Hypercholesterolemia , as a Predictor Factor of Severe Acute Pancreatitis

1 Department of Surgery, „Sf. Pantelimon” Emergency Clinical Hospital, „Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania 2 IIIrd Department of Surgery, Emergency University Hospital, „Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania 3 Department of Urology, Central Clinical Military Hospital, „Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania 4 Department of Internal Medicine, Emergency Clinical Hospital, „Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania Corresponding author: Bogdan Socea, Department of Surgery, „Sf. Pantelimon” Emergency Clinical Hospital, Bucharest, Romania. E-mail: bogdansocea@gmail.com Abstract


INTRODUCTION
Acute pancreatitis is a potentially severe disease that could lead to multiple organ dysfunction or failure.In our surgical clinic we observed lately an increasing number week of their fi rst admission.Some patients suff ered readmissions and surgical procedures for pancreatic pseudocysts, but all these evolution did not aff ect the study results.

RESULTS AND DISCUSSIONS
From the 237 patients, there were 149 men and 88 women (Figure 1).Th e disposition of age groups shows a predilection of onset at over 50 years for women (mean age for women in our study was 74.7 years) and over 30 years of age for men (mean age 58.3).Th e later onset for women could be explained by estrogen levels and the higher incidence of dyslipidemia and hypercholesterolemia after menopause 8,9 .We excluded a case of a pregnant woman 10 .
Th e diagram of age groups can be seen on Figure 2. Th e mean value of total cholesterol blood level at admission was 241 mg/dl.Th e mean values are diff erent between men and women (higher for men 249 mg/dl vs. 237 mg/dl for women).
From all the 237 patients included in study, a number of 206 patients (87%) had total blood cholesterol level above 240 mg/dl at admission time.Th is could be in Atlanta, in 2012, that introduced a new concept, of moderately-severe pancreatitis, compared to the initial classifi cation from 2007 1-3 .Severe acute pancreatitis (pancreatitis with unique or multiple persistent organ failure -over 48 hours) is responsible of approximately 15% from all acute pancreatitis.Th e mortality of this form is 7-10% 4,5 .
Moderately-severe pancreatitis means acute pancreatitis with transient organ failure, under 48 hours.
Th e most common causes of acute pancreatitis are: gallstones, alcohol consumption, dyslipidemia, iatrogenic pancreatitis, posttraumatic or postoperative.
Measuring cholesterol level is an eff ective method for identifying individuals with elevated triglyceride levels.Individuals with severe hyper-triglyceridemia have a substantially higher risk for developing coronary heart disease and acute pancreatitis than individuals with lower triglyceride levels 6,7 .
Th ere are discussions in the literature whether hypercholesterolemia in some specifi c cases is a trigger of a consequence of acute pancreatitis.We analyzed only the patients with a preexistent determination of total cholesterol level.

MATERIALS AND METHOD
We analyzed all the patients with acute pancreatitis admitted in the Surgical Department of "Sf.Pantelimon" Emergency Clinical Hospital in a fi ve years interval, 2013-2017.We excluded biliary and alcohol-induced pancreatitis.
We included in our study a total number of 237 cases of acute pancreatitis.Th e inclusion criteria were: non-biliary and non-alcoholic pancreatitis respecting the defi nition (abdominal pain and elevated pancreatic enzyme blood levels above three times of normal values).
Th e study was a prospective one.We collected any total cholesterol level determination before the moment of admission, on the admission day, after 72 hours (day four) and on day 7.
We treated and observed the patients, especially for organ dysfunction or failure (transitory or persistent), which are the elements of classifi cation for moderately-severe and severe forms.In our study, none of these patients underwent surgical interventions at in their fi rst week of admission.We had no criteria for operation (no complications requiring surgery in the fi rst moments).A number of 11 patients required surgical procedures for infected necroses in the second of third  considered a cut-off value for increased risk of developing acute pancreatitis.Comparing the results, a study form Spain found that prevalence of hypercholesterolemia ranged from 50 to 84% in diabetics, 64-74% with coronary heart disease, 40-70% in stroke patients, and 60-80% in those with peripheral artery disease 11 .A prevalence of 87% is above all these conditions.Some studies for hypercholesterolemia in general population found levels between 20% and 60%, depending on alimentary habits and direct corelated with obesity 12,13 .
We could not fi nd any other triggers that could be involved in ethiopathogeny of the patients from the study.
Severe acute pancreatitis developed in 21 cases (8.86%) and moderately-severe in 17 cases (7.17%) (Figure 3).Th e most encountered organ failures were renal, pulmonary and hepatic.Some cases had pancreatic encephalopathy, which seems to be more related to toxic (alcohol) induced pancreatitis than biliary or dyslipidemic ones 14 .
Together, moderately-severe and severe pancreatitis are responsible for 16% of cases, data concordant to literature (approximately 20% [1]).Th e mortality was 11.7% for moderately-severe form (2 cases), respectively 23.8% (5 patients) with severe pancreatitis, comparable with that mentioned in literature 15 .All the 5 patients that died of severe pancreatitis had increased abdominal pressure 16 .
We compared the cholesterol blood levels in day 3 and day 7 to the admission value for patients with mild pancreatitis, on one hand, and for patients that developed moderately-severe and severe forms, on the other hand.We did not found any major changes in cholesterol levels, in evolution of patients with mild form of disease.
For the group of patients with organ failure, no matter of organ failure persistence, we found an increased value of cholesterol level with a mean rate of 21% at day 3 and 53% at day 7. So, increasing values of total blood cholesterol in evolution of patients with acute pancreatitis can predict an evolution to severity.Th is is concordant to some studies in literature 17 .
An elevated cholesterol level at admission was not associated with increased mortality in our cohort, which is in accord with the fi ndings of some recent metaanalysis regarding triglycerides levels 18,19 .

CONCLUSIONS
Hypercolesterolemia is a trigger for acute pancreatitis.A blood level over 240 mg/dl could be considered a risk factor.
Increasing values of cholesterol blood levels during evolution predicts an poor outcome and an evolution to organ failure (transient -moderately-severe pancreatitis or persistent -severe pancreatitis) with high mortality.
Compliance with ethics requirements: Th e authors declare no confl ict of interest regarding this article.Th e authors declare that all the procedures and experiments of this study respect the ethical standards in the Helsinki Declaration of 1975, as revised in 2008(5), as well as the national law.Informed consent was obtained from all the patients included in the study.

Figure 2 .
Figure 2. Age distribution for men and women.