Acute pancreatitis reclassified - twice!

Acute pancreatitis is a fairly common disease mot often caused by either gallstone disease or alcohol, with a number of other causes involved as well. The natural history may be unpredictable - mild disease usually resolves without any or just little medical support, while severe disease may involve into several complications, need for organ support and intensive care, and have a mortality as high as 30%.
Predicting which patient will develop severe disease is difficult, with a number of scoring systems proposed over the years; the Ranson score, Imrie (or Glasgow) score, the Harmless Acute Pancreatitis Score (HAPS), the APACAHE II score, JSS, BISAP, SIRS, Panc, POP, and so on...
However, noen of these work perfectly - the clinical prediction riles have reached their limitation (see Mounzer, Gastroenterology, 2012).

Disease severeity and classification of acute pancreatitis have been based on the Atlanta consensus from 1992. Several components of this classification have been controversial and critized over the years, and several research groups have argued for better definitions in order to compare results between studies and generate commonly agreed definitions for conducting trials.

This work has over the past several years come to fruition through two released international consensus reports:

One from the "Acute Pancreatitis Classification Working Group"

Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, Tsiotos GG, Vege SS; Acute Pancreatitis Classification Working Group. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2012 Oct 25. [Epub ahead of print]


and the other one from the PANCREA group

Dellinger EP, Forsmark CE, Layer P, Lévy P, Maraví-Poma E, Petrov MS,Shimosegawa T, Siriwardena AK, Uomo G, Whitcomb DC, Windsor JA; Pancreatitis Across Nations Clinical Research and Education Alliance (PANCREA). Determinant-Based Classification of Acute Pancreatitis Severity: An International Multidisciplinary Consultation. Ann Surg. 2012 Dec;256(6):875-880.

The consensus reports will hopefully allow for commonly agreed terms and definitions for future research. A problem is obviously that the two reports divert somewhat in their agreement in the number of categories neede for classifying acute pancreatitis. In the Gut paper the authors have defined a 3-tier system og mild, moderate and severe pancreatitis. The Annals paper have added a fourth group, named crititcal acute pancreatitis, when organ failure persists WITH the addition of infected (peri)pancreatic necrosis.

The Gut paper has emphasized several agreed terms and definitions for radiological classification of early (<4 weeks) and late (>4 weeks) fluid collections (such as "acute peripancreatic fluid collection; APFC" and "walled off necrosis; WON") to be distinguished from other terms such as "pseudocysts" and the now abandonded term "pancreatic abcess".

Which of the two suggestions will prevail over the other remains to be seen.