Journal of Gastrointestinal Surgery

, Volume 11, Issue 6, pp 733–742

Co-morbidity is a Strong Predictor of Early Death and Multi-organ System Failure among Patients with Acute Pancreatitis

  • Charles Frey
  • Hong Zhou
  • Danielle Harvey
  • Richard H. White
Article

Abstract

A small but significant percentage of patients with acute pancreatitis die within 2 weeks of hospitalization, usually with multiorgan system failure. To determine the effect of chronic medical comorbidities on early death, we conducted a retrospective analysis of all patients who were hospitalized in California with first-time pancreatitis between 1992 and 2002. Among 84,713 patients, 1514 (1.8%) died within 2 weeks. In a risk-adjusted multivariate model, the strongest predictors of early death were age 65 to 75 years (OR = 2.6, 95% CI: 2.2–3.1 versus <55 years), age over 75 years (OR = 5.2, 95% CI: 4.4–6.1), and the presence of either two chronic comorbid conditions (OR = 3.5, CI: 2.7–4.6) or three or more comorbidities (OR = 7.4, 95% CI: 5.7–9.5). Among the 14,280 patients younger than 55 years who had no chronic comorbid conditions, only 14 (0.1%) died in the first 14 days compared to 701 (5.9%) of 24,852 patients 64 years or older who had three or more comorbidities (RR = 29, 95% CI: 17–50). Comorbid conditions associated with early death included recent cancer, heart failure, renal disease, and liver disease. We conclude that advancing age and the number of chronic comorbid conditions are very strong predictors of early death among patients with acute pancreatitis.

