| Objective: Acute pancreatitis (Acute pancreatitis AP) is one of the most common clinical acute abdomen. It is a mild self-limited disease, usually without complications.However, due to the severe inflammatory reaction still 10% to 20% of the patients develop into severe acute pancreatitis, resulting in multiple organ damage, which prolong the duration of hospitalization and higher mortality rate[1]. Therefore, it is a great significance in judging the severity of acute pancreatitis in treatment and prognosis at present. The determination of the severity of clinical manifestations of acute pancreatitis based on clinical symptoms and imaging, mainly based on the indexes including PCT, CRP, IL-6 and other inflammatory factors as well as related evaluation standard. To improve the clinical accuracy and efficiency of the judgment of severity of acute pancreatitis, monitoring the traditional inflammation indexes such as IL-6 PCT, CRP simultaneously, and comparing the Ranson score can be taken into consideration. On the other hand, the pertinent individual treatment of antibiotics(antibiotic personalized management", Individual Patient-adapted Antibiotic Therapy:" Antibiotic Stewardship") for patients with acute pancreatitis should be chosen to intensify the rational use of antibiotics and reduce the double infection. This paper will explore the significance of application of PCT in monitoring the severity of acute pancreatitis, and compare hs-CRP, IL-6 and normal white blood cell count,neutrophil ratio and other common inflammatory indices, finally evaluate PCT combined with hs-CRP, IL-6, Ranson score to explore the significance of joint monitoring in diagnosing the severity of acute pancreatitis and the significance of dynamic monitoring of PCT on the application of antibiotics in acute pancreatitis.Methods: Retrospective analysis method was used in this study, all data were collected from 154 patients who were diagnosed for acute pancreatitis (49 female, 105 male, aged 16-75 years) from July 2014 to August 2016 in the Second Affiliated Hospital of Kunming Medical University. The inclusion criteria were: compliance with the guidelines for the diagnosis and treatment of acute pancreatitis in [2] (2014)criteria. Exclusion criteria: undiagnosed for acute pancreatitis, or patients with incomplete clinical data were excluded in this study. Patients' general information include sex, age and etiology etc. According to the severity grading standard in the guidelines for the diagnosis and treatment of acute pancreatitis[2] (2014), as well as relevant collected data and calculated Marshall scores combined with clinical evidence, 104 AP patients were divided into mild acute pancreatitis (MAP, 54 cases),moderately severe acute pancreatitis (MSAP, 28 cases) and severe acute pancreatitis(SAP,22 cases), namely A, B, C three groups. The content of PCT, hs-CRP, IL-6 was measured by Electrochemiluminescence Method within 24 hours after patients were admitted to hospital, and data were collected and the score of Ranson was calculated within 48 hours. The 100 patients with moderately severe and severe acute pancreatitis were categorized into: group D, discontinuation of antibiotics after guidance of PCT,moderately severe acute pancreatitis and severe acute pancreatitis(50 cases); group E,antibiotics was used without dynamic monitoring of PCT value,discontinuation of antibiotics by common inflammatory indexes and traditional clinical evidence (including white blood cell count, neutrophil ratio, body temperature,heart rate etc.), moderately severe acute pancreatitis and severe acute pancreatitis (50 cases).Spss19.0 software was used for statistical analysis: (1) the relationship between PCT, hs-CRP, IL-6, Ranson score and severity of acute pancreatitis; (2) the value of classification in the diagnosis of acute pancreatitis; (3) correlation between PCT,hs-CRP, IL-6, Ranson score and severity of acute pancreatitis; (4)The difference of D,E groups in duration of using antibiotics, hospitalization, single use and combined use of antibiotics.Results:1. Moderately severe and severe acute pancreatitis accounted for about 48% in 104 patients. The three groups of patients with acute pancreatitis: PCT(median){0.14(0.07,0.34), 0.92 (0.50,1.42), 6.69 (4.82,11.57) ng/ml}; hs-CRP (median) {70.94±76.22,157.94±88.96202.75±104.05}; IL-6 (median) {37.20 (8.45,71.38),97.80(53.94,178.36), 161.40 (78.76,274.13)}; Ranson score (median) {1.00 (1.00,2.00), 5(4.00,5.00), 8 (6.75,8.00)}; the overall difference of PCT, hs-CRP, IL-6, and Ranson score of three groups after Kruskal-Wallis H test had obvious statistical significance(P < 0.001).The use of LSD method for comparison of hs-CRP between the every two groups showed hs-CRP of mild acute pancreatitis was significantly lower than that of moderately severe acute pancreatitis and