이상협 34 Table 1. Ratings of Evidence Used for This Guideline I. Strong evidence from at least one published systematic review of multiple well-designed

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1 SESSION Ⅲ THE KOREAN JOURNAL OF PANCREAS AND BILIARY TRACT The assessment of the severity of acute pancreatitis 이상협 서울대학교의과대학분당서울대학병원내과 The assessment of severity at the initial medical examination plays an important role in introducing adequate early treatment and the transfer of patients to a medical facility that can cope with severe acute pancreatitis. Under these circumstances, guideline for severity assessment have been prepared in various countries, including Japan, Italy, United States of America, and United Kingdom and these criteria are now being evaluated. In this review, we are going to examine above guidelines and suggest the guideline of Korean Pancreatobiliary Association for further discussion. 서론 1) 급성췌장염은췌장의급성염증과정이며흔히췌장주변조직과다른원격장기의이상이동반된다. 급성췌장염의중증도는매우다양하여췌장에만염증이발생하는경증의형태에서부터다발장기부전및사망이동반되는중증의형태까지발생할수있다. 급성췌장염은전형적인자가치유의과정을겪는질환으로의경증췌장염에서는사망률이 1% 미만인데반해 1,2 중증췌장염에서는매우높아져서무균괴사췌장염에서는 10%, 감염괴사췌장염의경우는 25-30% 에이른다. 3 급성췌장염환자에서사망은약 50% 에서발병 2주내에발생하므로급성췌장염의적절한중증도평가는초기에중증경과를보일것으로예측되는환자를선별하여적절한치료를제공하고, 여의치않은경우향후적절한치료를제공할수있는기관으로전원하는기준을제시하는데유용하게사용될수있다. 아울러, 초기에경증또는중등도의췌장염도중증췌장염으로진행할수있기때문에췌장염의중증도는지속적으로평가되어야한다. 최근, 일본 4,5, 이탈리아 6, 미국 7 및영국 8 에서급성췌장염의중증도 Correspongding author. 경기도성남시분당구구미동 300 분당서울대학교병원내과 Tel : gidoctor@snubh.org 평가에대한가이드라인이발표되었다. 본고에서는급성췌장염의중증도평가의가이드라인과관련하여중증도평가의필요성 (necessity for severity assessment), 임상증상, 징후및혈액검사를통한중증도평가 (severity assessment based on clinical symptoms, signs and clinical laboratory tests), 영상검사를통한중증도평가 (severity assessment based on diagnostic imaging), 중증도판정기준을이용한평가 (severity assessment based on scoring system) 및전원기준 (Transfer criteria) 의항목에걸쳐최근발표된일본 (2010) 4, 이탈리아 (2010) 6, 미국 (American College of Gastroenterology, 2006) 7 및영국 (2005) 8 의가이드라인을소개하고, 이를바탕으로우리나라의적합한급성췌장염의중증도평가에대한가이드라인을도출하기위한토론의자료를제공하고자한다. 아울러, 가이드라인에제시된근거평가의등급및권고안등급은 Table 1, 2에제시하였다. 본론 1. 중증도평가의필요성 (Necessity for severity assessment) 1) 일본 Are severity scoring systems useful for assessing the severity of acute pancreatitis? 33

2 이상협 34 Table 1. Ratings of Evidence Used for This Guideline I. Strong evidence from at least one published systematic review of multiple well-designed randomized controlled trials II. Strong evidence from at least one published properly designed randomized controlled trial of appropriate size and in an appropriate clinical setting III. Evidence from published well-designed trials without randomization, single group prepost, cohort, time series, or matched case-controlled studies IV. Evidence from well-designed nonexperimental studies from more than one center or