Acute Pancreatitis

Acute Pancreatitis: 

Acute Pancreatitis Dr A Aditya Satya Prasanna M.D.,D.M Arunaditya Institute of Gastroenterology and Hepatology

Definition : 

Definition The clinical definition of acute pancreatitis, whether in the presence or absence of underlying chronic pancreatitis, requires 2 of the following 3 features: 1) Abdominal pain suggestive strongly of acute pancreatitis, 2) Serum amylase and/or lipase activity at least 3 times greater than the upper limit of normal, and 3) Characteristic findings of acute pancreatitis on transabdominal ultrasonography or on CECT, which is considered to be the best, most universally available imaging modality

Pathogenesis : 

Pathogenesis

Classification : 

Classification Working Group Classification – 2007 ACUTE PANCREATITIS Interstitial edematous pancreatitis (IEP) Necrotizing pancreatitis (pancreatic necrosis and/or peripancreatic necrosis) Sterile necrosis Infected necrosis

Classification: 

Classification FLUID COLLECTIONS DURING ACUTE PANCREATITIS (<4 weeks after onset of pancreatitis) Acute peripancreatic fluid collection (APFC) Sterile Infected Post-necrotic pancreatic/ peripancreatic fluid collection (PNPFC) Sterile Infected

Classification: 

Classification (>4 weeks after onset of pancreatitis) Pancreatic pseudocyst (usually has increased amylase/lipase activity) Sterile Infected Walled-off pancreatic necrosis (WOPN) (may or may not have increased amylase/lipase activity) Sterile Infected

Diagnosis : 

Diagnosis Sensitivity for serum amylase of 72% and specificity of 99% Sensitivity of lipase was 100% and the specificity was 96%

Diagnosis: 

Diagnosis

Assessment of Severity: 

Assessment of Severity 15%–20% of patients with acute pancreatitis will develop severe disease and follow a prolonged course, typically in the setting of pancreatic parenchymal necrosis. Only about 2%–3% of patients overall die from acute pancreatitis Half the deaths occur in the first week due to multiorgan system failure Deaths after the first week are also usually due to multiorgan system failure but secondary to the development of infected pancreatic necrosis

Assessment of Severity: 

Assessment of Severity Ranson’s Criteria - Sensitivity of 3 or more criteria to predict severe disease was 65% with a specificity of 99%, yielding a PPV of 95% and a NPV of 86%

Assessment of Severity: 

Assessment of Severity Parameter 1974 Criteria for Nongallstone Pancreatitis 1982 Criteria for Gallstone Pancreatitis At Admission Age (years) >55 >70 White blood cell count (cells/mm3 ) >16,000 >18,000 Blood glucose (mg/ dL ) >200 >220 Lactate dehydrogenase (IU/L ) >350 >400 Aspartate aminotransferase >250 >250

Assessment of Severity: 

Assessment of Severity Parameter 1974 Criteria for Nongallstone Pancreatitis 1982 Criteria for Gallstone Pancreatitis During Initial 48 Hours Decrease in hematocrit (%) >10 >10 Increase in blood urea nitrogen (mg/ dL ) >5 >2 Calcium (mg/dL) <8 <8 pO2 (mm Hg) <60 NA Base deficit (mEq/L) >4 >5 Estimated fluid sequestration >6 >4

Assessment of Severity: 

Assessment of Severity At admission, the sensitivity of an APACHE II score ≥ 7 to predict severe acute pancreatitis is 65%, with a specificity of 76%, a PPV of 43%, and an NPV of 89%. At 48 hours, the sensitivity of an APACHE II score ≥ 7 to predict severe acute pancreatitis is 76%, with a specificity of 84%, a PPV of 54%, and an NPV of 93%

Assessment of Severity: 

Assessment of Severity Pancreatic isoamylase , Phospholipase A2, Elastase 1, Anionic trypsinogen (trypsinogen-2), etc Serum C-reactive protein level 150 mg/L at 48 hours after disease onset is preferred

Assessment of Severity: 

Assessment of Severity The definition of severe acute pancreatitis is the persistence of organ failure that exceeds 48 hours duration

Assessment of Severity: 

Assessment of Severity

CECT Abdomen: 

CECT Abdomen The role of CT in patients with acute pancreatitis can be to confirm the diagnosis, exclude alternative diagnoses, determine severity, and identify complications. It has been stated that 15%–30% of patients with mild pancreatitis may have a normal CT scan

CT Scoring System: 

CT Scoring System

Determination of Etiology: 

Determination of Etiology Extensive or invasive evaluation is not recommended in those with a single episode of unexplained pancreatitis who are younger than 40 years of age

Determination of Etiology: 

Determination of Etiology

Determination of Etiology: 

Determination of Etiology

Determination of Etiology: 

Determination of Etiology Proven Probable Possible/Questionable L- Asparaginase Protease inhibitors Carbamazepine Azathioprine Acetaminophen Corticosteroids Didanosine 5-Aminosalicylic acid Cimetidine Estrogens Ergotamine Furadantin ACE inhibitors Furosemide Metronidazole 6-Mecaptopurine Isoniazid Minocycline Pentamidine Procainamide Piroxicam Sulfasalazine Rifampicin Ranitidine Valproate Thiazides Tetracycline

Management : 

Management Supportive care includes Appropriate triage, Adequate fluid resuscitation, Correction of electrolyte and metabolic imbalances, Effective pain control, Provision of nutrition if a prolonged period of “nothing by mouth” is anticipated

Management: 

Management Adequate fluid resuscitation should produce a urine output of at least 0.5 mL · kg body wt1 · h1 The acute respiratory distress syndrome occurs in up to 20% of patients with severe acute pancreatitis.

