are not considered to contribute to the defini-
tion of severity in patients with acute pancreatitis.
Since the first attempt to classify the severity of acute pan-
creatitis by Fitz in 1889 and until the most recent Atlanta sym-
posium in 1992, a morphological component has always been
included (11). Whereas Fitz believed that the morphological
features of severe disease were evidence of pancreatic hemor-
rhage and disseminated fat necrosis, the morphological features
of severe disease in the original Atlanta classification were pan-
creatic necrosis, abscess, and pseudocyst. Since then, a number
of studies have demonstrated that infectious (peri)pancreatic
complications (IPCs), rather than the presence of necrosis
per se, are a key determinant of the high morbidity and morta-
lity in patients with acute pancreatitis (12–15). It therefore
seems reasonable to consider local complications in classifying
the severity of acute pancreatitis.
A retrospective study from the Mayo Clinic (16) showed that
patients with local pancreatic complications (as defined by the
1992 Atlanta classification) and no systemic complications at any
time during hospitalization had an almost negligible mortality
but an appreciable morbidity. Only 2 (2%) patients died among
99 patients with local complications and no OF, and this was
similar to those with mild acute pancreatitis. At the same time, it
was shown that these patients required an average stay in the ICU
of 5 days and a total hospital stay of 28 days, both of which are
more than expected for patients with mild acute pancreatitis. This
was recently confirmed by the same research group in a prospec-
tive study of 82 patients (17), as well as in a prospective study of
135 patients from Spain (18). On the basis of these findings, the
revision to the Atlanta classification should include a third cat-
egory, those with “moderate” acute pancreatitis, and these would
be those with local (peri)pancreatic complications but no persist-
ent systemic complications. These patients would have previously
been classified as having severe acute pancreatitis.
There is another subgroup of patients among those who
would have previously been classified as having severe acute
pancreatitis. This proposed category is at the severe end of
the spectrum and these patients have both local and systemic
complications during the course of acute pancreatitis. The rea-
son for defining this subgroup of patients as having extremely
severe (or “critical”) acute pancreatitis stems from findings of
several studies that demonstrated a marked difference in the
mortality rate of patients with OF depending on whether IPCs
are present or not. This was shown in a study from Switzerland
that prospectively enrolled 204 patients with acute pancreatitis,
Classification of the Severity of Acute Pancreatitis:
How Many Categories Make Sense?
Maxim S. Petrov, MD, MPH1
and John A. Windsor, MBChB, MD, FRACS1
There is an ongoing effort to revise the 1992 Atlanta classification of acute pancreatitis in the light of emerging
evidence. The categorization of the severity of acute pancreatitis is one of the key elements of the classification.
This paper aims to define the optimal number of categories and provide their definitions on sound clinical
grounds.
Am J Gastroenterol 2010; 105:74–76; doi:10.1038/ajg.2009.597; published online 20 October 2009
1
Department of Surgery, The University of Auckland, Auckland, New Zealand. Correspondence: Maxim S. Petrov, MD, MPH, Department of Surgery, The
University of Auckland, Private Bag 92019, Auckalnd 1142, New Zealand. E-mail: max.petrov@gmail.com
Received 13 May 2009; accepted 11 September 2009
3. The American Journal of GASTROENTEROLOGY VOLUME 105 | JANUARY 2010 www.amjgastro.com
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REVIEW
Petrov and Windsor
6. Mole DJ, Olabi B, Robinson V et al. Incidence of individual organ
dysfunction in fatal acute pancreatitis: analysis of 1024 death records.
HPB 2009;11:166–70.
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what we ought to know for tomorrow. Pancreas 2009;38:494–8.
8. Buter A, Imrie CW, Carter CR et al. Dynamic nature of early organ dysfunction
determines outcome in acute pancreatitis. Br J Surg 2002;89:298–302.
9. Johnson CD, Abu-Hilal M. Persistent organ failure during the first week as
a marker of fatal outcome in acute pancreatitis. Gut 2004;53:1340–4.
10. Acute Pancreatitis Classification Working Group. Revision of the Atlanta
classification of acute pancreatitis (3rd revision). www. pancreasclub.com/
resources/AtlantaClassification.pdf Accessed 1 April 2009.
11. Pannala R, Kidd M, Modlin IM. Acute pancreatitis: a historical perspective.
Pancreas 2009;38:355–66.
12. Gloor B, Müller CA, Worni M et al. Late mortality in patients with severe
acute pancreatitis. Br J Surg 2001;88:975–9.
13. Garg PK, Madan K, Pande GK et al. Association of extent and infection
of pancreatic necrosis with organ failure and death in acute necrotizing
pancreatitis. Clin Gastroenterol Hepatol 2005;3:159–66.
14. Beger HG, Rau BM. Severe acute pancreatitis: clinical course and manage-
ment. World J Gastroenterol 2007;13:5043–51.
