Organ Failure due to Systemic Injury in Acute Pancreatitis

Clinical correlates of OF: Can we predict Organ Failure?
By definition, persistent OF should last >48 hours. Therefore, it will take at least 3 days to 
document persistent OF even if a patient develops OF within a day of onset of pain. From 
triage and prognostic points of view, it is important to predict development of persistent OF 
in patients who present early to the hospital. Prediction of severe AP is largely based on 
several clinical scores, such as APACHE II, which are multifactorial and somewhat tedious 
to use. BISAP score has been developed and validated to predict development of severe AP 
and outcome.
34, 35
Single prognostic markers are also used; CRP and IL-6 being sensitive 
markers.
36, 37
Persistent SIRS is a reliable clinical marker to predict development of OF. 
However, despite a reasonably good sensitivity of 50-95%, SIRS has a lower specificity of 
75% and suboptimal positive predictive value (PPV) of 16%-56%.
38, 39
Although almost all 
patients with persistent OF have persistent SIRS, a significant proportion of patients with 
non-severe AP may also have persistent SIRS. PPV is an important attribute for a test 
variable as a low PPV may lead to unnecessary and avoidable referrals from primary/
secondary care centers, increase monitoring and the overall cost of hospitalization. Recently, 
a study has shown that a combination of serum IL6 >160 pg/ml and SIRS at admission had a 
much higher PPV of 85% and a higher specificity of 95% for the development of severe AP.
40
Clinical trajectory of Organ Failure - Impact on outcome:
OF accounts for almost all the mortality in patients with AP. Patients who develop OF early 
on are at risk of having a severe course of the disease. In a population based study of 1024 
deaths due to AP, the median interval between the onset of AP and death was 6 days and 
from the onset of OF to death was 3 days.
33
The concept of transient and persistent OF was 
introduced in 2004.
4
Transient OF lasting <48 hours also has a negative impact on outcome.
4
The mortality in patients with transient OF was 1.4% to 10% although the mortality was 
Garg and Singh
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Gastroenterology. Author manuscript; available in PMC 2020 May 01.
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most likely due to other contributing factors such as IPN.
4, 10, 13
The overall mortality in 
patients with persistent OF is >40% (Table 2). Patients with persistent OF have a high risk of 
early mortality within the first 2 weeks.
9, 10, 33