Clinical Characteristics of 5375 Cases of Acute Pancreatitis in China (1996–2015)

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Clinical Characteristics of 5375 Cases of Acute Pancreatitis from a Single Chinese Center, 1996–2015

Acute pancreatitis (AP) is a common gastrointestinal emergency with significant morbidity and mortality. This retrospective study analyzed 5,375 AP cases admitted to Ruijin Hospital in Shanghai, China, between 1996 and 2015, providing insights into the evolving epidemiology, etiology, severity patterns, clinical outcomes, and treatment trends in a Chinese population.

Demographics and Severity Distribution

The cohort comprised 3,137 males (58.4%) and 2,238 females (41.6%), with a median age of 53 years (interquartile range [IQR]: 42–65). Age distribution revealed the 51–60-year group as most susceptible to AP. Notably, biliary AP predominated in older patients (median age: 55 years), while cases attributed to “other” etiologies occurred in younger individuals (median age: 49 years). Over the 20-year period, the median age of patients remained stable (P = 0.05).

Severity classification followed the 2012 Atlanta criteria: mild AP (MAP) accounted for 49.0% (2,635 cases), moderately severe AP (MSAP) for 21.3% (1,146 cases), and severe AP (SAP) for 29.7% (1,594 cases). SAP cases demonstrated higher morbidity, with a hospital mortality rate of 12.4%, compared to 3.5% for MSAP and 0.1% for MAP.

Etiological Patterns and Temporal Trends

Gallstone-related AP was the predominant etiology (63.0%, 3,386 cases), followed by hyperlipidemia (8.5%, 457 cases), alcohol (7.4%, 398 cases), and other factors (21.1%, 1,134 cases). Significant shifts occurred over time: biliary AP increased from 58.0% (1996–2000) to 67.6% (2011–2015), hyperlipidemic AP rose from 4.0% to 12.3%, and alcohol-related AP remained stable. Conversely, cases attributed to “other” causes declined from 29.0% to 16.1% (Figure 1).

Etiology-specific analysis revealed distinct clinical profiles (Table 2):

  • Biliary AP: Lowest progression to SAP (21.2%) but highest surgical intervention rate (22.7%) and crude mortality (5.1%). After severity adjustment, biliary AP mortality dropped to 3.5%, suggesting better outcomes when accounting for disease severity.
  • Alcoholic AP: Highest SAP proportion (41.5%, P < 0.001), highest pancreatic necrosis rate (22.6%, P = 0.003), and lowest crude mortality (1.8%). Adjusted mortality increased to 5.8%, indicating worse outcomes in severe cases.
  • Hyperlipidemic AP: Second-highest SAP rate (39.6%) with adjusted mortality of 5.6%.
  • Other Etiologies: Highest adjusted mortality (6.5%) despite intermediate SAP frequency (46.7%).

Hospital Course and Economic Burden

Median hospital stay was 14 days (IQR: 9–25), with no significant variation across etiologies (P = 0.999). Median hospitalization costs reached $5,231 USD (IQR: $2,769–$10,920). SAP required longer admissions (median: 29–40 days depending on period) and incurred higher costs.

Mortality Trends and Causes of Death

Overall hospital mortality was 4.5% (240 deaths), primarily driven by SAP (197 deaths, 12.4% mortality). Mortality rates showed limited improvement: severity-adjusted rates were 5.9% (1996–2000) versus 4.0% (2011–2015) (P = 0.207). SAP mortality decreased from 15.9% to 14.3% (Table 4), but this reduction lacked statistical significance (P = 0.530).

Multiple organ dysfunction syndrome (MODS) caused 79.3% of deaths in 1996–2000, decreasing to 66.7% by 2011–2015. Hemorrhagic complications rose from 10.3% to 15.7%, while septic deaths remained stable (9.5–13.8%).

Treatment Evolution in Severe AP

Management of SAP evolved significantly (Table 4):

  1. Early Interventions:
    • Median fluid resuscitation within 72 hours decreased from 3,050 mL (1996–2000) to 1,785 mL (2011–2015) (P = 0.029).
    • Early enteral nutrition (EN) utilization dropped from 13.7% to 5.0% (P < 0.001).
  2. Invasive Procedures:
    • Laparotomy rates fell from 46.7% to 26.1% (P < 0.001).
    • Percutaneous drainage declined non-significantly (17.6% to 11.8%, P = 0.258).
    • Emergent ERCP for biliary SAP remained stable (11.3% to 7.6%, P = 0.517).
  3. Complications:
    • Pancreatic necrosis decreased from 47.8% to 21.0% (P < 0.001).
    • Digestive leakage rates remained low (0.8–2.2%, P = 0.427).

Age-Related Outcomes

SAP incidence declined with advancing age, but mortality inversely correlated with age. Patients >80 years had the lowest SAP proportion (23.9%) yet highest mortality (26.7%), highlighting age as an independent risk factor for poor outcomes.

Discussion

This study provides the largest longitudinal analysis of AP in China, revealing three key findings:

  1. Etiological Shifts: Rising biliary and hyperlipidemic AP parallel Western trends, while alcohol-related AP remains stable. The decline in “other” etiologies likely reflects improved diagnostic capabilities.
  2. Outcome Paradox: Despite reduced complications (e.g., pancreatic necrosis) and shorter hospital stays, mortality stagnated. This suggests current therapies inadequately address MODS and hemorrhage—the predominant causes of death.
  3. Treatment Evolution: Declining surgical interventions and fluid volumes reflect global shifts toward conservative management. However, reduced EN utilization contradicts guidelines advocating early enteral feeding to mitigate intestinal barrier dysfunction.

Conclusion

Over two decades, AP in China exhibited rising biliary and hyperlipidemic etiologies, stable alcohol-related cases, and improved complication profiles. However, persistent mortality rates—particularly in elderly patients—underscore unmet needs in managing systemic inflammatory responses and organ failure. Future strategies should optimize early resuscitation protocols, enhance EN implementation, and develop targeted therapies for MODS prevention.

doi.org/10.1097/CM9.0000000000000208

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