Acute Pancreatitis Case Discussion

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Clinical case presentation and discussion on acute severe pancreatitis

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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

Acknowledgement :

Acknowledgement This presentation has been prepared from Uptodate ESICM PACT Module Adult Multiprofessional Critical Care

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Identifying & Managing the Complications of Acute Pancreatitis Pancreatic Infection Infected Necrosis or Abcess

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Identifying & Managing the Complications of Acute Pancreatitis

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Pancreatic Necrosis

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Pancreatic Abcess

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Haemorrhage and perforation

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Pseudocysts and pancreatic fistulas

Case 1:

Case 1 You are called to the Gastroenterology unit to attend to a 56-year-old obese man who is in cardio-respiratory distress. While reviewing the patient's record you see that he has a four-year history of alcohol abuse and that he was admitted to the hospital via the emergency room 36h previously with a two-day history of epigastric pain and vomiting.

On admission vital signs:

On admission vital signs blood pressure of 95/30 mmHg, a pulse rate of 110 beats/min, a respiratory rate of 28 breaths/min and an axillary temperature of 38.6 ºC. The abdomen was distended and diffusely tender on palpation without guarding. No bowel sounds were heard.

Laboratory data included: :

Laboratory data included: Haematocrit 51% White blood cell count 18 000/ml Blood glucose 11.6 mmol /l Calcium 1.95 mmol /l Creatinine 195 μ mol/l Lactate dehydrogenase 980 IU/l C-reactive protein 15 mg/dl Amylase 180 IU/l Lipase 1540 IU/l The serum was lipaemic .

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What you’d like to know? Early assessment of severity Scoring systems Biochemical indicators Role of CT PaO2 of 7.7 kPa lactate 2.4 mmol /l A chest X-ray demonstrated a moderate right pleural effusion and elevation of the diaphragm Abdominal ultrasound examination showed a slightly dilated common bile duct without evidence of stones.

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CT revealed a moderate enlargement of the pancreas without enhancement defect and small fluid collections around the head and the tail of the gland. The patient was on the ward, having ‘nil by mouth’ and had received non- opioid analgesics, oxygen by nasal cannulae and crystalloids 3000 ml/day.

What is your assessment & plan?:

What is your assessment & plan? Immediate referral to ICU is appropriate. There are signs of hypovolaemia , renal dysfunction, major risks of respiratory failure as well as biochemical indicators of an ongoing inflammatory and necrotising process in the pancreatic area. Early multiple organ dysfunction syndrome is a likely event and this warrants at least close observation and preventive measures in a Critical Care area.

What therapeutic measures would you have taken from the outset?:

What therapeutic measures would you have taken from the outset? Firstly, aggressive fluid resuscitation in an effort to protect or restore the microcirculation, especially in the splanchnic area and at the same time respiratory support. The latter should include chest physiotherapy, relief of pain, nasogastric suction supplemental oxygen. Consideration could be given to non-invasive positive pressure ventilation. Aspiration and atelectasis with secondary bacterial infection are the main causes of early respiratory failure in acute pancreatitis especially in an alcoholic patient.

During the next 72h, his condition remains precarious. :

During the next 72h, his condition remains precarious. Central venous cannulation , titrated fluids High dose of norepinephrine MAP 70 mmHg. Lactate levels range between 1.5 and 3 mmol /l Haemodynamic assessment demonstrates a hyperdynamic circulation and increased extravascular lung water. Mechanical ventilation is carried out with low tidal volume and an adjusted positive end-expiratory pressure (PEEP) between 10–15 cm H2O. The PaO2/FiO2 ratio is 60–100 mmHg. The patient is anuric and is started on continuous veno -venous haemodiafiltration (CVVH). Core temperature ranges from 37.4 ºC -39.5ºC. Ecchymotic spots appear on the flanks. There is 1000 ml/day of bile-stained nasogastric reflux.

Relevant laboratory data on ICU admission are: :

Relevant laboratory data on ICU admission are: White blood-cell count 23 000/ml Platelets 40 000/ml C-reactive protein 30 mg/dl Creatinine 362 μ mol/l Total bilirubin 68 μ mol/l On admission to the ICU Ranson and APACHE II scores are 9 and 24, respectively. On the fourth day FiO2 was decreased to 0.6.

Which procedure is now urgently required for this patient?:

Which procedure is now urgently required for this patient? You should recommend a contrast-enhanced abdominal CT scan in order to identify and localise the presence of ( peri )pancreatic necrosis, to appreciate its extent and to assess bacteriologic status by CT-guided percutaneous sampling, Gram stain and appropriate cultures.

