Acute Pancreatitis in Elderly Patients
2021; Elsevier BV; Volume: 161; Issue: 6 Linguagem: Inglês
10.1053/j.gastro.2021.06.081
ISSN1528-0012
AutoresArmando A. Baeza-Zapata, Diego García‐Compeán, Joel Omar Jáquez-Quintana, Susanna I. Scharrer-Cabello, Ángel Noé del Cueto-Aguilera, Héctor Jesus Maldonado‐Garza,
Tópico(s)Appendicitis Diagnosis and Management
ResumoAcute pancreatitis (AP) is 1 of the most common gastrointestinal causes of hospital admissions worldwide and represents more than 275,000 cases per year. It is an inflammatory disease with an unpredictable clinical outcome. Because the incidence of AP has been increasing globally, it has been seen more frequently in elderly individuals because of an aging population. Some reports indicate that AP in these individuals is clinically more severe and systemic complications more frequent, leading to higher mortality compared with younger individuals. Because AP in the elderly has some particular clinical features that cause worse outcomes, today physicians are urged to understand the clinical behavior of this disease in this selected population. This commentary describes the clinical, epidemiologic, and outcome characteristics of AP in elderly patients for optimization of the diagnostic and therapeutic approach to reduce morbidity and mortality. In addition, some information gaps in this field are highlighted to propose them for future research. The global incidence rate of AP is increasing.1Yu B. Li N. Li J. et al.The clinical characteristics of acute pancreatitis in gerontal patients: a retrospective study.Clin Interv Aging. 2020; 15: 1541-1553Crossref PubMed Scopus (2) Google Scholar It is reported in 34 per 100,000 inhabitants. Elderly populations have also seen an increase in AP. Although the World Health Organization has defined "elderly" individuals as those over age 65 years, in published AP prevalence studies the age cut-off used for defining "elderly" has been very diverse. AP has been found in 52% of individuals aged >55 years, in 55.6% of those aged > 60 years, from 20.3% to 47.8% of those aged > 65 years, from 35.8% to 50% of those aged > 70 years, and from 12% to 18% in individuals over age 80 years.2Xin M.J. Chen H. Luo B. et al.Severe acute pancreatitis in the elderly: etiology and clinical characteristics.World J Gastroenterol. 2008; 14: 2517-2521Crossref PubMed Scopus (41) Google Scholar, 3Gardner T.B. Vege S.S. Chari S.T. et al.The effect of age on hospital outcomes in severe acute pancreatitis.Pancreatology. 2008; 8: 265-270Crossref PubMed Scopus (55) Google Scholar, 4Somasekar K. Foulkes R. Morris-Stiff G. et al.Acute pancreatitis in the elderly—can we perform better?.Surgeon. 2011; 9: 305-308Crossref PubMed Scopus (18) Google Scholar, 5Kim J.E. Hwang J.H. Lee S.H. et al.The clinical outcome of elderly patients with acute pancreatitis is not different in spite of the different etiologies and severity.Arch Gerontol Geriatr. 2012; 54: 256-260Crossref PubMed Scopus (22) Google Scholar, 6Malik A.M. Biliary pancreatitis. Deadly threat to the elderly. Is it a real threat?.Int J Health Sci (Qassim). 2015; 9: 35-39PubMed Google Scholar, 7Carvalho J.R. Fernandes S.R. Santos P. et al.Acute pancreatitis in the elderly: a cause for increased concern?.Eur J Gastroenterol Hepatol. 2018; 30: 337-341Crossref PubMed Scopus (20) Google Scholar, 8Roulin D. Girardet R. Duran R. et al.Outcome of elderly patients after acute biliary pancreatitis.Biosci Trends. 2018; 12: 54-59Crossref PubMed Scopus (5) Google Scholar, 9Patel K. Li F. Luthra A. et al.Acute biliary pancreatitis is associated with adverse outcomes in the elderly: a propensity score-matched analysis.J Clin Gastroenterol. 2019; 53: 291-297Crossref Scopus (8) Google Scholar, 10Kara B. Olmez S. Yalcın M.S. et al.Update on the effect of age on acute pancreatitis morbidity: a retrospective, single-center study.Prz Gastroenterol. 2018; 13: 223-227PubMed Google Scholar, 11Quero G. Covino M. Fiorillo C. et al.Acute pancreatitis in elderly patients: a single-center retrospective evaluation of clinical outcomes.Scand J Gastroenterol. 2019; 54: 492-498Crossref PubMed Scopus (13) Google Scholar, 12Koziel D. Gluszek-Osuch M. Suliga E. et al.Elderly persons with acute pancreatitis—specifics of the clinical course of the disease.Clin Interv Aging. 2019; 14: 33-41Crossref PubMed Scopus (13) Google Scholar, 13Kayar Y. Dertli R. Konur S. Clinical outcomes of acute pancreatitis in elderly patients: an experience of single tertiary center.Pancreatology. 2020; 20: 1296-1301Crossref PubMed Scopus (5) Google Scholar Biliary lithiasis is the most frequent cause in these population (39.3%–70%).2Xin M.J. Chen H. Luo B. et al.Severe acute pancreatitis in the elderly: etiology and clinical characteristics.World J Gastroenterol. 