Management of Acute pancreatitis.ppt.

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Management of Acute Pancreatitis: 

Management of Acute Pancreatitis GUIDE : Dr. A. Vishnar CANDIDATE : Dr. Ashish Damor

OUTLINE: 

OUTLINE Diagnosis Etiology Assessing severity Treatment Complications

DIAGNOSIS: 

DIAGNOSIS FAIRLY SUDDEN ONSET UPPER ABD PAIN RADIATION TO BACK ELEVATED AMYLASE ELEVATED LIPASE UPPER LIMIT NORMAL > 3 IS DIAGNOSTIC CULLEN SIGN (PERIUMBILICAL BRUISING) GREY-TURNER SIGN (FLANK BRUISING)

CAUSES: 

CAUSES The Big Three: Gall Stones (40%) Alcohol (35%) Idiopathic (20%)

CAUSES: 

CAUSES The Others: Trauma (pancreatic duct injury) Post-ERCP Drugs (rare) 30 meds identified Azathioprine ( Imuran – immune suppressant) Valproic acid ( Depakote – seizures/mood stabilizer) Didanosine ( Videx – HIV med) Pentamidine (HIV – pneumocystis carinii Tx ) Mesalamine ( Asacol – ulcerative colitis Tx )

CAUSES: 

CAUSES Organ transplant, major surgery Hypertryglycerides (rare) Greater than 1000 mg/ dL Pregnancy Third trimester until 6 weeks post partum HIV 35 to 800 times greater risk of AP c/w general pop. Hypercalcemia Most often secondary to hyperparathyroidism Scorpion, spider, and Gila Monster lizard bites

PREDICTING CAUSES: 

PREDICTING CAUSES Gallstones: ALT > 150 IU/ dL  PPV >95% Ultrasound will see gallstones in 60-80% of cases (Less reliable for stones in CBD) MRCP sensitivity 90-100% Diagnostic Lipase > amylase

Initial management: 

Initial management Prompt fluid resuscitation. Oxygen supplementation to maintain SPO2 more than 95% Maintain urine output >0.5 ml/kg/Hr body weight. The rate of fluid replacement should be monitored by CVP Treat aggressively until disease severity has been established. Prophylactic IV Meropenem

Goal of initial management: 

Goal of initial management To maintain good organ perfusion Prevention of pancreatic necrosis Prevention of multi-organ damage Assess the severity of disease at presentation and at 48 hrs

SEVERITY : 

SEVERITY APACHE II Best test Can be done at 24 hrs, can be repeated Ranson’s Criteria (1974) Needs to be done at 24 and 48 hrs Balthazar’s (CT scan criteria) Glascow Single Markers of Severity

Assessment of severity: 

Assessment of severity Initial assessment Clinical impression of severity, BMI >30 Pleural effusion on CXR, APACHE II score >8 24 h after admission Clinical impression of severity APACHE II score >8 Persisting organ failure, especially if multiple C reactive protein >150 mg/l 48 h after admission Clinical impression of severity C reactive protein >150 mg/l Persisting organ failure for 48 h Multiple or progressive organ failure

Ranson’s criteria: 

Ranson’s criteria On admission Age > 55 years WBC > 16,000/ uL Glucose >200 mg/ dL (>11 mmol /L) LDH > 350 IU/L SGOT (AST) > 250 IU/L Ranson's criteria after 48hr of admission: Fall in hematocrit >10% Increase in BUN to > 5 mg/ dL (>1.98 mmol /L) Calcium <  8 mg/ dL (<2 mmol /L) PO2 < 60 mmHg Base deficit > 4 meq /L (>4 mmol /L) Fluid sequestration > 6 Liters

Atlanta criteria: 

Atlanta criteria Severity of AP Early Prognostic Signs Ranson signs ≥3 APACHE-II score ≥8 Organ Failure and/or Local Complications Necrosis Abscess Pseudocyst Severity of Organ Failure Shock–systolic pressure <90 mmHg PaO2 ≤60 mmHg Creatinine >2.0 mg/L after rehydration Gastrointestinal bleeding >500 cc/24 h

Indication for CT Scan: 

Indication for CT Scan Persisting organ failure Signs of sepsis Deterioration in clinical status 6-10 days after admission

Balthazar Grade : 

Balthazar Grade Appearance on CT CT Grade Points Grade A Normal CT 0 points Grade B Focal or diffuse enlargement 1 points of the pancreas Grade C Pancreatic gland 2 points abnormalities and peripancreatic inflammation Grade D Fluid collection in a single location 3 points Grade E Two or more fluid collections and / or 4 points gas bubbles in or adjacent to pancreas

Prognosis in Acute Pancreatitis : 

Prognosis in Acute Pancreatitis Median (%) Range (%) All cases 5 2–9 Interstitial pancreatitis 3 1–7 Necrotizing pancreatitis 17 8–39 Infected necrosis 30 14–62 Sterile necrosis 12 2–44

NUTRITION: 

NUTRITION Enteral nutrition is tolerated by most patients with severe acute pancreatitis. Mild- within 24 hrs, Severe 48-72 Hrs The naso-gastric route for feeding can be used as it appears to be effective in 80% of cases No added benefit of Naso-jejunal tube feeding If not tolerated then TPN may be an alternative

NUTRITION : 

NUTRITION Traditionally – NBM, then introduce oral nutrition when tolerating. TPN for severe cases who failed to settle SE’s of TPN (line, metabolic) may offset any advantages Recently trials of enteral feeding shown to be safe, well tolerated in AP Controlled trials enteral v TPN - no difference or marginal benefit for enteral Try to establish enteral nutrition in all pts with AP. Reserve TPN for those pts with persistent ileus

GALLSTONES: 

GALLSTONES ERCP – Clinical deterioration or lack of improvements after 24 hrs. Detection of CBD stones or dilated intrahepatic or extrahepatic ducts on CT Urgent therapeutic ERCP + Surgery all for pts with AP due to gallstones OR when there is cholangitis / jaundice / dilated CBD Best carried out  72h onset pain

Prophylactic Antibiotics: 

Prophylactic Antibiotics Prophylactic antibiotic use is not recommended routinely In severe disease it may be considered Imipenem-cilastin and meropenem are found to be most effective in preventing infective complications If antibiotic prophylaxis is used, it should be given for a maximum of 14 days

Complications of AP: 

Complications of AP Pancreatic necrosis sterile, infected Pancreatic pseudocyst

SURGICAL INTERVENTIONS OF NECROSIS: 

SURGICAL INTERVENTIONS OF NECROSIS Difficult area, high mortality, no controlled trials Decision to intervene depends on clinical picture/evidence of sepsis/demonstration of necrosis on CT General agreement that infected necrosis requires drainage, sterile necrosis treated conservatively Infection diagnosed by FNA aspiration or gas bubbles on CT

Conclusion: 

Conclusion Acute pancreatitis is common clinical problem Early diagnosis and prompt treatment may prevent organ failure Severe disease carries high mortality Nutritional support should be given within 72 hrs Prophylactic antibiotic use is controversial

THANK YOU: 

THANK YOU