Acute Pancreatitis Basics

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Acute Pancreatitis Department of Critical Care Medicine King Saud Medical City Riyadh, Saudi Arabia Muhammad Asim Rana MBBS, MRCP, SF-CCM, EDIC, FCCP

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Learning Objectives Diagnose acute pancreatitis and determine the severity, etiological factors and complication s. Recognize the patient at risk. Manage severe acute pancreatitis with appropriate use of supportive therapy for organ function, antibiotics and surgery. Feed the patient with acute pancreatitis. Determine nutritional needs of patients with acute pancreatitis and the optimum mode of delivery. Identify and manage local and systemic complications of acute pancreatitis 1 2 3 4

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INTRODUCTION Reported incidence ranges from 21 to 900 cases per million, per year. 2. Overall mortality rate ranges from 2 to 10% but reaches 10 to 40% in ANP. Those > 60 years are at the highest risk of death as consequence of co morbidity. The male/female ratio ranges from 1/1.2 - 1/1.5. Females for biliary pancreatitis & males for acute pancreatitis secondary to alcohol abuse. Epidemiology of acute pancreatitis 1 2 3 4

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GALL STONES ETHANOL TRAUMA STEROIDS MUMPS/VIRUSES AUTOIMMUNE (PAN) SCORPION VENOM/Toxins HYPERLIPIDEMIA ERCP DRUGS G E T S M A S H E D Causes of Acute Pancreatitis

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Diagnosis of acute pancreatitis Symptoms Signs Grey Turner’s sign Cullen’s Sign

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Laboratory Investigations S/Amylase S/Lipase Urine amylase Other Enzymes Non enzymatic pancreatic secretory products  PAP TAP CAPAP Markers of immune activation & nonspecific markers   IL-6, IL-8, IL- 10 TNF PMN Elastase CRP

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Radiological Investigations Plain X-Ray Ultrasound CT Scan MRI Pancreatitis without pain is particularly misleading. Lack of a major symptom is usually attributed to a postoperative situation where analgesics/sedatives are in use. Diagnostic pitfalls Diabetic coma severe hypothermia remote organ failures Severe GI bleeding

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Pancreatic swelling Lack of enhancement Peri -pancreatic fluid collection Diagnostic Imaging

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How to recognize the at risk patient System Manifestations Significance General CVS Pulmonary Renal Neurological Abdominal Age > 60 BMI > 30 Kg/m 2 Risk of local & systemic complications ↓ BP, ↑HR,↑ Lactate Tachypnea, Cyanosis ↓ OUT PUT ↑ Creatinine Confusion Agitation Tense abdomen Rebound Tenderness Risk of local & systemic complications Impending remote organ failure Impending remote organ failure Impending remote organ failure Extent of peritoneal involvement

Definition of severe pancreatitis:

Definition of severe pancreatitis Acute pancreatitis + organ failure and/or Acute pancreatitis + local complications Three or more Ranson Criteria OR APACHE II > 8

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Early assessment of severity Ranson’s criteria ON Admission After 48 hours G A L A W Glucose > 200 mg% Age > 55 yrs LDH > 350 AST > 250 WBCs > 16000 C H O B B S Calcium < 8.0 Haematocrit ↓ by > 10% PaO 2 < 60 Base Excess > 4 BUN ↑ > 5 mg% Sequestered fluid > 6 liters

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Glasgow ( Imrie ) scoring system P A N C R E A S PaO2 < 8kPa Age > 55yrs Neutrophils (WBCs)> 15x 10 9 / L Calcium < 8mg% (2mmol) Renal – Urea > 16 mmol /L (45 mg/ dL ) Enzymes LDH > 600 iU /L, AST > 200iU/L Albumin < 32 G /L Sugar (Blood Glucose)> 10 mmol /L (180mg%)

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Grading based upon findings on unenhanced CT Grade Findings Score A Normal pancreas - normal size, sharply defined, smooth contour, homogeneous enhancement, retroperitoneal peripancreatic fat without enhancement 0 B Focal or diffuse enlargement of the pancreas, contour may show irregularity, enhancement may be inhomogeneous but there is on peripancreatic inflammation 1 C Peripancreatic inflammation with intrinsic pancreatic abnormalities 2 D Intrapancreatic or extrapancreatic fluid collections 3 E Two or more large collections of gas in the pancreas or retroperitoneum 4

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Necrosis, percent SCORE 0 0 Less than 33% 2 33-50% 4 More than 50% 6 Necrosis score based upon contrast enhanced CT

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AGA Guidelines for CT Scan Patients in whom the diagnosis is in doubt. Patients with Ranson >3 or APACHE II ≥8 In patients with predicted severe disease and those with evidence of organ failure during the initial 72 hours, rapid-bolus CT should be performed after 72 hours of illness to assess the degree of pancreatic necrosis. Labs adjunct to clinical judgment and the APACHE II . A CRP level of >150 mg/L at 48 hours is preferred

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Other Severity Indices The APACHE II score Systemic inflammatory response syndrome score Bedside index of severity in acute pancreatitis (BISAP) score Harmless acute pancreatitis score Organ failure-based scores 

