Early Upper Gastrointestinal Endoscopic Findings as Predictors of Disease Course and Severity in Acute Pancreatitis: A Prospective Observational Cohort Study

Acute pancreatitis is one of the most common acute gastrointestinal conditions requiring hospital admission and is associated with a highly variable clinical course. Although most patients develop a mild and self-limiting form of the disease, a clinically important proportion progress to moderately severe or severe acute pancreatitis, with local complications, systemic inflammatory response, organ failure, prolonged hospitalization, need for invasive interventions, and increased mortality. Early identification of patients at risk of an unfavorable course remains a major clinical challenge. Existing prognostic systems and laboratory markers are useful, but they do not fully capture all clinically relevant determinants of disease progression, particularly those related to early upper gastrointestinal mucosal injury, gastric and duodenal involvement, and local inflammatory response in the upper gastrointestinal tract.

The revised Atlanta classification provides a widely accepted framework for the diagnosis and severity assessment of acute pancreatitis. According to this classification, acute pancreatitis is diagnosed when at least two of the following three criteria are present: typical abdominal pain, serum amylase or lipase activity at least three times the upper limit of normal, and imaging findings consistent with acute pancreatitis. Disease severity is classified as mild, moderately severe, or severe. Mild acute pancreatitis is characterized by the absence of organ failure and local or systemic complications. Moderately severe acute pancreatitis is associated with transient organ failure lasting less than 48 hours and/or local or systemic complications without persistent organ failure. Severe acute pancreatitis is defined by persistent organ failure lasting longer than 48 hours, which may involve one or multiple organ systems.

Despite this classification, early prediction of clinical course remains imperfect. Laboratory parameters such as C-reactive protein, white blood cell count, blood urea nitrogen, creatinine, hematocrit, procalcitonin, and biochemical markers of cholestasis may be associated with severity, but their predictive performance varies. Radiological evaluation, particularly contrast-enhanced computed tomography, plays a key role in detecting pancreatic necrosis and local complications; however, early computed tomography may underestimate evolving changes, and the optimal timing for imaging is usually several days after symptom onset or admission. Clinical scores are available, but they can be complex, may require repeated measurements, and may not sufficiently reflect local upper gastrointestinal effects of the disease.

Upper gastrointestinal symptoms are common in acute pancreatitis. Patients frequently present with nausea, vomiting, epigastric pain, feeding intolerance, ileus, gastroesophageal reflux symptoms, or signs of gastric outlet dysfunction. The stomach and duodenum are anatomically close to the pancreas and may be affected by inflammatory edema, local vascular disturbances, impaired motility, stress-related mucosal injury, duodenal compression, and systemic inflammatory changes. Endoscopic abnormalities such as gastritis, duodenitis, erosions, ulcerations, mucosal edema, hemorrhagic lesions, bile reflux, esophagitis, or signs of impaired gastric emptying may therefore reflect both local and systemic consequences of acute pancreatitis. However, early upper gastrointestinal endoscopy is not routinely performed in all patients with acute pancreatitis, and the prognostic significance of early endoscopic mucosal changes remains insufficiently defined.

Preliminary retrospective observations from the study center suggest that upper gastrointestinal mucosal abnormalities are frequent in patients hospitalized with acute pancreatitis and may be associated with disease severity, inflammatory burden, Helicobacter pylori status, and the subsequent clinical course. These observations provide the rationale for a prospective study designed to systematically evaluate early endoscopic findings in a predefined cohort of adult patients with acute pancreatitis. A prospective design will allow standardized timing of endoscopy, uniform collection of clinical and laboratory data, systematic assessment of disease severity, and evaluation of the relationship between mucosal injury and clinically meaningful outcomes.