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Objective: The aim of this study was to develop a new international classification of acute pancreatitis severity on the basis of a sound conceptual framework, comprehensive review of published evidence, and worldwide consultation. Background: The Atlanta definitions of acute pancreatitis severity are ingrained in the lexicon of pancreatologists but suboptimal because these definitions are based on empiric descriptions of occurrences that are merely associated with severity. Methods: A personal invitation to contribute to the development of a new international classification of acute pancreatitis severity was sent to all surgeons, gastroenterologists, internists, intensive medicine specialists, and radiologists who are currently active in clinical research on acute pancreatitis. The invitation was not limited to members of certain associations or residents of certain countries. A global Web-based survey was conducted and a dedicated international symposium was organised to bring contributors from different disciplines together and discuss the concept and definitions. Result: The new international classification is based on the actual local and systemic determinants of severity, rather than descriptions of events that are correlated with severity. The local determinant relates to whether there is (peri)-pancreatic necrosis or not, and if present, whether it is sterile or infected. The systemic determinant relates to whether there is organ failure or not, and if present, whether it is transient or persistent. The presence of one determinant can modify the effect of another such that the presence of both infected (peri) pancreatic necrosis and persistent organ failure have a greater effect on severity than either determinant alone. The derivation of a classification based on the above principles results in 4 categories of severity - mild, moderate, severe, and critical. Conclusions: This classification is the result of a consultative process amongst pancreatologists from 49 countries spanning North America, South America, Europe, Asia, Oceania, and Africa. It provides a set of concise up-to-date definitions of all the main entities pertinent to classifying the severity of acute pancreatitis in clinical practice and research. This ensures that the determinant-based classification can be used in a uniform manner throughout the world.

Intestinal tuberculosis is a diagnostic challenge, particularly in the absence of active pulmonary infection. It mimics many other abdominal diseases, such as other infectious processes, tumours, periappendiceal abscess and Crohn’s disease. A case of primary intestinal tuberculosis without pulmonary disease is presented. A 40-year-old male was admitted with episodic right lower quadrant pain and weight loss (10 kg in 6 months). He was anaemic (haemoglobin 10.2 g ⁄ dl) and had a high erythrocyte sedimentation rate (76 mm ⁄ h). Other biochemical parameters were normal. Colonoscopy revealed a mass lesion at the ileocaecal valve (Fig. 1). The initial endoscopic diagnosis suggested a malignant lesion, but histological examination of biopsies showed chronic inflammation and noncaseous granulomas with Langhans giant cells (Fig. 2). Staining for acid-fast bacilli was negative. Although he had no history of tuberculosis, the patient’s father had been treated for pulmonary tuberculosis 4 years previously. The tuberculine skin test was 18 mm. Urine and stool cultures for acid-fast bacilli were all negative, as was PCR analysis. Chest radiography showed fibro-calcific signs in the apices of the lungs, but computed tomography was normal. Antituberculosis therapy was started and the patient’s condition improved on a four-drug regimen (isoniazide, pyrazinamid, ethambutol and rifampicine). He gained 15 kg during therapy and a colonoscopy 9 months later was normal. At this time the patient was free of symptoms and the antituberculous treatment was stopped. Tuberculosis can affect any part of the gastrointestinal tract but the most common site is the ileocaecal region. Lesions can be ulcerative, hypertrophic or a combination of both. Hypertrophic lesions are rare but can mimic a mass lesion as in our patient [1]. The PCR analysis of biopsy specimens obtained endoscopically has been shown to be more sensitive than culture and acid-fast stains in diagnosing intestinal tuberculosis, with positivity in 60% of colonic biopsies [2–4]. In our patient, histological examination of colonic biopsies showed noncaseous granulomas with Langhans giant cells, which are commonly seen in tuberculosis, sarcoidosis and Crohn’s disease. Sarcoidosis was excluded by the normal chest X-ray and normal angiotensinconverting enzyme levels. We also excluded Crohn’s disease as mass lesions are extremely rare. Histologically it is difficult to differentiate tuberculosis Crohn’s disease, but large granulomas (> 400 lm) and caseation gave a positive predictive value of 100% for tuberculosis in Pulimood’s study [5]. In our patient there were two large granulomas and caseation in the biopsy material, although staining of acid-fast bacilli was negative. This case illustrates that the diagnosis of colonic tuberculosis requires a high index of suspicion. Colonoscopic biopsy histology is a useful method for diagnosing colonic tuberculosis. Figure 1 Colonoscopy showing a mass lesion at the ileocaecal valve. Figure 2 Colonic biopsy showing a noncaseating granuloma.