research group or opinion of respected authorities, based on clinical evidence, descriptive studies, or reports of expert consensus committees Table 2. Grades of recommendation Grade of recommendation A Contents Recommended strongly to perform Evidence is strong and clear clinical effectiveness can be expected B Recommended to perform Evidence is moderate or strong, although evidence of effectiveness is sparse C Evidence is sparse, but may be considered to perform Effectiveness can possibly be expected D Considered to be unacceptable Modifications from the JPN Guidelines 2010 There is evidence to deny effectiveness(to show harm) The severity scoring system is useful for assessing the severity and for deciding the treatment strategy and the need for transfer to a specialist unit. (Reco- mmendation A) 4 2) 이탈리아 Is severity assessment necessary in the management of acute pancreatitis? Severity assessment is essential for proper initial treatment in the management of acute pancreatitis (recommendation A) 5,6 3) 미국 The importance of establishing risk factors of severity of acute pancreatitis at admission is several- fold: to transfer those patients who are most likely to have a severe episode to a step-down unit or an intensive care unit for closer supervision, to allow physicians to compare results of optimal therapy, and to facilitate the identification of seriously ill patients for inclusion in randomized prospective trials. (Level of evidence: Unmentioned) 7 4) 영국 The definitions of severity, as proposed in the Atla- nta criteria, should be used. However, organ failure present within the first week, which resolves within 48 hours, should not be considered an indicator of a severe attack of acute pancreatitis. (Recommendation grade B) 8 급성췌장염의임상양상은다양하여중증도에대한주관적인평가는쉽지않아서현재까지중증췌장염의예측은다인자를이용한몇가지의중증도판정기준이이용되고있다. 급성췌장염은초기에경증또는중등도로평가된경우에도중증급성췌장염으로갑자기진행할수있기때문에지속적인중증도평가가필요하다. 5 Ranson score 와 Glasgow score를이용한평가는 48시간이소요되지만, 급성췌장염의악화를 70 80% 정도예측할수있는것으로알려져있다 APACHE (Acute Physiology and Chronic Health Evaluation )II score 는급성췌장염의

3 The assessment of the severity of acute pancreatitis 35 초기중증도예측에유용한것으로받아들여지고있다. 12 5) 대한췌담도학회제안급성췌장염의중증도평가는적절한초기치료와향후치료전략의결정에필요하다. ( 권고등급 B?) 2. 임상증상, 징후및임상검사를통한중증 (severity assessment based on clinical symp toms, signs and clinical laboratory tests) 1) 일본 Are clinical signs and symptoms, blood tests, and BMI useful for severity assessment of acute pancreatitis? Clinical signs and symptoms alone are not reliable in severity assessment and they should be supported by objective measures. (Recommendation A) 4 2) 이탈리아 Are blood tests useful for severity assessment of acute pancreatitis? Serum C-reactive protein values are useful for severity assessment, but they may not reflect severity