MANAGEMENT of ACUTE

PANCREATITISDr. Aishwarya Bhattacharya

• Acute pancreatitis – disease of high morbidity and motality

• Mortality

• Mild cases : ~1%• Severe cases : (10-30)%

EVIDENCE BASED

APPROACH

GUIDELINES• Atlanta• British Society of Gastroenterology• American College of Gastroenterology• International Association of Pancreas• Santorini Conference• World Congress of Gastroenterology

Risk factor assessment

Clinical risk stratificationMonitoring responseTo initial therapy

3D Approach towards management of acute pancreatitis

• Risk stratification Mild cases – general ward

Severe cases – Always in ICU setting

Strategy tailoring according to :•Severity•Risk factors (eg: age,obesity)•Presence of SIRS•Routine lab values(Hct, Ser.creatinine ) NONOPERATIVE MANAGEMENT IS THE MAINSTAY

PRINCIPLES of Management :Fluid resuscitation

Nutritional Support

Symptomatic Treatment

Management of Metabolic Complications

Prophylactic Antibiotic Coverage

Monitoring and Reassessment

Role of ERCP

Role of surgery

FLUID RESUSCITATION • Approach : Aggressive fluid resuscitation • Amount of fluid required : (250-500) ml/hr [acc. to AGC guidelines ] or (5-10) ml/kg/hr [acc. to IAP guidelines ]

• Ideal fluid : Isotonic crystalloids – RINGER LACTATE

In severe volume depletion -20ml/kg over 30 min followed by

3ml/kg/hr for (8-12) hrs

• Goal : Reduction in BUN IAP suggested resuscitation goals : * HR < 120 bpm *MAP : ( 65-85 )mm of Hg *Urine output > ( 0.5-1) ml/kg/hr *Hematocrit ( 35-44 )% ( one of the best indicators of survival )

• Importance : * Prevention of acute pancreatitis induced

hypovolaemic shock * Inadequate resuscitation – increased chance of necrosis * Most beneficial over first 12-24 hrs

• EXCEPTIONS : Pre-existing CARDIOVASCULAR and RENAL comorbidities

Acute pancreatitis

Third space fluid loss

HYPOVOLEMIC SHOCK

Reduced pancreatic microcirculation Acute renal insufficency

Pancreatic Necrosis

MULTIPLE ORGAN FAILURE

( Early inflammatory phase )

NUTRITIONAL SUPPORT • Different school of thoughts – 1. Continue oral feeding 2. Nil per oral 3. Nasojejunal tube feeding 4. Nasogastric tube feeding 5. Total parenteral nutrition

1. Oral feeding : continuation of oral feeding may not be possible due to - * Aggravasion of pain after oral intake * Nausea and recurrent vomiting * Preexisting abdominal distension caused by ileus• In mild AP, oral feedings can be started immediately if

• In mild AP, initiation of feeding with a low-fat solid diet appears as safe as a clear liquid diet (Level II evidence)

There is no nausea and vomiting, and Abdominal pain has resolved (level II evidence)

2.Nil per oral :The traditional school of thought Rationale for:1. Avoidance of oral intake prevents stimulation of

exocrine pancreatic functions Pancreatic rest 2. Patient often unable to retain oral feed.3. Ileus resulting from pancreatitis. Rationale against:1. Acute pancreatitis – inflammatory stress - 2. Prolonged avoidance of enteral feeding – altered gut

mucosal integrity – increased chance of infection.

3. Total Parenteral Nutrition : Rationale for :• Maintenance of proper nutrition avoiding

gastrointestinal complications Rationale against :• Increased chance of altered gut mucosal integrity• Acts as a portal for introduction of additional infection• Increased expenses4. Nasogastric and 5. Nasojejunal Tube Feeding :• Maintenance of Nutrition Enterally avoiding the

gastrointestinal complications Of both NPM and TPN• Low expenses Rationale against :• Not applicable in patiens with Ileus

Latest Recommendations :

• Strict limitation of enteral nutrition is unnecessary Nasojejunal tube feeding not better than Nasogastric tube

feeding Jejunal tube feeding only in patients unable to resume enteral

feed early TPN not required unless severely debilitated patient In case TPN or tube feeding required , resume oral feed as

soon as pain disappears and patient is able to retain feed ( generally 3-7 days in mild disease) Suggested addition of Lactobacillus sp. Preparations to enteral

feed may reduce infective complications of acute pancreatitis

Symptomatic Treatment • Pain control : - Essential for quality patient care - Ensures patient comfort , pulmonary toilet , sedation - commonly used : Diclofenac , Acetamenophen , Tramadol , • Controlling Emesis – ondransetron mostly used

• Mobilization of patient

Management of metabolic complications

• Hypocalcemia : (500-2000)mg IV one time , rate not to exceed (0.5-2) ml/min ( under continuous cardiac monitoring ) • Hyperglycemia : Insulin

