The revised Atlanta criteria more accurately reflect severity of post‐ERCP pancreatitis compared to the consensus criteria

Abstract

Background and objective: Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is the most prevalent complication after ERCP with an incidence of 3.5%. PEP severity is classified according to either the consensus criteria or the revised Atlanta criteria. In this international cohort study we investigated which classification is the strongest predictor of PEP-related mortality. Methods: We reviewed 13,384 consecutive ERCPs performed between 2012 and 2017 in eight hospitals. We gathered data on all pancreatitis-related adverse events and compared the predictive capabilities of both classifications. Furthermore, we investigated the correlation between the two classifications and identified reasons underlying length of stay. Results: The total sample consisted of 387 patients. The revised Atlanta criteria have a higher sensitivity (100 vs. 55%), specificity (98 vs. 72%) and positive predictive value (58 vs. 5%). There is a significant difference (p < 0.001) between the two classifications. In 124 patients (32%), the length of stay was influenced by concomitant diseases. Conclusion: The revised Atlanta classification is superior in predicting mortality and better reflects PEP severity. This has important implications for researchers, clinicians and patients. For the diagnosis of PEP pancreatitis, the consensus criteria remain the golden standard. However, the revised Atlanta criteria are preferable for defining PEP severity. Key summary Established knowledge. Post-ERCP pancreatitis (PEP) is the most prevalent complication of ERCP, with an incidence rate of 3.5%. /home/ueg . Adequate assessment of PEP severity is necessary for researchers and clinicians to predict prognosis and compare efficacy of prophylactic measures for PEP. . Two classification systems for PEP severity exist: the consensus criteria and the revised Atlanta criteria. New findings. Our study shows that the diagnostic performance of the revised Atlanta criteria for PEP-related mortality is better than the consensus criteria, because of its focus on necrosis and organ failure. . In that way, use of the revised Atlanta criteria allows for a better and more objective evaluation of PEP prophylaxis efficacy. . However, the consensus criteria, with its focus on length of hospital stay, could still be useful in light of patient-reported outcome measures and patient-centered care.

ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

“…At the core of this system was the consequence of AEs in terms of admission to hospital and/or intensive care unit, the type of treatment applied, and death or permanent disability outcomes. This system is useful for research and comparison purposes but for some AEs, more specific classification systems are available: ▪ Pancreatitis: the revised Atlanta classification of severity [10] is a better predictor for PEP-related mortality than a system based on hospital duration as shown in a multicenter comparison with the 1991 consensus criteria (retrospective study of 387 patients with PEP) [22]. The determinant-based classification is accurate but has not been compared with alternatives in the setting of PEP [23,24] ▪ Cholangitis and cholecystitis: the revised Tokyo severity grading systems may offer more accurate predictive power than the generic alternatives; they are presented in a ▶ Table 1 Incidence, mortality and severity grading of the most common ERCP-related adverse events.…”

Usefulness of serum lipase for early diagnosis of post-endoscopic retrograde cholangiopancreatography pancreatitis

“…The limitation is the fact that it is not primarily developed to define PEP. For an assessment of the severity of PEP, it has been reported that the revised Atlanta classification is superior for predicting PEP mortality[6]. The frequency of PEP is reported to be 3% to 15%[7,8,9].…”

Rectal indometacin dose escalation for prevention of pancreatitis after endoscopic retrograde cholangiopancreatography in high-risk patients: a double-blind, randomised controlled trial

“…These consensus criteria have been most commonly used in landmark trials on post-ERCP prevention, epidemiological studies and in ERCP guidelines. 35 However, duration of hospitalization is a key component of these criteria, which may be confounded by patient pain tolerance and physician practice, among other factors. The revised Atlanta classification of acute pancreatitis consensus definitions stratify pancreatitis severity based on the presence of local and systemic adverse events, including duration of organ failure, rather than duration of hospitalization.…”