2008; 14: 2517-2521Crossref PubMed Scopus (41) Google Scholar,4Somasekar K. Foulkes R. Morris-Stiff G. et al.Acute pancreatitis in the elderly—can we perform better?.Surgeon. 2011; 9: 305-308Crossref PubMed Scopus (18) Google Scholar,5Kim J.E. Hwang J.H. Lee S.H. et al.The clinical outcome of elderly patients with acute pancreatitis is not different in spite of the different etiologies and severity.Arch Gerontol Geriatr. 2012; 54: 256-260Crossref PubMed Scopus (22) Google Scholar,7Carvalho J.R. Fernandes S.R. Santos P. et al.Acute pancreatitis in the elderly: a cause for increased concern?.Eur J Gastroenterol Hepatol. 2018; 30: 337-341Crossref PubMed Scopus (20) Google Scholar,10Kara B. Olmez S. Yalcın M.S. et al.Update on the effect of age on acute pancreatitis morbidity: a retrospective, single-center study.Prz Gastroenterol. 2018; 13: 223-227PubMed Google Scholar,12Koziel D. Gluszek-Osuch M. Suliga E. et al.Elderly persons with acute pancreatitis—specifics of the clinical course of the disease.Clin Interv Aging. 2019; 14: 33-41Crossref PubMed Scopus (13) Google Scholar Lithogenic bile, delayed gallbladder emptying, and dilation of the bile duct may favor the development of AP in older people.12Koziel D. Gluszek-Osuch M. Suliga E. et al.Elderly persons with acute pancreatitis—specifics of the clinical course of the disease.Clin Interv Aging. 2019; 14: 33-41Crossref PubMed Scopus (13) Google Scholar Biliary AP is significantly more frequent in the elderly compared with younger patients (56.4%–64.9% vs 20.2%–37.3%).2Xin M.J. Chen H. Luo B. et al.Severe acute pancreatitis in the elderly: etiology and clinical characteristics.World J Gastroenterol. 2008; 14: 2517-2521Crossref PubMed Scopus (41) Google Scholar,5Kim J.E. Hwang J.H. Lee S.H. et al.The clinical outcome of elderly patients with acute pancreatitis is not different in spite of the different etiologies and severity.Arch Gerontol Geriatr. 2012; 54: 256-260Crossref PubMed Scopus (22) Google Scholar,7Carvalho J.R. Fernandes S.R. Santos P. et al.Acute pancreatitis in the elderly: a cause for increased concern?.Eur J Gastroenterol Hepatol. 2018; 30: 337-341Crossref PubMed Scopus (20) Google Scholar Alcohol toxicity is the second most common cause followed by the idiopathic pancreatitis (14.3%–31% of cases).2Xin M.J. Chen H. Luo B. et al.Severe acute pancreatitis in the elderly: etiology and clinical characteristics.World J Gastroenterol. 2008; 14: 2517-2521Crossref PubMed Scopus (41) Google Scholar,3Gardner T.B. Vege S.S. Chari S.T. et al.The effect of age on hospital outcomes in severe acute pancreatitis.Pancreatology. 2008; 8: 265-270Crossref PubMed Scopus (55) Google Scholar,5Kim J.E. Hwang J.H. Lee S.H. et al.The clinical outcome of elderly patients with acute pancreatitis is not different in spite of the different etiologies and severity.Arch Gerontol Geriatr. 2012; 54: 256-260Crossref PubMed Scopus (22) Google Scholar,10Kara B. Olmez S. Yalcın M.S. et al.Update on the effect of age on acute pancreatitis morbidity: a retrospective, single-center study.Prz Gastroenterol. 2018; 13: 223-227PubMed Google Scholar, 11Quero G. Covino M. Fiorillo C. et al.Acute pancreatitis in elderly patients: a single-center retrospective evaluation of clinical outcomes.Scand J Gastroenterol. 2019; 54: 492-498Crossref PubMed Scopus (13) Google Scholar, 12Koziel D. Gluszek-Osuch M. Suliga E. et al.Elderly persons with acute pancreatitis—specifics of the clinical course of the disease.Clin Interv Aging. 2019; 14: 33-41Crossref PubMed Scopus (13) Google Scholar Idiopathic AP may include diverse causes such as genetic polymorphisms, smoking, environmental toxins, and other comorbidities typically observed in aging.4Somasekar K. Foulkes R. Morris-Stiff G. et al.Acute pancreatitis in the elderly—can we perform better?.Surgeon. 2011; 9: 305-308Crossref PubMed Scopus (18) Google Scholar Drug intake appeared to be the cause of AP in around 10% because of polypharmacy. Angiotensin-converting enzyme inhibitors, azathioprine, 6-mercaptopurine, didanosine, valproic acid, and mesalamine have been indicated.14Cheng R.M. Mamdani M. Jackevicius C.A. et al.Association between ACE inhibitors and acute pancreatitis in the elderly.Ann Pharmacother. 2003; 37: 994-998Crossref PubMed Scopus (16) Google Scholar In women aged > 65 years, body mass index >30 kg/m2, cardiovascular disease, high blood pressure, and hormone replacement therapy have been found as risk factors.15Prizment A.E. Jensen E.H. Hopper A.M. et al.Risk factors for pancreatitis in older women: the Iowa Women's Health Study.Ann Epidemiol. 2015; 25: 544-548Crossref PubMed Scopus (20) Google Scholar In a Chinese study, level of education, smoking, and history of gallstones were independent risk factors for AP in individuals over age 55 years.16Chen H.J. Wang J.J. Tsay W.I. et al.Epidemiology and outcome of acute pancreatitis in end-stage renal disease dialysis patients: a 10-year national cohort study.Nephrol Dial Transplant. 