• Hypoglycemia : glucose containing fluid infusion

• Diabetic Ketoacidosis

• Avoid prophylactic antibiotic doses – use ONLY for DEFINED INFECTIONS ( INFECTIVE NECROSIS or EXTRAPANCREATIC inf)• Infection : Source : Gut flora Organisms : Escherichia coli , Klebsiella pneumonia , Enterococcus sp. INDICATIONS : 1. Infective necrosis 2. Sterile necrosis > 50% 3. Extrapancreatic infections

Prophylactic Antibiotic Therapy

• “….broad-spectrum antibiotics should be used early in the course of necrotizing

pancreatitis particularly in patients with signs of organ failure or systemic sepsis.” – Maingot’s Abdominal Operations 12th Edition

The role of antibiotics in acute pancreatitis•

Cholangitis, catheter-acquired infections, bacteremia, urinary tract infections, pneumonia (strong recommendation, Level I evidence)

Routine use of prophylactic antibiotics in patients with severe acute pancreatitis is not recommended (strong recommendation, Level II evidence).

Selection of antibiotics : i. Either CT guided FNA for aspiration of pus, Gram stain and culture should be done for determining apt antibiotic or ii. Emperical antibiotic therapy should be started after attaining proper specimen for C/S• Preferred antibiotics : 1. Carbapenem ( Imipenem+cilastatin) 2. Quinolones 3. Metronidazole 4. 3rd generation cephalosporines

• Secondary fungal infection (mainly Candida sp. ) - Fluconazole

Fig : FNA needle

Monitoring and reassessment • Careful monitoring – Mild acute pancreatitis – general ward setting - Severe acute pacreatitis – ICU setting• Parameters in use : 1. Vitals 2. Laboratory Values : Hct, TLC , serum creatinine ,RBG , serum Na,K,Ca , Plateles , Bilirubin 3. Follow up of symptoms 4. Others : PaO2 , FiO2 , Arterial pH , Urine output , GCS

Scoring systems in use : APACHE II Marshall ( for Organ Failure ) SOFA ( Mortality prediction in asso. With MODS )

These scores can be used as : * Individual scores for each organ ( for Organ dysfunction ) * Sum of Scores on single ICU day * Sum of worst scores during ICU stay

* Better stratification of mortality risk *Dynamic procedure *NOT RESTRICTED BY ADMISSION VALUES

ERCP in acute pancreatitis

• Patients with acute pancreatitis and concurrent acute cholangitis should undergo ERCP within 24 h of admission (strong recommendation, Level I evidence).

• ERCP is not needed in most patients with gallstone pancreatitis who lack laboratory or clinical evidence of ongoing biliary obstruction (strong recommendation, Level II evidence).

In the absence of cholangitis and / or jaundice, MRCP or endoscopic ultrasound (EUS) rather than diagnostic ERCP should be used to screen for choledocholithiasis if highly suspected.

• ERCP : Diagnostic and potentially therapeutic

When is early ERCP indicated

• Concomitant cholangitis (Evidence Level I)• Significant persistent biliary obstruction (bilirubin > 5 mg/ dl)

(Evidence A)• ERCP in severe biliary pancreatitis without biliary sepsis or

obstruction (Evidence Level I)

When is early ERCP NOT indicated

• Mild pancreatitis of suspected or proven biliary etiology in the absence of the biliary obstruction (Evidence Level I)

• DRAWBACK : Post ERCP Pancreatitis Conditional recommendations of Pancreatic ducts/stentsOr Post-procedure Rectal NSAID Suppositories

Role of Surgery• Surgical interventions addressed to : a. Aetiology b. Complications • Surgery in acute pancreatitis :

Emergency Elective Prevention of recurrence

• Infected Necrosis • Haemorrhage• Pancreatic

abcess• Fulminant

pancreatitis • Abdominal

compartment syn.

• Colonic perforation

• Pseudocyst• Pancreatic fistula

• cholecystectomy

• In stable patients with infected necrosis

• In symptomatic patients with infected necrosis:

• Surgical, radiologic, and / or endoscopic drainage

Should be delayed preferably for more than 4 weeks

To allow liquefication of the contents and the development of a fibrous wall around the necrosis (walled-off necrosis) (Level II evidence).

Minimally invasive methods of necrosectomy are preferred to open necrosectomy (Level II evidence).

Surgery in Sterile Pancreatic Necrosis

Surgery in selected cases • Massive pancreatic necrosis (>50%) with a

deteriorating clinical course (Evidence level I)• Patients with progression of organ dysfunction

(Level II)• No signs of the improvement (Level II)

Management Algorithm in a patient

of ACUTE

PANCREATITIS

Mistakes in the management of acute

pancreatitis and how to avoid them • Mistake 1 | Failing to adequately assess fluid status• Mistake 2 | Delaying ERCP in patients with acute pancreatitis

and cholangitis • Mistake 3 | Delaying cholecystectomy in patients with biliary

pancreatitis• Mistake 4 | Early surgical or endoscopic intervention for

acute necrotizing pancreatitis• Mistake 5 | Administering prophylactic antibiotics• Mistake 6 | Recommending unnecessary bowel rest• Mistake 7 | Performing routine cross-sectional imaging on

admission

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