Context Acute pancreatitis is a protean disease with wide and varied presentation from mild to critical with no accurate predictors of severity available. Objective Since pancreatic and leucocyte proteases are the early markers to rise in acute pancreatitis, we hypothesised that these mediators may be early predictors of pancreatitis severity. Methods The literature was searched for all studies that evaluated proteases, protease precursors, anti-proteases and protease-anti-protease complex in the prediction of acute pancreatitis severity from January 1985 to December 2014. A study was included in this systemic review if it had a prospective design and provided sensitivity, specificity or allowing the derivation of true positive, false positive, false negative and true negative results. A random-effects model was used to calculate the pooled estimates. Results There were 44 studies with 9 different serological protease-related markers with seven of these studies yielding data on more than one marker. Serum polymorphonuclear elastase at 24 hrs had a diagnostic odds ratio of 70.4 (21-235.7) with a positive predictive value of 80% followed by serum carboxypeptidase activation peptide with diagnostic odds ratio of 18.4 (5.1-66.7) and positive predictive value of 66%. Conclusions Serum polymorphonuclear elastase may be a very early and sensitive predictive marker of acute pancreatitis severity.
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