2017; 32: 1731-1736PubMed Google Scholar Conversely, diabetes mellitus and chronic kidney disease were independently associated with the development of severe AP (SAP). The diagnosis of AP in the elderly may be difficult given the atypical clinical manifestations and overlapping of coexisting comorbidities. Abdominal pain, the cardinal symptom of AP, is absent or mild in 53.7% of cases, perhaps because of neuropathy, greater pain tolerance, or fibrosis of the perineurium due to aging.1Yu B. Li N. Li J. et al.The clinical characteristics of acute pancreatitis in gerontal patients: a retrospective study.Clin Interv Aging. 2020; 15: 1541-1553Crossref PubMed Scopus (2) Google Scholar Fever and leukocytosis are often absent, and a confusional state with rapid development of shock may be found. The elderly also show more frequently increased serum creatinine levels10Kara B. Olmez S. Yalcın M.S. et al.Update on the effect of age on acute pancreatitis morbidity: a retrospective, single-center study.Prz Gastroenterol. 2018; 13: 223-227PubMed Google Scholar and decreased serum albumin and hemoglobin levels.10Kara B. Olmez S. Yalcın M.S. et al.Update on the effect of age on acute pancreatitis morbidity: a retrospective, single-center study.Prz Gastroenterol. 2018; 13: 223-227PubMed Google Scholar,12Koziel D. Gluszek-Osuch M. Suliga E. et al.Elderly persons with acute pancreatitis—specifics of the clinical course of the disease.Clin Interv Aging. 2019; 14: 33-41Crossref PubMed Scopus (13) Google Scholar Furthermore, AP may be clinically indistinguishable from other intra-abdominal conditions with similar clinical features and serum amylase enzyme elevations, including mesenteric ischemia, acute biliary disease, and perforated peptic ulcer. For those reasons, early systematic unenhanced computed tomography has been proposed in elderly patients with suspected AP.17Millet I. Sebbane M. Molinari N. et al.Systematic unenhanced CT for acute abdominal symptoms in the elderly patients improves both emergency department diagnosis and prompt clinical management.Eur Radiol. 2017; 27: 868-877Crossref PubMed Scopus (30) Google Scholar Compared with the younger population, elderly people (particularly those over 80 years) present more frequently with SAP and multiorgan failure.2Xin M.J. Chen H. Luo B. et al.Severe acute pancreatitis in the elderly: etiology and clinical characteristics.World J Gastroenterol. 2008; 14: 2517-2521Crossref PubMed Scopus (41) Google Scholar,6Malik A.M. Biliary pancreatitis. Deadly threat to the elderly. Is it a real threat?.Int J Health Sci (Qassim). 2015; 9: 35-39PubMed Google Scholar,7Carvalho J.R. Fernandes S.R. Santos P. et al.Acute pancreatitis in the elderly: a cause for increased concern?.Eur J Gastroenterol Hepatol. 2018; 30: 337-341Crossref PubMed Scopus (20) Google Scholar,9Patel K. Li F. Luthra A. et al.Acute biliary pancreatitis is associated with adverse outcomes in the elderly: a propensity score-matched analysis.J Clin Gastroenterol. 2019; 53: 291-297Crossref Scopus (8) Google Scholar, 10Kara B. Olmez S. Yalcın M.S. et al.Update on the effect of age on acute pancreatitis morbidity: a retrospective, single-center study.Prz Gastroenterol. 2018; 13: 223-227PubMed Google Scholar, 11Quero G. Covino M. Fiorillo C. et al.Acute pancreatitis in elderly patients: a single-center retrospective evaluation of clinical outcomes.Scand J Gastroenterol. 2019; 54: 492-498Crossref PubMed Scopus (13) Google Scholar Conversely, some studies have reported similar frequency of local complications of AP between elderly and young patients.2Xin M.J. Chen H. Luo B. et al.Severe acute pancreatitis in the elderly: etiology and clinical characteristics.World J Gastroenterol. 2008; 14: 2517-2521Crossref PubMed Scopus (41) Google Scholar,3Gardner T.B. Vege S.S. Chari S.T. et al.The effect of age on hospital outcomes in severe acute pancreatitis.Pancreatology. 2008; 8: 265-270Crossref PubMed Scopus (55) Google Scholar,12Koziel D. Gluszek-Osuch M. Suliga E. et al.Elderly persons with acute pancreatitis—specifics of the clinical course of the disease.Clin Interv Aging. 2019; 14: 33-41Crossref PubMed Scopus (13) Google Scholar Severity classification of AP is essential to identify patients requiring early intensive treatment and referral to specialized centers and intensive care units. This segment represents around 20%–30% of all patients.18Bollen T.L. Acute pancreatitis: international classification and nomenclature.Clin Radiol. 