Keywords

Pancreatitis Mortality Epidemiology Multiple-organ failure 

References

  1. 1.
    Uhl W, Warshaw A, Imrie C, et al. IAP Guidelines for the surgical management of acute pancreatitis. Pancreatology 2002;2:565–573.PubMedCrossRefGoogle Scholar
  2. 2.
    Eland IA, Sturkenboom MC, van der Lei J, Wilson JH, Stricker BH. Incidence of acute pancreatitis. Scand J Gastroenterol 2002;37:124.PubMedCrossRefGoogle Scholar
  3. 3.
    Floyd A, Pedersen L, Nielsen GL, Thorladcius-Ussing O, Sorensen HT. Secular trends in incidence and 30-day case fatality of acute pancreatitis in North Jutland County, Denmark: a register-based study from 1981 to 2000. Scand J Gastroenterol 2002;37:1461–1465.PubMedCrossRefGoogle Scholar
  4. 4.
    Gullo L, Migliori M, Olah A, et al. Acute pancreatitis in five European countries: etiology and mortality. Pancreas 2002;24:223–227.PubMedCrossRefGoogle Scholar
  5. 5.
    Gislason H, Horn A, Hoem D, et al. Acute pancreatitis in Bergen, Norway. A study on incidence, etiology and severity. Scand J Surg 2004;93:29–33.PubMedGoogle Scholar
  6. 6.
    Goldacre MJ, Roberts SE. Hospital admission for acute pancreatitis in an English population, 1963–98: database study of incidence and mortality. BMJ 2004;328:1466–1469.PubMedCrossRefGoogle Scholar
  7. 7.
    Andersson R, Andren-Sandberg A. Fatal acute pancreatitis. Characteristics of patients never reaching hospital. Pancreatology 2003;3:64–66.PubMedCrossRefGoogle Scholar
  8. 8.
    Mutinga M, Rosenbluth A, Tenner SM, Odze RR, Sica GT, Banks PA. Does mortality occur early or late in acute pancreatitis? Int J Pancreatol 2000;28:91–95.PubMedGoogle Scholar
  9. 9.
    Johnson CD, Abu-Hilal M. Persistent organ failure during the first week as a marker of fatal outcome in acute pancreatitis. Gut 2004;53:1340–1344.PubMedCrossRefGoogle Scholar
  10. 10.
    McKay CJ, Evans S, Sinclair M, Carter CR, Imrie CW. High early mortality rate from acute pancreatitis in Scotland, 1984–1995. Br J Surg 1999;86:1302–1305.PubMedCrossRefGoogle Scholar
  11. 11.
    Lowham A, Lavelle J, Leese T. Mortality from acute pancreatitis. Late septic deaths can be avoided but some early deaths still occur. Int J Pancreatol 1999;25:103–106.PubMedGoogle Scholar
  12. 12.
    Blum T, Maisonneuve P, Lowenfels AB, Lankisch PG. Fatal outcome in acute pancreatitis: its occurrence and early prediction. Pancreatology 2001;1:237–241.PubMedCrossRefGoogle Scholar
  13. 13.
    Gloor B, Muller CA, Worni M, Martignoni ME, Uhl W, Buchler MW. Late mortality in patients with severe acute pancreatitis. Br J Surg 2001;88:975–979.PubMedCrossRefGoogle Scholar
  14. 14.
    Halonen KI, Leppaniemi AK, Lundin JE, Puolakkainen PA, Kemppainen EA, Haapiainen RK. Predicting fatal outcome in the early phase of severe acute pancreatitis by using novel prognostic models. Pancreatology 2003;3:309–315.PubMedCrossRefGoogle Scholar
  15. 15.
    Poves Prim I, Fabregat Pous J, Garcia Borobia FJ, Jorba Marti R, Figueras Felip J, Jaurrieta Mas E. Early onset of organ failure is the best predictor of mortality in acute pancreatitis. Rev Esp Enferm Dig 2004;96:705–709;709–713.PubMedCrossRefGoogle Scholar
  16. 16.
    Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med 1985;13:818–829.PubMedCrossRefGoogle Scholar
  17. 17.
    Ranson JH, Rifkind KM, Roses DF, Fink SD, Eng K, Spencer FC. Prognostic signs and the role of operative management in acute pancreatitis. Surg Gynecol Obstet 1974;139:69–81.PubMedGoogle Scholar
  18. 18.
    Imrie CW, Ferguson JC, Murphy D, Blumgart LH. Arterial hypoxia in acute pancreatitis. Br J Surg 1977;64:185–188.PubMedCrossRefGoogle Scholar
  19. 19.
    Triester SL, Kowdley KV. Prognostic factors in acute pancreatitis. J Clin Gastroenterol 2002;34:167–176.PubMedCrossRefGoogle Scholar
  20. 20.
    Sandberg AA, Borgstrom A. Early prediction of severity in acute pancreatitis. Is this possible? Jop 2002;3:116–125.PubMedGoogle Scholar
  21. 21.
    Rettally CA, Skarda S, Garza MA, Schenker S. The usefulness of laboratory tests in the early assessment of severity of acute pancreatitis. Crit Rev Clin Lab Sci 2003;40:117–149.PubMedGoogle Scholar
  22. 22.
    Dervenis C, Johnson CD, Bassi C, et al. Diagnosis, objective assessment of severity, and management of acute pancreatitis. Santorini consensus conference. Int J Pancreatol 1999;25:195–210.PubMedGoogle Scholar
  23. 23.
    Lankisch PG, Burchard-Reckert S, Petersen M, et al. Etiology and age have only a limited influence on the course of acute pancreatitis. Pancreas 1996;13:344–349.PubMedCrossRefGoogle Scholar
  24. 24.
    Paajanen H, Jaakkola M, Oksanen H, Nordback I. Acute pancreatitis in patients over 80 years. Eur J Surg 1996;162:471–475.PubMedGoogle Scholar
  25. 25.
    Lankisch PG, Blum T, Maisonneuve P, Lowenfels AB. Severe acute pancreatitis: when to be concerned? Pancreatology 2003;3:102–110.PubMedCrossRefGoogle Scholar
  26. 26.
    Piccirillo JF, Tierney RM, Costas I, Grove L, Spitznagel EL Jr. Prognostic importance of comorbidity in a hospital-based cancer registry. JAMA 2004;291:2441–2447.PubMedCrossRefGoogle Scholar
  27. 27.