CT Done!!:

CT Done!! CT indicates the presence of necrosis of more than 50% of the pancreas as well as widespread fluid collections. The Balthazar CT severity index is 10 No gas is detected outside the digestive tract and cultures of percutaneous aspirates yield no micro-organisms.

Lets Talk!!!:

Lets Talk!!! Assuming sterile necrosis would you now consider surgery? Assuming sterile necrosis which specific therapeutic measures would you implement other than continuing intensive support of failing organs? Would you have recommended an alternative approach to the patient's management given that multiple organ failure persisted in spite of intensive therapy? What are the two main metabolic issues relating to early feeding in this kind of patient?

The patient left the hospital on day 50. At the follow-up visit one year later abdominal CT indicated complete resolution of fluid collections and atrophy of the pancreas:

The patient left the hospital on day 50. At the follow-up visit one year later abdominal CT indicated complete resolution of fluid collections and atrophy of the pancreas After your Successful Management

Case 2:

Case 2 A 61-year-old male, with a history of severe Parkinson's disease and hypertension, is admitted to the local hospital with acute pancreatitis of moderate severity.

Case 2 progress:

Case 2 progress On day 2, endoscopic ultrasound is performed, showing a stone in the main bile duct. On day 4, endoscopic sphincterotomy removes the stone, but this is followed by clinical deterioration with fever, chills and blood culture positive for E. Coli. Antibiotic treatment is ineffective and the patient is referred to the University Hospital on day 13.

What would you do?:

What would you do? The appearances on the initial CT scan are dramatic, with necrosis of the peripheral areas of the pancreas, associated with a heterogeneous collection, while the core of the gland remains well perfused .

Now What?:

Now What? Fine needle aspiration under CT guidance produces a purulent exudate containing Gram-negative rods (E. Coli). The patient undergoes surgery on day 30. Debridement of the necrotic tissue situated around the gland results in large cavities, which are then packed. A jejunostomy and an ileostomy (with a view to preventing colonic complications) are undertaken. No biliary drainage is possible. Packing is subsequently replaced by drains. FNA & Culture!!!

Case 2 progress:

Case 2 progress Despite the development of a pancreatic fistula the general condition of the patient improves and he is discharged at day 75.

Case 2 progress:

Case 2 progress One year later the patient is admitted for recurring episodes of abdominal pain, vomiting and increased pancreatic enzymes. Now What to do ?

Case 3:

Case 3 A 45-year-old alcoholic male, is admitted to a local hospital with acute pancreatitis. Severity criteria are not available, therefore the Ranson score is unknown. The general symptoms recede but pain recurs following every attempt at feeding. A CT scan is performed on day 19 after onset, showing a rupture of the pancreas and a fluid collection at the level of the neck of the gland. What do U want to do?

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Food intolerance is a sign of complications or of persisting inflammation. CT-scan allows direct observation of the local evolution of the disease. Organisation of a diffuse infiltrate into an organised collection is frequent

The patient is in a good general condition, but still unable to tolerate any food.:

The patient is in a good general condition, but still unable to tolerate any food. The patient is referred to the University Hospital on day 23. A CT scan is performed on day 27 showing that the fluid collection is thick walled.

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Q. What approach would you suggest at this stage: Operate, continue medical treatment, or establish percutaneous or endoscopic drainage? A. You should establish percutaneous , endoscopic, or surgical drainage . Local expertise may play a decisive role in the choice of the therapeutic approach. Persistent illness is the only remaining (late) surgical indication for sterile ‘ organised ’ necrosis

Case 3 progress:

Case 3 progress A percutaneous drainage of the collection is performed. The fluid is sterile. Despite effective drainage (200 ml/24h) and treatment with octreotide (300 mcg/24h iv), intolerance of enteral feeding persists, leading to a decision to operate.

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On day 50, the patient finally undergoes surgery. Operation confirms rupture of the gland and shows the presence of solid necrotic debris in the collection. A drain is inserted, together with a feeding jejunostomy and a cholecystotomy is performed. The post-operative course is unremarkable. There is a persisting fistula (50 ml/24h) from the rupture site. The patient is discharged one month after operation with a well fitted appliance to collect the fistula fluid. Three months after operation, the pancreatic fistula is still open. An ERCP shows the duct in the head of the gland and a fistulography outlines the remaining, glandular duct.

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Questions? Thank you very much

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