[Severe acute pancreatitis: diagnostic approaches and therapeutic implications]

Diagnosis of acute pancreatitis (AP) can be obtained with a high level of accuracy by clinical assessment and determination of common laboratory parameters such as serum amylase and lipase concentrations. However, the key of an optimal management of patients with AP is based on an early discrimination between interstitial oedematous and necrotizing forms. The former resolves spontaneously whereas parenchymal necrosis acting as a focus for bacteria has a very high severity. In this respect, multifactor prognostic scoring systems and new biological assessments like C reactive protein are valuable methods for forecasting the prognosis of AP. However, these indicators of severity require a full 48 hour period of observation. In order to overcome these drawbacks, other prognostic criteria have been explored based mainly, on laboratory data. The most interesting ones are trypsinogen activation peptides and leucocyte elastase. Finally, the more useful tool is computed tomography (CT). Combined with high dose intravenous contrast agent, it allows an early identification of necrosis. Other goals of computed tomography are an accurate diagnosis of infection by guided needle aspirations and a preoperative recognition of devitalized and infected tissues, which require a careful surgical necrosectomy. A prolonged drainage is always recommended but relative merits of a conventional closed drainage and an open one are controversial. Another therapeutic challenge is gallstone associated to severe pancreatitis. An early stone removal is advocated by some authors but others prefer delayed surgery because of high mortality rates in case of emergency surgery. Delayed surgery until biological parameters of pancreatitis are normalized seems preferable. An early endoscopic sphincterotomy in an attractive alternative method.