Management: 

Management Nutritional support should be considered when patients are unlikely to be able to eat for at least 7 days. Artificial feeding has no role or benefit in patients with mild acute pancreatitis who are expected to begin eating within 7 days A meta-analysis of 6 randomized trials of TPN compared with enteral nutrition delivered by a nasojejunal tube placed beyond the ligament of Treitz noted an overall reduction in infections in those receiving enteral nutrition (relative risk, 0.45; 95% CI, 0.26 – 0.78) and a reduction in the need for pancreatic surgery but no reduction in other complications (organ failure) or mortality

Efforts to “rest” the pancreas: 

Efforts to “rest” the pancreas The simplest method of limiting pancreatic secretion is prescribing nothing by mouth Largest single randomized trial of octreotide in 302 patients with moderate to severe acute pancreatitis found absolutely no effect on mortality, organ failure, or secondary infections

Efforts to reduce or remove activated proteases.: 

Efforts to reduce or remove activated proteases. Small-molecular- weight antiprotease gabexate mesilate Meta-analyses of 5 randomized studies noted no decrease in overall mortality (OR, 0.94; 95% CI, 0.55–1.62) but found a reduction in the overall complication rate

Gallstone pancreatitis: 

Gallstone pancreatitis Urgent ERCP (within 24 hours) should be performed in patients with gallstone pancreatitis who have concomitant cholangitis . Early ERCP (within 72 hours) should be performed in those with a high suspicion of a persistent common bile duct stone (visible common bile duct stone on noninvasive imaging, persistently dilated common bile duct, jaundice). Endoscopic sphincterotomy in the absence of choledocholithiasis at the time of the procedure is a reasonable therapeutic option

Gallstone pancreatitis: 

Gallstone pancreatitis Pts with gallbladder in situ, definitive surgical management ( cholecystectomy ) should be performed in the same hospital admission if possible and, otherwise, no later than 2–4 weeks after discharge. Preoperative ERCP was the most cost-effective approach when the prevalence of common bile duct stones reached ≥ 80%. If prevalence of common bile duct stones was ≤ 80%, laparoscopic common bile duct exploration or, if unavailable, postoperative ERCP were most cost effective. In patients in whom a preoperative question exists as to the presence of persistent common bile duct stones, preoperative EUS or MRCP is appropriate rather than proceeding directly to ERCP

Prophylactic Antibiotics: 

Prophylactic Antibiotics Most experts agree that if antibiotic prophylaxis is considered, it should be restricted to patients who are at reasonable risk of developing infected pancreatic necrosis (a cutoff of at least 30% of the gland being necrotic on CECT is a reasonable one). The choice of antibiotic should be one with adequate penetration into the necrotic material, either imipenem-cilastatin , meropenem , or a combination of a quinolone and metronidazole Prophylactic antibiotic therapy, once started, should continue for no more that 14 days

Complications : 

Complications

Complications: 

Complications

Management of necrosis: 

Management of necrosis Sterile necrosis does not usually require therapy. The development of infected necrosis should be suspected in those patients with preexisting sterile pancreatic necrosis who have persistent or worsening symptoms or symptoms and signs of infection, typically after 7–10 days of illness. The finding of gas within the pancreas in CECT is highly suggestive, although not diagnostic, of infected necrosis Fine-needle aspiration guided by CT imaging should be performed and the sample should be cultured and Gram stained to document infection

Management of necrosis: 

Management of necrosis The standard approach to infected necrosis has been open surgical debridement. Increasing trend to delay surgery as long as possible, even in the face of a positive result on FNA, if the clinical situation allows. This delay has the advantage of allowing necrotic material to demarcate and begin to liquefy, making complete initial necrosectomy more likely, and reducing the need for repeated debridement. The delay-until liquefaction strategy also allows nonsurgical therapies

Pancreatic fluid collections and pseudocyst: 

Pancreatic fluid collections and pseudocyst Acute fluid collections around the pancreas in the setting of acute pancreatitis require no therapy in the absence of infection or obstruction of a surrounding hollow viscus Approximately half of these fluid collections will resolve within 6 weeks, and up to 15% will persist as encapsulated pseudocysts Pseudocysts can be managed conservatively, particularly if they are small (6 cm) and asymptomatic

Pancreatic fluid collections and pseudocyst: 

Pancreatic fluid collections and pseudocyst Pseudocysts may produce symptoms (generally abdominal pain), obstruct surrounding organs (duodenum, stomach, or bile duct), become infected, rupture, or bleed Surgical, radiologic, and endoscopic options are available for the management of large or symptomatic or complicated pseudocysts . The choice of approach depends on location, size, pancreatic ductal anatomy, and, most importantly, local expertise

Pancreatic fluid collections and pseudocyst: 

Pancreatic fluid collections and pseudocyst Infected pseudocysts Bleeding from a pseudocyst

Pancreatic fluid collections and pseudocyst: 

Pancreatic fluid collections and pseudocyst

Role of Surgery: 

Role of Surgery Surgery has no immediate role in patients with mild acute pancreatitis. The development of infected pancreatic necrosis is an indication for intervention, with surgery or an alternative technique Early surgery (within the first 14 days) should be avoided because it is associated with increased mortality.

Thank you for your Patience : 

Thank you for your Patience