2016; 71: 121-133Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar In the past multiple prognostic scores have been used. The Revised Atlanta Classification, currently the most used, classifies patients according to the presence of local or systemic complications and the persistence of multiorgan failure. Most of these prognostic scores are impractical because they are cumbersome. In addition, reliability of their use in elderly patients is limited because scores that include age as a risk factor use different cutoff points. For example, the Ranson criteria and the modified Glasgow Score use an age cutoff of >55 years, the Acute Physiology and Chronic Health Evaluation II of >45 years, the Bedside Index for Severity in Acute Pancreatitis (BISAP) score of >60 years, the Simplified Acute Physiology score of >40 years, and the Japanese Severity Score of >70 years The lack of age uniformity of these scores makes it difficult to interpret the results in light of the definition of "elderly patient". Furthermore, the application of these scales has given controversial results in elderly patients. In a study with 169 patients with SAP, the Acute Physiology and Chronic Health Evaluation II and Ranson scores were significantly higher in the elderly compared with young patients. However, mortality was only correlated with the severity of AP, multiple comorbidity, and incidence of multiorgan dysfunction syndrome.2Xin M.J. Chen H. Luo B. et al.Severe acute pancreatitis in the elderly: etiology and clinical characteristics.World J Gastroenterol. 2008; 14: 2517-2521Crossref PubMed Scopus (41) Google Scholar In another study with 90 patients with AP, elderly patients showed more severe Revised Atlanta Classification and higher Ranson scores than younger patients, but there were no differences in mortality or local complication frequency. Only the Ranson score was associated with severity of AP.19Losurdo G. Iannone A. Principi M. et al.Acute pancreatitis in elderly patients: a retrospective evaluation at hospital admission.Eur J Intern Med. 2016; 30: 88-93Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar In other study with 550 patients, the BISAP and the Ranson scores were associated with the severity of the AP: nevertheless, only BISAP was independently associated with mortality7Carvalho J.R. Fernandes S.R. Santos P. et al.Acute pancreatitis in the elderly: a cause for increased concern?.Eur J Gastroenterol Hepatol. 2018; 30: 337-341Crossref PubMed Scopus (20) Google Scholar. Conversely, another study found a greater mortality in AP patients over age 80 years, but no correlation with the modified Glasgow score was found.4Somasekar K. Foulkes R. Morris-Stiff G. et al.Acute pancreatitis in the elderly—can we perform better?.Surgeon. 2011; 9: 305-308Crossref PubMed Scopus (18) Google Scholar The Charlson Comorbidity Index is a prognostic scale that takes comorbidities into account to predict short- and long-term mortality in acutely ill hospitalized elderly adults.20Frenkel W.J. Jongerius E.J. Mandjes-van Uitert M.J. et al.Validation of the Charlson Comorbidity Index in acutely hospitalized elderly adults: a prospective cohort study.J Am Geriatr Soc. 2014; 62: 342-346Crossref PubMed Scopus (201) Google Scholar In 1 study with 212 patients with biliary AP, elderly patients had a higher Charlson Comorbidity Index score at admission. Nevertheless, no difference was observed in clinical and radiologic severity of AP or in-hospital 90-day mortality.8Roulin D. Girardet R. Duran R. et al.Outcome of elderly patients after acute biliary pancreatitis.Biosci Trends. 2018; 12: 54-59Crossref PubMed Scopus (5) Google Scholar Finally, in another study with 227 patients with AP, the Acute Physiology and Chronic Health Evaluation II score did not predict mortality among 85 patients >65 years old.5Kim J.E. Hwang J.H. Lee S.H. et al.The clinical outcome of elderly patients with acute pancreatitis is not different in spite of the different etiologies and severity.Arch Gerontol Geriatr. 2012; 54: 256-260Crossref PubMed Scopus (22) Google Scholar Thus, currently there is not an ideal severity score for elderly patients with AP in clinical practice, particularly for predicting mortality. The use of a combination of 2 or more scores including a computed tomography imaging score may improve results. The global mortality of patients with AP is estimated at 2%–5%. Many studies have reported that mortality is associated with age. In a meta-analysis of 194,702 patients with AP, mortality rate showed a continuous linear elevation of 0.08% per year between ages 20 and 59 years and grew to 0.76% per year between ages 59 and 70 years, representing an increase of 9 times.21Márta K. Lazarescu A.M. Farkas N. et al.Aging and comorbidities in acute pancreatitis I: a meta-analysis and systematic review based on 194,702 patients.Front Physiol. 