How to evaluate the severity of acute pancreatitis: back to the past?

Selecting patients with severe acute pancreatitis as early as possible after the onset of symptoms is crucial for appropriate treatment [1]. The guidelines indicate that the assessment of severity should be carried out as soon as possible by a scoring system, such as Acute Physiology and Chronic Health Evaluation (APACHE) II which is a grade A recommendation [2, 3]. The comment added by the authors of the Italian guidelines is that an APACHE II score greater than 8 is important for determining treatment policy and identifying the need for transfer to a referral unit. In addition, the Italian guidelines also suggest that serum C-reactive protein (CRP) values are useful for severity assessment, although they may not reflect severity within the first 48 h after onset; this is also a grade A recommendation [3]. An open question is: " should we use a scoring system or a single marker? ". The question is not semantic but practical because a single marker is easy to use and clearly comparable between the various hospitals whereas scoring systems may be complex and difficult to use in routine clinical practice. Another open question regarding single markers is: " should we continue to use (CRP) or should we use markers, such as interleukin (IL)-6 or IL-8 which are able to predict the severity of acute pancreatitis earlier than CRP? " [4]. In 2009, Aoun et al. [5] carried out a meta-analysis to assess the accuracy of IL-6 and IL-8 in predicting severe acute pancreatitis. They identified relevant published articles and calculated pooled sensitivities, specificities and likelihood ratios using the random-effect model. The authors included eight reports for IL-6 and analyzed five studies for IL-8. The pooled IL-6 sensitivities ranged from 81.0 to 83.6% and specificities from 75.6 to 85.3% with positive likelihood ratios of 3.43, 4.90 and 4.40 for days 1, 2 and 3, respectively. The IL-8 pooled sensitivities ranged from 65.8 to 70.9% with specificities of 66.5 and 91.3% for days 1 and 2 with positive likelihood ratios of 1.96 and 8.15, respectively. The diagnostic odds ratio for IL-6 was higher than that of IL-8 on the first day of illness. Thus, the authors concluded that IL-6 and IL-8 seem to perform at an acceptable level in predicting severe acute pancreatitis, and we believe that these two markers, or at least IL-6, should be used in the clinical setting in place of CRP. Subsequently, a …