Organ Failure due to Systemic Injury in Acute Pancreatitis

Clinical determinants/Characteristics of Organ Failure:
There are various characteristics of OF that affect the clinical course and outcome. The 
important determinants are – (i) grade of OF as per the Modified Marshall score, (ii) specific 
type of OF e.g. respiratory/renal, (iii) number of organs affected i.e. single or multi-organ 
failure, and (iv) the timing of OF from the onset of AP. A higher grade of OF naturally has a 
greater impact on outcome. Patients with grade 3 or 4 OF requiring organ assistance such as 
mechanical ventilation have a worse outcome.
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Respiratory failure is the commonest OF.
10, 32, 33
Respiratory and renal failures are quite similar in their impact on the outcome but 
cardiovascular failure leads to the worst outcome.
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Multi-organ failure has a worse 
prognosis than single OF.
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The timing of onset of OF has important connotation regarding 
the likely cause of OF and possibly its impact on survival. Inflammation is the key 
pathological response both at the local and systemic levels in AP. Organ failure may develop 
early within a few days of onset of AP, which is termed as early severe acute pancreatitis and 
carries a high mortality.
19, 31
This is primarily due to a sterile inflammatory response. Organ 
failure may also develop late during the course of AP due to sepsis as we discuss next.
Garg and Singh
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Gastroenterology. Author manuscript; available in PMC 2020 May 01.
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Primary (Early) Sterile and Secondary (Late) Septic Organ Failure in Acute 
Pancreatitis:
Although organ failure and its consequences are well recognized in AP, there is limited 
understanding about primary OF that develops early due to pancreatitis per se (sterile 
inflammation) and may precede necrosis, and late secondary OF due to infected pancreatic 
necrosis (IPN) induced sepsis (Figure 1). Infection of the necrotic pancreatic tissue is an 
ominous development during the course of AP. IPN is the cause of most of the late mortality 
during the course of AP. Although many studies have shown development of early and late 
OF in patients with AP, the relative contributions of primary OF and secondary OF to 
mortality have not been well studied. One recent study of 805 patients with AP has provided 
the concept of primary and secondary OF and shown several differences between the two 
(Table 1).
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The window of opportunity is small in case of primary OF because it leads to 
early mortality while temporally there is a larger window of opportunity to intervene in 
those with sepsis and secondary OF. The treatment is largely supportive for primary OF 
while control of sepsis is the goal in secondary OF. Prognosis is poorer in primary OF and 
somewhat better in secondary OF.