15. Xue P, Deng LH, Zhang ZD et al. Infectious complications in patients with
severe acute pancreatitis. Dig Dis Sci 2008; [e-pub ahead of print].
16. Vege SS, Gardner TB, Chari ST et al. Low mortality and high morbidity
in severe acute pancreatitis without organ failure: a case for revising the
Atlanta classification to include “moderately severe acute pancreatitis”.
Am J Gastroenterol 2009;104:710–5.
17. Talukdar R, Vege SS, Chari ST et al. Moderately severe acute pancreatitis:
a prospective validation study of this new subgroup of acute pancreatitis.
Pancreatology 2009;9:434.
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of severity of acute pancreatitis: should a moderate category be included?
Pancreatology 2009;9:433–4.
19. Büchler MW, Gloor B, Müller CA et al. Acute necrotizing pancreatitis: treat-
ment strategy according to the status of infection. Ann Surg 2000;232:619–26.
20. Lytras D, Manes K, Triantopoulou C et al. Persistent early organ failure:
defining the high-risk group of patients with severe acute pancreatitis?
Pancreas 2008;36:249–54.
21. Le Mée J, Paye F, Sauvanet A et al. Incidence and reversibility of organ fail-
ure in the course of sterile or infected necrotizing pancreatitis. Arch Surg
2001;136:1386–90.
22. Isenmann R, Rau B, Beger HG. Early severe acute pancreatitis: characteris-
tics of a new subgroup. Pancreas 2001;22:274–8.
23. Tao HQ, Zhang JX, Zou SC. Clinical characteristics and management of
patients with early acute severe pancreatitis: experience from a medical
center in China. World J Gastroenterol 2004;10:919–21.
24. Petrov MS, van Santvoort HC, Besselink MG et al. Enteral nutrition
and the risk of mortality and infectious complications in patients with
severe acute pancreatitis: a meta-analysis of randomized trials. Arch Surg
2008;143:1111–7.
25. Windsor JA. Minimally invasive pancreatic necrosectomy. Br J Surg
2007;94:132–3.
26. Petrov MS. Meta-analyses on the prophylactic use of antibiotics in acute
pancreatitis: many are called but few are chosen. Am J Gastroenterol
2008;103:1837–8.
27. Cavallini G, Frulloni L. Somatostatin and octreotide in acute pancreatitis:
the never-ending story. Dig Liver Dis 2001;33:192–201.
28. Abu-Zidan FM, Windsor JA. Lexipafant and acute pancreatitis: a critical
appraisal of the clinical trials. Eur J Surg 2002;168:215–9.
29. Ishikawa K, Idoguchi K, Tanaka H et al. Classification of acute pancreatitis
based on retroperitoneal extension: application of the concept of
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tives of the revision of the Atlanta classification, which are to
improve clinical assessment, facilitate communication between
treating physicians and promote standardization for reporting
clinical studies.
ACKNOWLEDGMENTS
We are indebted to Professor Peter A. Banks (Brigham and
Women’s Hospital, Harvard Medical School, Boston, MA) for
helpful discussion. Dr. Maxim S. Petrov is supported by the
Kenneth Warren Foundation of the International
Hepato-Pancreato-Biliary Association.
CONFLICT OF INTEREST
Guarantor of the article: Maxim S. Petrov, MD, MPH.
Specific author contributions: Planning, conducting, and
drafting the manuscript: Maxim S. Petrov; drafting and critical
reviewing of the manuscript: John A. Windsor.
Financial support: None.
Potential competing interests: None.
REFERENCES
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Atlanta, Ga, September 11 through 13, 1992. Arch Surg 1993;128:586–90.
2. Vege SS, Chari ST. Organ failure as an indicator of severity of acute pancreatitis:
time to revisit the Atlanta classification. Gastroenterology 2005;128:1133–5.
3. Banks PA, Freeman ML. Practice guidelines in acute pancreatitis. Am J
Gastroenterol 2006;101:2379–400.
4. Pandol SJ, Saluja AK, Imrie CW et al. Acute pancreatitis: bench to the
bedside. Gastroenterology 2007;132:1127–51.
5. Flint R, Windsor JA. Early physiological response to intensive care as a
clinically relevant approach to predicting the outcome in severe acute
pancreatitis. Arch Surg 2004;139:438–43.
Table 1. Classification and definitions of four categories for
the severity of acute pancreatitis
Severity
category
Local complications Systemic
complications
Mild No (peri)pancreatic
complication
and No organ failure
Moderatea
Sterile (peri)pancreatic
complication
or Transient organ
failure
Severea
Infectious (peri)pancreatic
complication
or Persistent organ
failure
Critical Infectious (peri)pancreatic
complication
and Persistent organ
failure
a
Severity is graded on the basis of more severe local or systemic complication
(e.g., sterile pancreatic necrosis without organ failure has to be graded as
“moderate”; sterile pancreatic necrosis with persistent organ failure has to be
graded as “severe”).