2019; 10: 328Crossref PubMed Scopus (14) Google Scholar Few prospective and retrospective studies reporting mortality rates in elderly patients with AP have been published. Although the cutoff points for age used in these studies for the definition of elderly have been diverse, most of them show increased mortality in the aged population compared with younger counterparts2Xin M.J. Chen H. Luo B. et al.Severe acute pancreatitis in the elderly: etiology and clinical characteristics.World J Gastroenterol. 2008; 14: 2517-2521Crossref PubMed Scopus (41) Google Scholar, 3Gardner T.B. Vege S.S. Chari S.T. et al.The effect of age on hospital outcomes in severe acute pancreatitis.Pancreatology. 2008; 8: 265-270Crossref PubMed Scopus (55) Google Scholar, 4Somasekar K. Foulkes R. Morris-Stiff G. et al.Acute pancreatitis in the elderly—can we perform better?.Surgeon. 2011; 9: 305-308Crossref PubMed Scopus (18) Google Scholar, 5Kim J.E. Hwang J.H. Lee S.H. et al.The clinical outcome of elderly patients with acute pancreatitis is not different in spite of the different etiologies and severity.Arch Gerontol Geriatr. 2012; 54: 256-260Crossref PubMed Scopus (22) Google Scholar, 6Malik A.M. Biliary pancreatitis. Deadly threat to the elderly. Is it a real threat?.Int J Health Sci (Qassim). 2015; 9: 35-39PubMed Google Scholar, 7Carvalho J.R. Fernandes S.R. Santos P. et al.Acute pancreatitis in the elderly: a cause for increased concern?.Eur J Gastroenterol Hepatol. 2018; 30: 337-341Crossref PubMed Scopus (20) Google Scholar, 8Roulin D. Girardet R. Duran R. et al.Outcome of elderly patients after acute biliary pancreatitis.Biosci Trends. 2018; 12: 54-59Crossref PubMed Scopus (5) Google Scholar, 9Patel K. Li F. Luthra A. et al.Acute biliary pancreatitis is associated with adverse outcomes in the elderly: a propensity score-matched analysis.J Clin Gastroenterol. 2019; 53: 291-297Crossref Scopus (8) Google Scholar, 10Kara B. Olmez S. Yalcın M.S. et al.Update on the effect of age on acute pancreatitis morbidity: a retrospective, single-center study.Prz Gastroenterol. 2018; 13: 223-227PubMed Google Scholar, 11Quero G. Covino M. Fiorillo C. et al.Acute pancreatitis in elderly patients: a single-center retrospective evaluation of clinical outcomes.Scand J Gastroenterol. 2019; 54: 492-498Crossref PubMed Scopus (13) Google Scholar, 12Koziel D. Gluszek-Osuch M. Suliga E. et al.Elderly persons with acute pancreatitis—specifics of the clinical course of the disease.Clin Interv Aging. 2019; 14: 33-41Crossref PubMed Scopus (13) Google Scholar, 13Kayar Y. Dertli R. Konur S. Clinical outcomes of acute pancreatitis in elderly patients: an experience of single tertiary center.Pancreatology. 2020; 20: 1296-1301Crossref PubMed Scopus (5) Google Scholar (Table 1). Studies using cutoff point of age > 65 years reported a mortality from 2% to 9.6%, those using >70 years from 3% to 21%, and those using >80 years up to 55%. In most of these studies older age,7Carvalho J.R. Fernandes S.R. Santos P. et al.Acute pancreatitis in the elderly: a cause for increased concern?.Eur J Gastroenterol Hepatol. 2018; 30: 337-341Crossref PubMed Scopus (20) Google Scholar,11Quero G. Covino M. Fiorillo C. et al.Acute pancreatitis in elderly patients: a single-center retrospective evaluation of clinical outcomes.Scand J Gastroenterol. 2019; 54: 492-498Crossref PubMed Scopus (13) Google Scholar,13Kayar Y. Dertli R. Konur S. Clinical outcomes of acute pancreatitis in elderly patients: an experience of single tertiary center.Pancreatology. 2020; 20: 1296-1301Crossref PubMed Scopus (5) Google Scholar comorbidities,2Xin M.J. Chen H. Luo B. et al.Severe acute pancreatitis in the elderly: etiology and clinical characteristics.World J Gastroenterol. 2008; 14: 2517-2521Crossref PubMed Scopus (41) Google Scholar,7Carvalho J.R. Fernandes S.R. Santos P. et al.Acute pancreatitis in the elderly: a cause for increased concern?.Eur J Gastroenterol Hepatol. 2018; 30: 337-341Crossref PubMed Scopus (20) Google Scholar severity of AP,7Carvalho J.R. Fernandes S.R. Santos P. et al.Acute pancreatitis in the elderly: a cause for increased concern?.Eur J Gastroenterol Hepatol. 2018; 30: 337-341Crossref PubMed Scopus (20) Google Scholar,12Koziel D. Gluszek-Osuch M. Suliga E. et al.Elderly persons with acute pancreatitis—specifics of the clinical course of the disease.Clin Interv Aging. 2019; 14: 33-41Crossref PubMed Scopus (13) Google Scholar,13Kayar Y. Dertli R. Konur S. Clinical outcomes of acute pancreatitis in elderly patients: an experience of single tertiary center.Pancreatology. 2020; 20: 1296-1301Crossref PubMed Scopus (5) Google Scholar and organ failure3Gardner T.B. Vege S.S. Chari S.T. et al.The effect of age on hospital outcomes in severe acute pancreatitis.Pancreatology. 2008; 8: 265-270Crossref PubMed Scopus (55) Google Scholar but not local complications have been independently associated with death. Individuals aged > 80 years showed a higher frequency of SAP and were significantly associated with death.6Malik A.M. Biliary pancreatitis. Deadly threat to the elderly. Is it a real threat?.Int J Health Sci (Qassim). 