severe acute pancreatitis group,the differences were statistically significant (P < 0.05); but there was no statistical significance in moderately severe acute pancreatitis and severe acute pancreatitis group (P > 0.05). The use of Mann-whitney U to test PCT, IL-6, Ranson scores among the three groups showed PCT of severe acute pancreatitis group was significantly higher than that of mild acute pancreatitis and moderately severe acute pancreatitis group,while PCT of moderately severe acute pancreatitis group was also significantly higher than that of mild acute pancreatitis group, the differences were both statistically significant (P < 0.05).The results of IL-6 and hs-CRP was consistent and the Ranson score was consistent with the PCT. The difference of the CT classification of three groups measured by Kruskal-Wallis H test had statistical significance (P <0.05). The overall difference of general data of the three groups, including age and heart rate after statistical analysis, was statistically significant (P < 0.05). While the mean arterial pressure and gender had no statistical significance (P > 0.05). After the statistical analysis of hematological indices,including the ratio of neutrophils (N%),serum calcium, blood glucose, white blood cell (WBC) and LIPASE among patients of three groups, the overall differences were statistically significant(P < 0.05), but there was no significance in AMY of three groups (P > 0.05).2. Moderately severe and severe acute pancreatitis accounted for about 48% in 104 patients. In order to insure the accuracy and get the threshold vale of PCT, hs-CRP,IL-6, Ranson score in clinical diagnosis of moderately severe and severe acute pancreatitis, the ROC curve (Receiver Operating Characteristic Curve, ROC) was used in analysis, results suggested that the area under the curve were: PCT (0.948±0.020),hs-CRP (0.802±0.045),IL-6 (0.801 ±0.043),Ranson score (0.980±0.014)respectively; the diagnostic threshold value in moderately severe and severe acute pancreatitis were: PCT (0.4825ng/ml), hs-CRP (91.69mg/l), IL-6 (74.25pg/ml),Ranson score (3.5 points) respectively; sensitivity (Sensitivity, SE) (%) and specificity(SP) (%) were respectively: PCT (88%, 88.9%), hs-CRP (86%, 70.4%), IL-6 (72%,77.8%), Ranson score (92%, 100%). Joint analysis based on the application of PCT combined with two threshold value of hs-CRP, the area under the curve was: (0.945±0.021),sensitivity and specificity: (80%,96.3%). Joint analysis based on the application of PCT combined with two threshold value of Ranson score, the area under the curve was: (0.997±0.003), sensitivity and specificity (100%, 96.3%).3. Moderately severe and severe acute pancreatitis accounted for about 48% in 104 patients..PCT, hs-CRP, IL-6, Ranson score were positively correlated with the severity of acute pancreatitis and the results were PCT (r=0.839, P < 0.001), hs-CRP(r=0.531,P < 0.001),IL-6 (R =0.541,P < 0.001),Ranson score (r=0.879, P <0.001).PCT, hs-CRP, IL-6, Ranson score were positively correlated with each other after analysis.4. The patients included 100 cases, age, gender and Ranson score had no statistical difference between two groups. Duration of using antibiotics and hospitalization(mean) of A group were respectively: (13.58±8.42,15.52±6.25), while B group were(17.34±4.95,22.68±6.14 days). Duration of using antibiotics and hospitalization of A,B group was examined by two independent samples t test, P < 0.05. Single use or combined use of antibiotics in two groups was tested by x2, P < 0.05.Conclusion1 .PCT, Ranson score, CT grading can be used as reference standard to determine the classification of the severity of acute pancreatitis, higher the three values or the grading, more severe the acute pancreatitis; while IL-6, hs-CRP can be used as a reference index for diagnosing mild pancreatitis.2. The diagnostic threshold in moderately severe and severe acute pancreatitis were PCT (0.4825ng/ml), hs-CRP (91.69mg/l), IL-6 (74.25pg/ml), Ranson score (3.5 points); threshold for the severity of acute pancreatitis: PCT combined with Ranson score > Ranson score > PCT > PCT combined with hs-CRP > hs-CRP > IL-6, which showed PCT combined with Ransonscore was the most effective diagnostic index for patients of moderately acute pancreatitis and severe acute pancreatitis and the combination of the two was better than separate diagnosis PCT combined with hs-CRP was better than hs-CRP diagnosis but inferior to PCT diagnosis.3. PCT, hs-CRP, IL-6, Ranson score were positively correlated with the severity of acute pancreatitis and they were also positively correlated with each other after analysis.4. Dynamic monitoring of PCT value can be used as an effective indicator for the treatment of moderately severe acute pancreatitis and severe acute pancreatitis. |
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