within the first 48 h after onset. (Recommendation A) 5,6 3) 미국 Older age (>55), obesity (BMI >30), organ failure at admission, and pleural effusion and/or infiltrates are risk factors for severity that should be noted at admi- ssion. Patients with these characteristics may require treatment in a highly supervised area, such as a step- down unit or an intensive care unit. (Level of evidence: III) 7 It is also recommended that serum hematocrit be obtained at admission, 12 h after admission, and 24 h after admission to help gauge adequacy of fluid resuscit- ation. (Level of evidence: III) 7 4) 영국 There is agreement that there is still a need for an early objective measure of severity (recommendation grade C). Clinical examination in the first 24 hours of admission although specific lacks sensitivity and hence is unreliable and should be supported by objective measures. (recommendation grade A) 8 입원시장기부전이동반된경우사망률이높은것으로알려져있다 입원시장기부전이동반된환자들중, 여러장기부전이동반된경우에는사망률이더욱높은것으로알려져있고 18 장기부전이오래지속될수록사망률이높아 16,17,20, 이를조기에교정하기위한노력이필요하다. 급성췌장염은복부합병증이나주요장기부전을시사하는광범위한임상증상및징후를발현하기때문에, 이러한임상증상및징후만으로는중증도를평가하는데있어서재현성이떨어지는것으로알려져있다. 21 환자의연령은많은연구들 13,18,22-26 에서급성췌장염의중증도와관련이있다는보고하였지만, 이에반하는연구들 12,27-31 도많아중증도를평가하는단일기준으로적용하기에는한계가있다. 서구에서는임상증상및징후이외에 BMI 30 kg/m 2 인비만이중증급성췌장염과관련이있는것으로알려져있다 (Level 2 4). 32,33 하지만, 비만이급성췌장염과관련된사망에는관련이없다는보고도있다. 입원후 24시간이내에시행한흉부단순촬영에서확인된흉수가췌장의괴사또는장기부전 35, 높은사망률 23,36 과비례하고, 흉부단순촬영에서의침윤도높은사망률과관련이있다는보고도있다. 25,36,37 CRP 수치는급성췌장염악화를제시하는믿을만한인자로여겨지고있다 Santorini consensus conference (1999) 41, World Congress of Gastroenterology 가이드라인 (2002) 42 과영국가이드라인 (2005) 8 은급성췌장염발생 48시간이후측정한 15 mg/dl 이상의혈청 CRP 수치를예후인자로추천하고있다. procalcitonin (PCT) 수치는급성췌장염의악화를예측에있어서 CRP 수치보다유용한것으로알려져있고 43, 췌장감염의예측에도유용한것으로알려져있다 (Level 2). 44 혈청검사를통해급성췌장염의중증도와연관성을찾으려는시도들이있었다. 입원시 blood urea nitrogen (BUN) 20 mg/dl 과입원 24시간이후 BUN 상승이사망률과연관성을가진다는보고가있었고 45, 입원시 28 과입원 24시간이내 36,46 의혈청 creatinine >2.0 mg/ dl이높은사망률과관련이있다는보고가있었다. 아울러, 입원 48시간내의혈청 creatinine 상승이췌장의괴사와관련이있다는보고도있다. 47 혈청 glucose >250 mg/dl 이높은사망률과관련을가진다는보고도있지만 28, 혈청 glucose >125 mg/dl 는장기부전이나사망률과는연관성이떨어진다는보고도있다. 48 급성췌장염환자에서입원시혈청 hematocrit 44 과

4 이상협 36 입원후 24시간이내에혈청 hematocrit 가감소되지않는경우췌장의괴사와연관된것으로알려져, 혈관내용적의감소와연관된혈청 hematocrit 의상승은췌장괴사의예측인자로제시되었다. 49 이후, 입원시혈청 hematocrit 의상승이없는경우괴사성췌장염의발생가능성이매우낮은것으로알려졌다. 49,50 하지만, 다른연구들에서는입원시와입원후 24시간의 hematocrit 의상승이중증급성췌장염의예측인자로확인되지는않았다. 46,50 췌장효소활성펩타이드, 특히 trypsinogen activation peptide 와 carboxypeptidase activation peptide 측정은급성췌장염의중증도예측에중요한정보를제공하지만 51-54, 혈청 CRP이외에는신속검사가어려워임상적유용성은떨어진다. 8 5) 대한췌담도학회제안임상증상과징후에만근거한중증도평가는신뢰성이떨어지므로단순흉부촬영, 혈청 C-reactive protein (CRP), 혈청 blood urea nitrogen (BUN), 혈청 creatinine 측정등의객관적인임상검사가필요하다. ( 권고등급 B?) 3. 