2015; 9: 35-39PubMed Google Scholar,9Patel K. Li F. Luthra A. et al.Acute biliary pancreatitis is associated with adverse outcomes in the elderly: a propensity score-matched analysis.J Clin Gastroenterol. 2019; 53: 291-297Crossref Scopus (8) Google Scholar,12Koziel D. Gluszek-Osuch M. Suliga E. et al.Elderly persons with acute pancreatitis—specifics of the clinical course of the disease.Clin Interv Aging. 2019; 14: 33-41Crossref PubMed Scopus (13) Google ScholarTable 1Summary of Recent Studies Reporting Mortality and Other Outcomes of AP in the ElderlyAuthor, Country, YearDesignCutoff Age (y)N/n (%)MortalityCommentsXin, China, 20082Xin M.J. Chen H. Luo B. et al.Severe acute pancreatitis in the elderly: etiology and clinical characteristics.World J Gastroenterol. 2008; 14: 2517-2521Crossref PubMed Scopus (41) Google ScholarR60169/94 (55.6)E: 17% vs NE 5.3%, P = .0291All cases were SAP. Multiple comorbidities were cause of death.Gardner, USA, 20083Gardner T.B. Vege S.S. Chari S.T. et al.The effect of age on hospital outcomes in severe acute pancreatitis.Pancreatology. 2008; 8: 265-270Crossref PubMed Scopus (55) Google ScholarR70112/56 (50)E: 21.4% vs NE: 7.1%, P = .028All elderly cases were SAP. Organ failure more frequent in elderly patients. (63.3% vs 48.2%).Somasekar, UK 20104Somasekar K. Foulkes R. Morris-Stiff G. et al.Acute pancreatitis in the elderly—can we perform better?.Surgeon. 2011; 9: 305-308Crossref PubMed Scopus (18) Google ScholarR80224/40 (18)SAP : 53% vs mild AP: 8%, P = .002No comparison was made with a younger population.Kim, South Korea 20125Kim J.E. Hwang J.H. Lee S.H. et al.The clinical outcome of elderly patients with acute pancreatitis is not different in spite of the different etiologies and severity.Arch Gerontol Geriatr. 2012; 54: 256-260Crossref PubMed Scopus (22) Google ScholarR65227/85 (37.4)E: 3.5% vs NE: 0.7%, P = .148Apache II score was higher in the elderly.Malik, Saudi Arabia, 20156Malik A.M. Biliary pancreatitis. Deadly threat to the elderly. Is it a real threat?.Int J Health Sci (Qassim). 2015; 9: 35-39PubMed Google ScholarP55131/68 (52)E: 19.11% vs NE: 7.93%, P < .001All cases were biliary AP. SAP was more frequent in elderly patients: 46 vs 14.7%, P < .05.Carvalho, Portugal, 20177Carvalho J.R. Fernandes S.R. Santos P. et al.Acute pancreatitis in the elderly: a cause for increased concern?.Eur J Gastroenterol Hepatol. 2018; 30: 337-341Crossref PubMed Scopus (20) Google ScholarR65550/263 (47.8)E:8.4% vs NE: 3.1%, P = .006Age was associated with increased mortality despite corrected comorbidities and etiology Other independent predictors of death were organ failure and SAP.Roulin, Switzerland, 20188Roulin D. Girardet R. Duran R. et al.Outcome of elderly patients after acute biliary pancreatitis.Biosci Trends. 2018; 12: 54-59Crossref PubMed Scopus (5) Google ScholarR70212/76 (35.8)E: 3 vs NE: 1, P = .133All cases were biliary AP. Similar clinical and radiologic characteristics between both groups.Patel, USA, 20189Patel K. Li F. Luthra A. et al.Acute biliary pancreatitis is associated with adverse outcomes in the elderly: a propensity score-matched analysis.J Clin Gastroenterol. 2019; 53: 291-297Crossref Scopus (8) Google ScholarR65184,763/73,643 (41)E: 2 vs NE: 0.32 P < .001All were biliary AP cases. Age > 85 (odds ratio, 2.21; 1.7–2.86) P < .001. Elderly patients had higher SAP, more ERCP, less cholecystectomies.Kara, Turkey, 2018 10Kara B. Olmez S. Yalcın M.S. et al.Update on the effect of age on acute pancreatitis morbidity: a retrospective, single-center study.Prz Gastroenterol. 2018; 13: 223-227PubMed Google ScholarR65608/208 (34.6)E: 9.6% vs NE: 0.5%, P < .001.Patients > 65 y had more biliary stone disease (64%) and moderate severe AP than <65 y.Quero, Italy, 201911Quero G. Covino M. Fiorillo C. et al.Acute pancreatitis in elderly patients: a single-center retrospective evaluation of clinical outcomes.Scand J Gastroenterol. 2019; 54: 492-498Crossref PubMed Scopus (13) Google ScholarR65884/352 (39.8)E: 7.4% vs NE: 1.9%, P < .001Age, Ranson score at admission, and necrosis were independent predictors of death.Koziel, Poland, 201912Koziel D. Gluszek-Osuch M. Suliga E. et al.Elderly persons with acute pancreatitis—specifics of the clinical course of the disease.Clin Interv Aging. 2019; 14: 33-41Crossref PubMed Scopus (13) Google ScholarP>65-79/>80963/196 (20.3)/117 (12)>80: 11.9% vs <65: 2.3%, P < .0001SAP more frequent in patients > 80 y and associated with death.Kayar, Turkey, 202013Kayar Y. Dertli R. Konur S. Clinical outcomes of acute pancreatitis in elderly patients: an experience of single tertiary center.Pancreatology. 