    Yancik R, Wesley MN, Ries LA, Havlik RJ, Edwards BK, Yates JW. Effect of age and comorbidity in postmenopausal breast cancer patients aged 55 years and older. JAMA 2001;285:885–892.PubMedCrossRefGoogle Scholar
  28. 28.
    Yancik R, Wesley MN, Ries LA, et al. Comorbidity and age as predictors of risk for early mortality of male and female colon carcinoma patients: a population-based study. Cancer 1998;82:2123–2134.PubMedCrossRefGoogle Scholar
  29. 29.
    Ouellette JR, Small DG, Termuhlen PM. Evaluation of Charlson-age comorbidity index as predictor of morbidity and mortality in patients with colorectal carcinoma. J Gastrointest Surg 2004;8:1061–1067.PubMedCrossRefGoogle Scholar
  30. 30.
    Ogle KS, Swanson GM, Woods N, Azzouz F. Cancer and comorbidity: redefining chronic diseases. Cancer 2000;88:653–663.PubMedCrossRefGoogle Scholar
  31. 31.
    Romano PS, Chan BK. Risk-adjusting acute myocardial infarction mortality: are APR-DRGs the right tool? Health Serv Res 2000;34:1469–1489.PubMedGoogle Scholar
  32. 32.
    Marcin JP, Romano PS. Impact of between-hospital volume and within-hospital volume on mortality and readmission rates for trauma patients in California. Crit Care Med 2004;32:1477–1483.PubMedCrossRefGoogle Scholar
  33. 33.
    Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care 1998;36:8–27.PubMedCrossRefGoogle Scholar
  34. 34.
    Healthcare Cost and Utilization Project (HCUP). Comorbidity software, version 3.1. 2005. Available at: http://www.hcup-us.ahrq.gov/toolssoftware/comorbidity/comorbidity.jsp; Accessed July 19, 2006.
  35. 35.
    Glance LG, Dick AW, Osler TM, Mukamel DB. Does date stamping ICD-9-CM codes increase the value of clinical information in administrative data? Health Serv Res 2006;41:231–251.PubMedCrossRefGoogle Scholar
  36. 36.
    Stukenborg GJ, Wagner DP, Connors AF Jr. Comparison of the performance of two comorbidity measures, with and without information from prior hospitalizations. Med Care 2001;39:727–739.PubMedCrossRefGoogle Scholar
  37. 37.
    Humphries KH, Rankin JM, Carere RG, Buller CE, Kiely FM, Spinelli JJ. Co-morbidity data in outcomes research: are clinical data derived from administrative databases a reliable alternative to chart review? J Clin Epidemiol 2000;53:343–349.PubMedCrossRefGoogle Scholar
  38. 38.
    Quan H, Parsons GA, Ghali WA. Validity of information on comorbidity derived rom ICD-9-CCM administrative data. Med Care 2002;40:675–685.PubMedCrossRefGoogle Scholar
  39. 39.
    Sands KE, Bates DW, Lanken PN, et al. Epidemiology of sepsis syndrome in 8 academic medical centers. Academic Medical Center Consortium Sepsis Project Working Group. JAMA 1997;278:234–240.PubMedCrossRefGoogle Scholar
  40. 40.
    Gollin G, Zieg PM, Cohn SM, Lieberman JM, Marks WH. Intestinal mucosal injury in critically ill surgical patients: preliminary observations. Am Surg 1999;65:19–21.PubMedGoogle Scholar
  41. 41.
    Rahman SH, Ammori BJ, Holmfield J, Larvin M, McMahon MJ. Intestinal hypoperfusion contributes to gut barrier failure in severe acute pancreatitis. J Gastrointest Surg 2003;7:26–35; discussion 35–26.PubMedCrossRefGoogle Scholar
  42. 42.
    Hirota M, Inoue K, Kimura Y, et al. Non-occlusive mesenteric ischemia and its associated intestinal gangrene in acute pancreatitis. Pancreatology 2003;3:316–322.PubMedCrossRefGoogle Scholar
  43. 43.
    Pates RD, Scully KW, Einbinder JS, et al. Adding value to clinical data by linkage to a public death registry. Medinfo 2001;10:1384–1388.PubMedGoogle Scholar
  44. 44.
    Frey CF, Zhou H, Harvey D, White RH. The incidence and case-fatality rate of acute biliary, alcoholic and idiopathic pancreatitis in California, 1994–2001. Pancreas 2006;33:336–344.PubMedCrossRefGoogle Scholar
  45. 45.
    Parker JP, Li Z, Damberg CL, Danielsen B, Carlisle DM. Administrative versus clinical data for coronary artery bypass graft surgery report cards: the view from California. Med Care 2006;44:687–695.PubMedCrossRefGoogle Scholar
  46. 46.
    Eland IA, Sturkenboom MJ, Wilson JH, Stricker BH. Incidence and mortality of acute pancreatitis between 1985 and 1995. Scand J Gastroenterol 2000;35:1110–1116.PubMedCrossRefGoogle Scholar
  47. 47.
    Company L, Saez J, Martinez J, et al. Factors predicting mortality in severe acute pancreatitis. Pancreatology 2003;3:144–148.PubMedCrossRefGoogle Scholar
  48. 48.
    Melfi C, Holleman E, Arthur D, Katz B. Selecting a patient characteristics index for the prediction of medical outcomes using administrative claims data. J Clin Epidemiol 1995;48:917–926.PubMedCrossRefGoogle Scholar
  49. 49.
    Wang PS, Walker A, Tsuang M, Orav EJ, Levin R, Avorn J. Strategies for improving comorbidity measures based on Medicare and Medicaid claims data. J Clin Epidemiol 2000;53:571–578.PubMedCrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2007

Authors and Affiliations

  • Charles Frey
    • 1
  • Hong Zhou
    • 2
  • Danielle Harvey
    • 3
  • Richard H. White
    • 2
    • 4
  1. 1.Department of SurgeryUC DavisDavisUSA
  2. 2.Department of MedicineUC DavisDavisUSA
  3. 3.Department of Public Health SciencesUC DavisDavisUSA
  4. 4.Division of General MedicineSacramentoUSA

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