영상검사를통한중증도평가 (severity assessment based on diagnostic imaging) 1) 일본 Are Contrast-enhanced computed tomography (CECT) and magnetic resonance imaging (MRI) useful for the severity assessment of acute pancreatitis? Accurate diagnosis of the presence and range of pancreatic ischemia or necrosis requires contrast-enhanced CT or contrast-enhanced magnetic resonance imaging (MRI). (Recommendation A) 4 2) 이탈리아 Is diagnostic imaging useful for severity assessment of acute pancreatitis? Contrast-enhanced CT scanning and contrast-enhanced MRI play an important role in severity assessment. (recommendation A) 5 The CT severity index, as proposed by Balthazar et al. 55, should be used. (recomm- endation B) 8 3) 미국 Pancreatic necrosis and organ failure are the two most important markers of severity in acute pancre- atitis. The distinction between interstitial and necrotizing pancreatitis can be reliably made after 2 3 days of hospitalization by contrast enhanced CT scan. (Level of evidence III) 7 4) 영국 Patients with persisting organ failure, signs of sepsis, or deterioration in clinical status 6 10 days after admission will require CT. (recommendation grade B) 8 급성췌장염에서췌장의허혈, 괴사및병변의범위를평가하기위해조영증강복부전산화단층촬영 (contrast enhanced CT) 이필요하다. 조영증강복부전산화단층촬영은괴사성췌장염과부종성췌장염을구별하는데가장유용한검사이다. 하지만, 입원시복부전산화단층촬영은급성췌장염과다른심각한복통의원인을감별하는유용한것으로알려져있다. 복부전산화단층촬영에서확인된췌장의괴사는국소및전신합병증과밀접한연관성이있는것으로알려져있어, 복부전산화단층촬영은췌장의괴사가의심되는경우에적절한검사이다. 조영증강복부전산화단층촬영은급성췌장염발병 4~10일후시행하면거의 100% 에서췌장괴사의진단이가능하고,, 입원초기 ( 입원후 36~48 시간이내 ) 에시행하여도급성췌장염의중증도평가에유용하다. 63,64 CT severity index 65 는췌장괴사의유무, 괴사범위및염증변화의범위등을결합하여수치화하였고 (Table 3) 예후와잘연관되어있는것으로받아들여지고있다. CT severity index 가 0 2 인경증급성췌장염환자는임상양상이악화되는경우에만복부전산화단층촬영을추가로시행하고, CT severity index 가 3 10 인중등도이상의급성췌장염환자에서는임상상의호전이없는경우에도시행한다. 42 중증도의경과관찰을위한복부전산화단층촬영의시행결정은입원후대략 1주일뒤에권고된다. 8 아울러, 급성췌장염이회복되어퇴원하는경우에도가성낭이나가성동맥류와같은무증상합병증을발견하기위해복부전산화단층촬영의시행이권고되기도한다. 42 조영증강복부자기공명영상도조영증강복부전산화단층촬영과유사한정도로췌장괴사의유무, 괴사및염

5 The assessment of the severity of acute pancreatitis 37 Table 3. Computed tomography (CT) grading of severity CT grade (A) Normal pancreas (B) Oedematous pancreatitis (C) B plus mild extrapancreatic changes (D) Severe extrapancreatic changes including one fluid collection (E) Multiple or extensive extrapancreatic collections Necrosis None <One third One third-one half >Half CT severity index = CT grade+necrosis score Complications 8% 35% 92% Deaths 3% 6% 17% Modified from the World Association guidelines3 and based on Balthazar and colleagues 증성변화의범위등을평가하는데유용한것으로알려져있다 하지만, 금속물체를가지고있는경우나응급상황에대처가어려운단점이있다. 5) 대한췌담도학회제안급성췌장염의중증도대한평가를위해서는조영증강복부전산화단층촬영의시행이필요하고, 장기부전, 패혈증및임상양상이악화되는경우경과관찰을위해추가시행을고려해야한다. ( 권고등급A?) 중증도평가를위해 CT severity index 가사용되어야한다. ( 권고등급 A?) 4. 중증도판정기준을이용한평가 (severity assessment based on scoring system) 중증도판정기준을이용한평가에대한가이드라인을논하기전에현재이용되고있는중증도판정기준들을살펴보고자한다.Ranson 지표는 1974년 Ranson 이발표한임상지표법으로다변수평가법중가장많이알려진것이다. 