2020; 20: 1296-1301Crossref PubMed Scopus (5) Google ScholarP65336/114 (33.9)E: 3.5% vs NE: 0.5%, P = .028Systemic complication higher in elderly, but local complications were similar. Age and severity of AP predicted complications.E, elderly; NE, nonelderly; P, prospective; R, retrospective. Open table in a new tab E, elderly; NE, nonelderly; P, prospective; R, retrospective. Some hypotheses have been formulated to explain the cause of severity of AP in aged individuals. A pre-existing proinflammatory state, which causes activation of innate immunity and the upregulation of the adrenergic autonomic nervous system, has been observed in aging animals and humans. It has been demonstrated that cytokine production (interleukin-6, interleukin-8, and tumor necrosis factor) in elderly patients with infection is higher than in young people. These findings support the concept that aging impairs the immune system and promotes inflammation.22Kudoh A. Katagai H. Takazawa T. et al.Plasma proinflammatory cytokine response to surgical stress in elderly patients.Cytokine. 2001; 15: 270-273Crossref PubMed Scopus (46) Google Scholar Conversely, a decreased production of innate pancreatic proteins with protective effects has been related to increased severity of AP in the older population. This may give rise to local complications aggravated by multiorgan failure facilitated by the proinflammatory status. Finally, bacterial translocation may be increased in elderly people due to intestinal barrier damage. This can perpetuate the systemic inflammatory response and multiorgan failure. Besides, genes promoting the production of intestinal intercellular junction proteins, such as occludin, zonula occluden-1, and junctional adhesion molecule-A, are decreased in elderly rats, in addition to an intestinal overexpression of COX2, which in turn increases intestinal permeability. The main goals of medical therapy of AP should include the prevention and management of local and systemic complications. It is highly advisable to monitor more intensively elderly patients in the early phase of AP even when signs of severe disease are absent. There is no consensus regarding a hydration schema to be used in the elderly patient, particularly the optimal speed, volume, and the type of liquids in order to avoid overload (Table 2). Initial hydration is especially a problem in older patients because they need higher systolic blood pressures for adequate perfusion due to arterial stiffening; therefore, they may require different targets for fluid replacement.Table 2Best Practices for Evaluation and Management of AP in the Elderly PatientSuspect AP in elderly patients with abdominal pain with or without acute abdominal signs.Request pancreatic enzymes (serum amylase and lipase) and serum markers of inflammation ( erythrocyte sedimentation rate and C-reactive protein ) along with routine examinations.Consider abdominal computed tomography on admission regardless of laboratory results.If diagnosis of AP occurs:•List comorbidities and consider that the patient is seriously ill from admission.•Assess AP severity: use at least 2 severity scores.•Close monitoring of patient. Consider admission to intensive care unit.Management•Cautious fluid resuscitation in small loads or less volume infused taking into account diuresis, renal function, hypoalbuminemia, pulmonary auscultation, oxygen requirements, edema of areas of decline, or pulmonary congestion.•Avoid nonsteroidal anti-inflammatory drugs.•Consider prophylactic antibiotics.•Early enteral nutrition in absence of abdominal pain and nausea and presence of peristalsis.•If biliary etiology is found:oERCP in severe cases or cholangitis.oConsider cholecystectomy if possible before hospital discharge. Open table in a new tab Thus far, no restrictions pertaining to pain medication in the elderly are available. However, nonsteroidal anti-inflammatory drugs should be avoided in presence of acute kidney injury. In general, although prophylactic antibiotics are not recommended in AP patients, there is no evidence that they are not useful in elderly patients, considering that sterile necrosis and translocation may be more frequently observed. For now, prophylactic antibiotics may be used only in carefully selected cases. Currently, there is no accepted treatment for bacterial translocation in AP elderly patients. Peritoneal lavage has been used in severe AP for reducing plasma levels of inflammatory cytokines and has been speculated to reduce mortality and incidence of complications.23Matsumoto K. Miyake Y. Nakatsu M. et al.Usefulness of early-phase peritoneal lavage for treating severe acute pancreatitis.Intern Med. 2014; 53: 1-6Crossref PubMed Scopus (9) Google Scholar Nevertheless, more studies are need for defining its clear role. Aging patients with AP should be considered at moderate to high malnutrition risk because of the catabolic nature of the disease and because of the impact of nutritional status on outcome. Malnutrition favors immunodeficiency, facilitating the development of multiorgan failure during a severe inflammatory process. In SAP, enteral nutrition is recommended to prevent infectious complications. Amino acid or short peptide formulas are used for patients with gastrointestinal function deficiency. In a study with 263 elderly patients with AP, enteral nutrition was associated with lower frequency of infections, surgical procedures, and days of hospitalization.24D'Angelo M. Lanteri R. Ventura L. et al.Nutritional support in elderly.BMC Geriatr. 