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Management of Severe Acute Pancreatitis General Intensive Care Specific Treatment Modalities Surgery or No Surgery Feeding the patient Managing the Complications

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General intensive care Supportive therapy of vital organs Cardiovascular system Nowadays infection of pancreatic necrosis accounts for 50-80% of the deaths Splanchnic ischaemia is a 2nd local hit: Retroperitoneal necrosis, gut barrier dysfunction, and Secondary pancreatic infection may ensue Local splanchnic perfusion may be worsened by abdominal compartment syndrome- increased pressure due to intra abdominal oedema , fluid sequestration and excessive fluid resuscitation. Respiratory system Prevention/correction of hypoxia. Early physiotherapy and adequate analgesia (perhaps using epidural analgesia) to ensure free airways and to prevent atelectasis , prevent pulmonary aspiration by nasogastric decompression. CPAP/ BIPAP/ Invasive Mechanical Ventilation Renal system Prevent and/or minimize renal injury by rapid correction of hypovolaemia If acute renal failure develops, start renal replacement therapy without delay to ensure optimal fluid and metabolic control and to enable nutritional support without haemodynamic instability. CVVHD is preferred. Gastrointestinal system Beware of intra-abdominal hypertension and assess the patient for this complication regularly. If abdominal compartment syndrome occurs, consider decompression either surgically or in cases of colonic distension with a wide bore tube inserted via the rectum. Abdominal compartment syndrome should be suspected whenever there is evidence of new or worsening organ dysfunction. Pain relief Conventional Analgesics (IV) Use of MORPHINE Epidural Analgesia ( mixture of diluted local anaesthetic solution ( bupivacaine ) and opiates) Miscellaneous Octreotide Somatostatin Protease Inhibitors ( Aprotinin & Gabexate Mesilate ) Anti inflammatory Rx Stress Ulcer Prophylaxis DVT Prophylaxis

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Specific therapeutic modalities Antibiotics Systemic Antibiotics Use antibiotics on demand for sepsis rather than prophylactically ! Selective Decontamination of the Digestive system (SDD) Antibiotics are an adjuvant therapy in infected pancreatic necrosis. Drainage is mandatory for most if not all pancreatic infections.

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Indications for surgery Controversial indications Undisputed indications Infected pancreatic necrosis when percutaneous /other techniques not indicated Severe retroperitoneal haemorrhage Acute abdomen – peritonitis Biliary obstruction in case of failure of Endoscopic Sphincterotomy Abdominal compartment syndrome where percutaneous /other drainage techniques not successful. Controversial indications Extensive (>50%) sterile pancreatic necrosis Early ‘routine’ debridement of necrosis irrespective of its bacteriological status in order to prevent remote organ dysfunction and pancreatic infection Persisting multiple organ failure despite intensive care therapy Early and repeated removal of necrotic tissue combined with continuous drainage/ lavage have been advocated to overcome systemic effects. Neither the extent of sterile pancreatic necrosis, the clinical severity of the disease or the duration of intensive supportive therapy should be regarded as indications for surgery. NOTE

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Feeding the pt of SAP Nutritional therapy: How, what and when? Route of nutrient delivery: Enteral versus parenteral The more distally that nutrients are infused in the gut, the less they stimulate pancreatic secretion The enteral route is safe in acute pancreatitis, so whenever possible, use it! In order to maximise clinical benefit, enteral feeding should be initiated as soon as possible after admission in all attacks predicted to be severe. Patients in whom enteral access cannot be achieved or in whom clear-cut contraindications (intestinal rupture, obstruction, or necrosis), intolerance, or exacerbation of the disease occurs should be considered for partial or total parenteral nutrition (TPN).

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Some Important Aspects of Feeding Composition of the diet Prescription and timing of nutrient administration Issue of Functional Ileus Oral refeeding Complications of nutritional therapy

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Resuscitation Severity Index Severe Disease Mild Disease Conservative Rx CT Scan Balthazar > 7 Balthazar < 7 Management of Severe Acute Pancreatitis

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Balthazar > 7 Aggressive Hydration/ Antibiotics/ Entral feeding/ TPN No Improvement Improvement Continue Same Rx CT Guided Aspiration Deterioration

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CT Guided Aspiration Infected Sterile Supportive Rx Appropriate Antibiotics Attempt to wait for 3-4 weeks from onset NO IMPROVEMENT ?

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NO IMPROVEMENT ? Organized Collection Diffuse Collection Percutaneous / Endoscopic/ Laparoscopic drainage Minimal access or Surgical Debridement

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Approach to Treat NECROSIS Fine Needle Aspiration Sterile Infected Aggressive ICU Rx Improvement No Improvement Endoscopic Expertise Available YES NO Necrosectomy Percutaneous Drainage

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Necrosectomy Necrosis Endoscopically Accessible (posterior gastric or medial duodenal wall) Necrosis in peripancreatic , retrodudenal , perinephric Endoscopic Necrosectomy Laparoscopic Necrosectomy No Improvement Surgical Drainage Adjuvant Percutaneous Drainage

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I think its enough Thanks a lot for your patience

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