43개의임상, 생화학지표를분석한결과 11개의항목이예후와관련있음이밝혀졌다. 9 입원시에 5개항목, 입원후 48시간이내에 6개항목을측정하여 3가지이상관찰되는경우중증췌장염으로정의하였다 (Table 4). Table 4. Ranson s Criteria for the Prediction of Severity of Acute Pancreatitis On admission Age>55 years (>70 years) White cell count>16,000/mm3 (18,000/mm3) Lactate dehydrogenase>350 U/L (>400 U/L) Aspartate aminotransferase>250 U/L (same Glucose>200 mg/dl (>220 mg/dl) During initial 48 h Decrease in hematocrit by 10% (same) Blood urea nitrogen increases by >5mg/dL (>2 mg/dl) Calcium<8 mg/dl (same) PaO2<60 mmhg (omitted) Base deficit>4 meq/l (>6 meq/l) ZFluid sequestration>6 L (>4 L) Glasgow 지표는 Imrie 등이개발한알코올과담석췌장염에모두사용할수있는 Ranson 지표와유사한다변수평가법으로, Ranson 지표중 3개지표를삭제하고알부민을첨가하여총 9개의지표로단순화하였다 (Table 5). 69

6 이상협 38 Table 5. Glasgow Severity Scoring System for Acute Pancreatitis Age>55 years White cell count>15,000/mm3 PaO2<60 mmhg Serum lactate dehydrogenase>600 U/L Serum aspartate aminotransferase>200 U/L Serum albumin<3.2 g/dl Serum calcium<8 mg/dl Serum glucose>180 mg/dl Serum urea>45 mg/dl APACHE II 지표는특정질환에대한임상평가가아니라중환자실에서이용되어온지표로 12가지의생리적인측정치와나이, 5개의장기에기초한만성건강상태를평가하고이를점수화하여전체점수를합산하는방법으로산출된다 (Table 6). 70 APACHE II 지표는입원수시간내에급성췌장염의중증도를판정할수있고수시로반복측정할수있어진행여부를평가할수있다는장점이있다. 비만이중증급성췌장염의발병과관련이있고사망의독립적인예측인자로인식되면서 APACHE II 지표에 bodymass index (BMI) 를더하여새로운 APACHE-O 지표가만들어졌다. 즉 BMI가 인경우 1점, 30 이상인경우 2점으로계산한다. 신일본중증도지표 (new Japanese severity scoring system) 는예후인자와조영증강복부전산화단층촬영등급이중증도평가에이용된다 (Table 7). 72 예후인자에는 base excess (BE) 3 meq/l or shock: (systolic blood pressure<80 mmhg), PaO2 60 mmhg (room air) or requiring respirator management, blood urea nitrogen (BUN) 40 mg/dl (or creatinine [Cr] 2.0 mg/dl) or oliguria after fluid replacement, lactic dehydrogenase (LDH) 2 times of upper limit of normal, platelet count 10 x 104/mm3, Ca 7.5 mg/dl, CRP 15 mg/dl, number of positive measures in SIRS criteria 3, 및 age 70 years 이포함되고. 조영증강복부전산화단층촬영등급은췌장외염증의진행정도와허혈성변화의범위를고려하여결정한다 년발표된 BISAP (Bedside index for severity in acute pancreatitis) 지표 (Table 8) 73 는입원 24시간동안 BUN>25 mg/dl, impaired mental status, SIRS, age>60, pleural effusion 5개항목을갖고각각 1점을주어점수가높아짐에따라사망률이높아짐을보고하였다. Table 6. APACHE II scoring system Physiological parameter Temperature, rectum ( C) Mean arterial pressure (mmhg) Heart rate (n/min) Respiration rate (n/min) Oxygenation (mmhg) a. FiO2>0.5,A-aDO2 b. FiO2<0.5,PO2 Arterial ph Serum sodium (mmol/l) Serum potassium (mmol/l) Serum creatinine (mg/dl) (Duplication in acute renal failure) Hematocrit (%) White cell blood count ( x 103/mm) 15minus Glasgow coma scale score <200 PO2> < <55 < <2.5 <20 <1 In these 12 parameters must be added the age (years) [<44:0, 45-54:2, 55-64:3, 65-74:5, >75:6] and the coexisting systemic disease (severe organ failure or immunosuppression:5; emergency operation:5; elective operation:2 )