2009; 9: A14Crossref PubMed Scopus (1) Google Scholar Parenteral nutrition should be administered only when the enteral route is not available, not tolerated, or not meeting caloric requirement. Because biliary lithiasis is the most frequent cause of AP in elderly patients, a prudent and wise management must be applied. Nonetheless, it is difficult to adopt a general strategy in these patients because they have more and diverse comorbidities and more severe disease. In addition, there are very few published studies on this issue. In gallstone pancreatitis, most authorities recommend prophylactic cholecystectomy during the same hospitalization because of the potential for recurrent attacks. Nevertheless, timing of surgery must be done case by case, taking into account the clinical condition; number, type, and severity of comorbidities; severity of AP; and the presence of systemic and local complications. Endoscopic retrograde cholangiopancreatography (ERCP) with sphyncterotomy may be used for patients with cholangitis, persistent bile duct stones, and biliary obstruction with worsening of the clinical condition. In a study with 40 patients aged > 80 year with SAP of biliary etiology, ERCP with sphincterotomy was used in 40% and cholecystectomy in 11%. Early intervention by means of ERCP improved outcome of patients. The authors recommended that laparoscopic cholecystectomy must be considered as a definitive treatment because available evidence suggests this can be performed with acceptable morbidity and mortality in this population.4Somasekar K. Foulkes R. Morris-Stiff G. et al.Acute pancreatitis in the elderly—can we perform better?.Surgeon. 2011; 9: 305-308Crossref PubMed Scopus (18) Google Scholar In another study with 119 patients aged >70 years with 148 admissions for biliary AP, 24% had a relapse after a previous episode. The 30-day mortality was 2.7%. During follow-up 40% were treated with cholecystectomy or ERCP and sphincterotomy. In a life-table analysis the probability of remaining relapse-free in the absence of cholecystectomy or ERCP was estimated to be 95% (95% confidence interval, 91–98) and 92% (95% confidence interval, 88–97) 2 and 8 weeks after discharge, respectively. The authors concluded that accurate timing of cholecystectomy or ERCP in the follow-up period is crucial to preclude readmissions for relapses for severe disease complications.25Sandblom G. Tommy B. Ib R. Acute pancreatitis in patients 70 years of age or older.Clin Med Geriatr. 2008; 1: 27-32Google Scholar Because of the worldwide aging population, incidence of AP has raised in elderly people. AP represents around the 20%–55% of all cases, and biliary lithiasis is the most frequent etiology. AP in elderly patients has some particular features: Clinical diagnosis may be challenging due to atypical presentation and progression, severity is more frequently observed and leads to increased multiorgan failure and high mortality that is facilitated by diverse comorbidities, and the utility of available severity scores has yielded conflicting results. Therefore, a high suspicion of the diagnosis is warranted, and close monitoring of elderly patients with AP even in early phases must be performed. Intravenous fluid use should be cautiously administered to avoid overload and cardiovascular complications. The treatment of biliary disease must be adapted case by case given the higher number of comorbidities and severity of the disease. Laparoscopic cholecystectomy must be considered as definitive treatment to reduce relapses. The following should be kept in mind for future research:•The term "elderly" must be uniform in clinical research to assess reproduction of findings in clinical practice.•Effective strategies for early detection of AP, perhaps based on biochemical markers or imaging studies, should be investigated in this population.•The use of prophylactic antibiotics must be evaluated given the high frequency of sterile necrosis and bacterial translocation.•More adapted severity scores must be evaluated in these population, particularly for predicting mortality.•Guidelines of medical and surgical management must be implemented.
Referência(s)