Prognostic factors of hemorragic complications in patients with a severe course of acute pancreatitis

Abstract

A feature of the severe condition of acute pancreatitis is the high risk of complications occurring in 50% of patients [1]. The most dangerous are thrombohemorrhagic complications and arrosive bleeding, with late diagnosis of which mortality can reach more than 85% [2]. The causes of erosive bleeding may be the result of ruptures of the mucous membrane in the cardioesophageal junction (MalloryWeiss syndrome), acute erosions and ulcers of the digestive tract, as well as arising from vessels feeding the pancreas, usually in the purulent phase, sequestration and melting of necrotized parenchyma of the organ and parapancreatic tissue [3]. Sources of arrosive bleeding are usually large arteries and venous trunks. Also, there is the development of arrosive bleeding in the postoperative period in 3.5-8.5% of patients with acute pancreatitis [4] The aim of the study was to determine early diagnostic criteria for the onset and development of bleeding in acute pancreatitis. Materials and methods. The results of treatment of 82 patients with severe acute pancreatitis were analyzed. The patients were divided into the main group (with bleeding) (30 people) and the comparison group (without bleeding) (52 people). All patients were determined the following parameters of the coagulation system: fibrinogen content in plasma, international normalized ratio, prothrombin time and activated partial thromboplastin time, activity of tissue plasminogen activator (PLAT), activator inhibitor type-1 and the level of excessive thrombin-antithrombin III complex (TAT). Patients were also tested for intra-abdominal pressure (IAP) and the activity of pancreatic enzymes (α-amylase) in the contents of the abdominal cavity in the case of surgery. The evaluation of the results was performed on the day of bleeding in patients of the main group, and on the 14th day after the disease in patients of the comparison group (corresponding to the average day of bleeding in the main group). MEDICINE INNOVATIVE WAYS OF LEARNING DEVELOPMENT 105 Results of the research. The PLAT аctivity and the level of TAT in the main group is of normative value and it is vital for the group of individuals who are in the range of norms, as well as candidates for early markers for the diagnosis of bleeding. From the ROC analysis, the analysis determined the informativeness of the proponated indicators in the predicted bleeding. For PLAT аctivity the area under the ROC-curve (AUROC) become 0.942 (95% CI 0.889-0.995; p = 0.001), the point of change is 4.5 IU/ml, for the TAT area under the ROC-curve (AUROC) it becomes 0.945 (95% DI 0.871-0.998; p = 0.001), the change point is 11.5 ng/ml. There was no statistically significant significant difference between the values of IAP and the level of α-amylase activity in the contents of the abdominal cavity, and IAP was increased in both groups, but in patients of the main group this indicator was higher (16.5 ± 3.6 mm Hg against 12.1 ± 1.9 mm Hg) (p>0.05). The level of α-amylase activity in the contents of the abdominal cavity was also increased in both groups and was in patients of the main group 771.7 ± 188.7 U/L and the comparison group - 311.2 ± 288.4 U/L (p>0.05). Conclusions. Severe acute pancreatitis is characterized by hemocoagulation disorders and can be complicated by the development of bleeding in 36.6% of cases. The main source of bleeding in severe acute pancreatitis are erosive-ulcerative lesions of the gastrointestinal tract (19.5% of patients), the development of which can be explained by the stress of the destructive process in the pancreas and concomitant severe endogenous intoxication. In patients with severe acute pancreatitis, the level of PLAT activity ≥ 4.5 IU/ml (sensitivity 90.2%, specificity 83.3%) and / or the level of TAT ≥ 11.5 ng/ml (sensitivity 92.2%, specificity 83.3%) can be considered as a probable predictor of bleeding. References: 1. Roberto Rasslan, Fernando da Costa Ferreira Novo, Alberto Bitran, Edivaldo Massazo Utiyama, Samir Rasslan. Management of infected pancreatic necrosis: state of the art. Rev Col Bras Cir. 2017 Oct; 44(5): 521-9 doi: 10.1590/0100- 69912017005015 2. Mamoon Ur Rashid, Saeed Ali, Akriti Gupta Jain, Neelam Khetpal, Ishtiaq Hussain, Sundas Jehanzeb, Waqas Ullah, Sarfraz Ahmad. Pancreatic necrosis: Complications and changing trend of treatment. World J Gastrointest Surg. 2019 Apr 27; 11(4):198-217. doi: 10.4240/wjgs.v11.i4.198 3. Kolosovych IV, Hanol IV. Hemocoagulation factors of hemorrhagic complications in acute pancreatitis. Fiziol. Zh. 2022; 68(1): 56-61. https://doi.org/10.15407/fz68.01.056 4. Vikas Gupta, Pradeep Krishna, Rakesh Kochhar, Thakur Deen Yadav, Venu Bargav, Asheesh Bhalla, Naveen Kalra, Jai Dev Wig. Hemorrhage complicating the course of severe acute pancreatitis. Ann Hepatobiliary Pancreat Surg. 2020 Aug 31; 24(3): 292-300. doi: 10.14701/ahbps.2020.24.3.292.