7 The assessment of the severity of acute pancreatitis 39 Table 7. The New Japanese severity scoring system of acute pancreatitis (2008) Prognostic factors (1 point for each factor) 1. Base Excess 3 meq/l or shock (systolic blood pressure <80 mmhg) 2. PaO2 60 mmhg (room air) or respiratory failure (respirator management is needed) 3. BUN 40 mg/dl (or Cr 2.0 mg/dl) or oliguria (daily urine output<400 ml even after IV fluid resuscitation) 4. LDH 2 times of upper limit of normal 5. Platelet count 100,000/mm3 6. Serum Ca 7.5 mg/dl 7. CRP 15 mg/dl 8. Number of positive measures in SIRS criteria 3 9. Age 70 years Table 8. BISAP (Bedside Index for Severity in Acute Pancreatitis) Scoring System BUN>25 mg/dl Impaired mental status (Glasgow Coma Scale Score<15) SIRS SIRS is defined as two or more of the following: (1) Temperature of <36 or >38 C (2) Respiratory rate >20 breaths/min or PaCO2<32 mmhg (3) Pulse>90 beats/min (4) WBC <4,000 or >12,000 cells/mm3or>10% immature bands Age>60 years Pleural effusion detected on imaging One point is assigned for each variable within 24 h of presentation and added for a composite score of 0-5. CT Grade by CECT 1. Extrapancreatic progression of inflammation Anterior pararenal space Root of mesocolon Beyond lower pole of kidney 2. Hypoenhanced lesion of the pancreas The pancreas is conveniently divided into three segments (head, body, and tail). Localized in each segment or only surrounding the pancreas Covers 2 segments Occupies entire 2 segments or more 1+ 2 = Total scores Total score = 0 or 1 Total score = 2 Total score = 3 or more Assessment of severity 0 point 1 point 2 points 0 point 1 point 2 points Grade 1 Grade 2 Grade 3 (1) If prognostic factors are scored as 3 points or more, or (2) If CT Grade grade is judged as Grade grade 2 or more, the severity grading is evaluated to be as severe. Measures in SIRS diagnostic criteria: (1) Temperature>38 or<36, (2) Heart rate[90 >beats/min, (3) Respiratory rate[20 > breaths/min or PaCO2<32 torr, (4) WBC [12,000 >cells/mm3, <4,000 cells/mm3, or[10% immature (band) forms 1) 일본 Is the new Japanese severity scoring system useful for assessing the severity of acute pancreatitis? The new Japanese severity scoring system is useful for assessing the severity of acute pancreatitis (Recommendation A) 2) 이탈리아 What is the best severity scoring system for assessing the severity of acute pancreatitis? Assessment of severity should be done by a scoring system such as Acute Physiology and Chronic Health Evaluation (APACHE) II. (recommendation A) 5,6 3) 미국 It is recommended that APACHE-II scores be generated during the first 3 days of hospitalization and thereafter as needed to help in this distinction. (Level of evidence: III) 7 4) 영국 Available prognostic features which predict complications in acute pancreatitis are clinical impression of severity, obesity, or APACHE II>8 in the first 24 hours of admission, and C reactive protein levels >150 mg/l, Glasgow score 3, or persisting organ failure after 48 hours in hospital (Table 9). (recommendation grade B) 8

