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Determinant-Based Classification of Acute Pancreatitis Severity: An International Multidisciplinary Consultation

Dellinger, E. Patchen MD; Forsmark, Christopher E. MD; Layer, Peter MD, PhD§; Lévy, Philippe MD; Maraví-Poma, Enrique MD, PhD; Petrov, Maxim S. MD, MPH, PhD#; Shimosegawa, Tooru MD, PhD**; Siriwardena, Ajith K. MD††; Uomo, Generoso MD‡‡; Whitcomb, David C. MD, PhD§§; Windsor, John A. MBChB, MD, FRACS#

doi: 10.1097/SLA.0b013e318256f778

Objective: To develop a new international classification of acute pancreatitis severity on the basis of a sound conceptual framework, comprehensive review of published evidence, and worldwide consultation.

Background: The Atlanta definitions of acute pancreatitis severity are ingrained in the lexicon of pancreatologists but suboptimal because these definitions are based on empiric description of occurrences that are merely associated with severity.

Methods: A personal invitation to contribute to the development of a new international classification of acute pancreatitis severity was sent to all surgeons, gastroenterologists, internists, intensivists, and radiologists who are currently active in clinical research on acute pancreatitis. The invitation was not limited to members of certain associations or residents of certain countries. A global Web-based survey was conducted and a dedicated international symposium was organized to bring contributors from different disciplines together and discuss the concept and definitions.

Result: The new international classification is based on the actual local and systemic determinants of severity, rather than description of events that are correlated with severity. The local determinant relates to whether there is (peri)pancreatic necrosis or not, and if present, whether it is sterile or infected. The systemic determinant relates to whether there is organ failure or not, and if present, whether it is transient or persistent. The presence of one determinant can modify the effect of another such that the presence of both infected (peri)pancreatic necrosis and persistent organ failure have a greater effect on severity than either determinant alone. The derivation of a classification based on the above principles results in 4 categories of severity—mild, moderate, severe, and critical.

Conclusions: This classification is the result of a consultative process amongst pancreatologists from 49 countries spanning North America, South America, Europe, Asia, Oceania, and Africa. It provides a set of concise up-to-date definitions of all the main entities pertinent to classifying the severity of acute pancreatitis in clinical practice and research. This ensures that the determinant-based classification can be used in a uniform manner throughout the world.

The latest published international classification of acute pancreatitis severity appeared 2 decades ago. There have been several important advances in the field since then. This article draws on the available evidence and international consultation process to provide a clinically meaningful and epidemiologically sound classification of acute pancreatitis severity.

Department of Surgery, University of Washington School of Medicine, Seattle

Division of Gastroenterology, Hepatology, and Nutrition, University of Florida College of Medicine, Gainesville

§Department of Internal Medicine, Israelitic Hospital, Hamburg, Germany

Pôle des Maladies de l'Appareil Digestif, Service de Gastroentérologie-Pancréatologie, Hôpital Beaujon, Clichy, France

Servicio de Medicina Intensiva B, Complejo Hospitalario de Navarra, Pamplona, Spain

#Department of Surgery, The University of Auckland, Auckland, New Zealand

**Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan

††Department of Surgery, Manchester Royal Infirmary, University of Manchester, Manchester, UK

‡‡Department of Internal Medicine, Cardarelli Hospital, Naples, Italy

§§Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Department of Cell Biology and Molecular Physiology, and Department of Human Genetics, University of Pittsburgh, Pittsburgh, PA.

Reprints: Max Petrov, MD, MPH, PhD, Department of Surgery, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand. E-mail:

The authors are listed in alphabetical order.

Disclosure: The authors declare no conflicts of interest.

© 2012 Lippincott Williams & Wilkins, Inc.