8 이상협 40 Table 9. Features that may predict a severe attack, present within 48 hours of admission to hospital Initial assessment Clinical impression of severity Body mass index >30 Pleural effusion on chest radiograph APACHE II score >8 24 h after admission Clinical impression of severity APACHE II score >8 Glasgow score 3 or more Persisting organ failure, especially if multiple C reactive protein >150 mg/l 48 h after admission Clinical impression of severity Glasgow score 3 or more C reactive protein >150 mg/l Persisting organ failure for 48 h Multiple or progressive organ failure Modified from the World Association guidelines. 급성췌장염은복부합병증이나주요장기부전을시사하는광범위한임상증상및징후를발현하는데, 이러한임상증상및징후는중증도판정기준 (severity scoring system) 의요인으로도이용되어오고있다. 69,74-76 Ranson 지표는해당항목이 3개미만인경우사망률이 0~3% 28,36,77 ; 3~5개인경우사망률이 11 15% 이고 28,36,77, 6개이상인경우에는사먕률이 40% 에달하는것으로알려져있다. 28 하지만, 최근 Ranson 지표에대한연구 110개를종합하여평가한결과에서는급성췌장염의중증도를예측하는정도가매우낮은것으로나타났다. 78 APACHE II 지표는급성췌장염의중증도평가에유용한지표로알려져있다. 입원시및입원직후 72시간동안의높은 APACHE-II 지표는높은사망률과연관이있는것으로알려져있다 (<4%,APACHE-II <8 ;11 18%, APACHE-II >8). 17,18,26-28,79,80 입원후첫 24시간동안의 APACHE-II 지표를이용한평가는 48시간이후 Ranson 지표를이용한평가와비교하여중증급성췌장염을예측하는데있어유사한예측도를가진다. 12 이러한이유, APACHE-II 지표는입원후첫 24시간동안유용하게이용될수있고, 매일중증도를평가하는데유용한것으로알려져있다. 12 Atlanta symposium (1992) 76, Santorini consensus conference (1999) 41, World Congress of Gastroenter- ology Guidelines (2002) 42 은 APACHE II 지표 >8을중증급성췌장염으로분류하여적절한치료방침수립에이용할것을권고하고있다. 신일본지표의유용성에대한평가에서중증도평가에신일본지표가 Ranson 지표와 APACHE II 만큼유용하다는보고가있었다. 81 이후최근발표된연구에서도 BISAP 지표는사망률과유의한상관관계를보였고, APACHE II 지표, Computed tomography severity index (CTSI) 와유사한정확도를보이는간단하면서도유용한검사로보고했다. 82,83 하지만, 최근 Ranson 지표, Glasgow 지표, APACHE II 지표, 신일본지표, BISAP 지표등을포함한여러중증도판정기준들의정확도를비교한연구에서는모든중증도판정기준들이어느정도유용하고, 유용성에서우열을가리기어려운것으로보고하였다. 5) 대한췌담도학회제안췌장암의중증도평가를위해서는중증도판정기준을이용하여야하고,APACHEII 지표등을포함한여러여러중증도판정기준들이유용하게이용될수있다. ( 권고등급 B?) 전원기준 (Transfer criteria) 1) 일본 What are the indications for transferring patients with severe acute pancreatitis to a specialist unit? Patients with severe acute pancreatitis (prognostic factor 3) assessed by the new Japanese criteria should be transferred promptly to a specialist medical instit- ution. 2) 이탈리아 What are the indications for transferring patients with acute pancreatitis to a referral unit? Every hospital in which there are acute admissions should have a single nominated clinical team to manage all patients with acute pancreatitis. (recommendation C) 8 Management in, or referral to, high-volume units is necessary for patients with extensive necrotizing pancreatitis or other complications who may require care in the intensive therapy unit or interventional radiological, endoscopic or surgical procedures. (recommendation B) 8

9 The assessment of the severity of acute pancreatitis 41 3) 미국 Prompt transfer to an intensive care unit should take place for sustained organ failure. Transfer to an intensive care unit (or possibly a step-down care unit) should be considered if there are signs that suggest that the pancreatitis is severe or is likely to be severe. (Level of evidence: III) 7 4) 영국 Management in, or referral to, a specialist unit is necessary for patients with extensive necrotizing pancreatitis (>30% necrosis) or with other complications who may require intensive therapy unit (ITU) care, or interventional radiological, endoscopic, or surgical procedures (recommendation grade B). Santorini consensus conference (1999) 는 BMI >30 kg/m 2 이상의비만, 흉수가관찰되는경우, APACHE II 지표 6, APACHE-O 지표 6 및혈청 CRP 수치15 mg/dl 이상인경우중증급성췌장염으로분류하여적절한치료가가능한병원으로전원을권고하였다. 미국 (American College of Gastroenterology) 가이드라인 (2006) 7 은장기부전이있는경우, 적극적인수액요법이필요한경우, 특히세심한수액요법이필요한심부전이있는고령의환자, 기관지삽관을포함한인공환기집중치료가필요할것으로예상되는환자는중환자실 (ICU) 에서치료가가능한병원으로신속한전원하고, 비만 (BMI >30), 핍뇨 (urine output <50 ml/h), 빈맥 (pulse >120 beats/min), 뇌병증, 마약성진통제의요구량이증가하는경우에는전원에대비하여주위깊게관찰하도록기술하였다 7. 이탈리아가이드라인 (2010) 은 APACHE II score> 8을전원의기준으로기술하였다. 6 5) 대한췌담도학회제안중증급성췌장염으로평가된환자는집중치료실이있고, 내시경중재시술, 영상중재시술및수술처치가가능한병원으로전원해야한다. ( 권고등급 B?) 결론 우리나라의적합한급성췌장염의중증도평가에대한 가이드라인을마련하기위해본고에제시된내용으로결론을내리기에는자료나토의등준비가충분치않지만, 향후보다진전된결론에도달하기위한하나의과정으로생각하고, 급성췌장염의중증도평가를위해제안내용을요약하면아래와같다. 1. 중증도평가의필요성 (Necessity for severity assessment) 급성췌장염의중증도평가는적절한초기치료와향후치료전략의결정에필요하다. ( 권고등급 B) 2. 임상증상, 징후및임상검사를통한중증도평가 (severity assessment based on clinical symptoms, signs and clinical laboratory tests) 임상증상과징후에만근거한중증도평가는신뢰성이떨어지므로단순흉부촬영, 혈청 C-reactive protein (CRP), 혈청 blood urea nitrogen (BUN), 혈청 creatinine 측정등의객관적인임상검사가필요하다. ( 권고등급 B) 3. 영상검사를통한중증도평가 (severity assessment based on diagnostic imaging) 급성췌장염의중증도대한평가를위해서는조영증강복부전산화단층촬영의시행이필요하고, 장기부전, 패혈증및임상양상이악화되는경우경과관찰을위해추가시행을고려해야한다. ( 권고등급A) 중증도평가를위해 CT severity index 가사용되어야한다. ( 권고등급 A) 4. 중증도판정기준을이용한평가 (severity assessment based on scoring system) 췌장염의중증도평가를위해서는중증도판정기준을이용하여야하고, APACHE II 지표등을포함한여러중증도판정기준들이유용하게이용될수있다. ( 권고등급 B) 5. 전원기준 (Transfer criteria) 중증급성췌장염으로평가된환자는집중치료실이있고, 내시경중재시술, 영상중재시술및수술처치가가능한병원으로전원해야한다. ( 권고등급 B) 참고문헌 1. Russo MW, Wei JT, Thiny MT, et al. Digestive and liver diseases statistics, Gastroenterology 2004;126: Uhl W, Warshaw A, Imrie C, et al. IAP Guidelines for the Surgical Management of Acute Pancreatitis.

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