THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow),...

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THE MANAGEMENT OF ACUTE PANCREATITIS

Professor Ravi KantMB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS,

DNB, FAIS, FAMS,

INTRODUCTION

Introduction “In the growing world of EBM, only 30%

of surgery is based on evidence while 70% of medicine is evidence based” EJS, Sep 2005

Introduction Stress will be on Diagnosis, workup,

prognostic predictors and management Basic sciences

DEFINITION

Definition “Acute pancreatitis”:

Inflammation of the pancreas without, or with minimal fibrosis.

EPIDEMIOLOGY

Epidemiology 300,000 annually in US 10-20% are severe Total annual cost of 2 billion $$$ (Biliary + alcoholic) 90% Even in the west, biliary pancreatitis is

the most prevalent type. Incidence among AIDS patients 4-22%

Epidemiology Local statistics?

Epidemiology “Profile of acute pancreatitis in Jizan,

Saudi Arabia” Saudi Med J. 2003 Jan;24(1):72-5. (KFCH), Jizan, KSA over 12 years regional 42% (biliary), 18% Post ERCP

“Pattern of acute pancreatitis” Saudi Med J. 2001 Mar;22(3):215-8.

Cross sectional, 2 years, Asir central hospital

68% found to be biliary

PATHOPHYSIOLOGY

Pathophysiology Causes

Biliary tract disease Alcohol

Hyperlipedemia Hypercalcemia Trauma ERCP Ischemia

Pancreatic neoplasia

Pancreas divisum Ampullary lesions Duodenal lesions Infections Venom Drugs idiopathic

Pathophysiology Theories behind mechanism of biliary

pancreatitis Common channel theory Incompetent sphincter theory Co-localization theory

PATHOPHYSIOLOGY Common channel theory

“Opie 1901” Detergent effect of bile

Pathophysiology Critique of common channel theory

Higher hydrostatic pressure in PD Introduction of bile into PD in animal

models failed to cause AP

Pathophysiology Incompetent sphincter theory

Incompetent sphincter of Oddi due to stone passage reflux AP

Critique How come papillotomy doesn’t routinely

cause AP??

Pathophysiology Co-localization theory “Steer & Saluja”

1998 Most acceptable Stones PD ductal hypertension

ducutle rupture Ductal pH = 9 …… parynchemal pH = 7 trypsinogen + cathepsin B trypsin

autodigestion cascade

Pathophysiology

Pathophysiology Support of co-localization theory

CA-074me (cathepsin B inhibitor) prevented AP in 2 different models of acute pancreatitis

Pathophysiology Alcoholic pancreatitis

No such thing as acute alcoholic pancreatitis

It is actually the first attack of chronic alcoholic pancreatitis

DIAGNOSIS

Diagnosis Clinical picture Investigations “Acute pancreatitis is a diagnosis of

exclusion” Schwartz’s

Diagnosis Hx:

Epigastric pain Radiating to back Nausea, vomitting Precipitating factor?

Diagnosis Physical

V/S variable Epigastric tenderness Cullen’s / Grey Turner’s (1%) Findings of complication(s)

Cullen’s sign

Grey Turner’s sign

Diagnosis Serum markers

Amylase Easiest to measure and most widely used Rises immediately Peaks in few hours Remains for 3-5 days “Three fold rise is diagnostic” May be normal in severe attacks May be falsely negative in hyperlipedimic patients Inverse correlation between severity and serum

amylase level No need to repeat

Diagnosis Serum markers

Urine amylase Remains elevated for a few more days Increase excretion of amylase with

attacks of AP Of great value when dealing with severe

pancreatitis

Serum markers P/S – amylase

P amylase increases specificity to 93% Lipase

“the serum marker of highest probability of disease”

Specificity of 96% Remains elevated for longer time than

total amylase

Diagnosis

Causes of hyperamylesemia Pancreatitis p Choledocolethiasis p Parotitis s Renal failure s/p Liver cirrhosis s/p perforated bowel p mesenteric infarction p intestinal obstruction p Appendicitis p Peritonitis. P Gyne disease s

Malignancies Lung CA Ovarian CA

pancreatic CA Colonic CA pheochromocytoma; Thymoma multiple myeloma breast cancer

RADIOLOGY (diagnostic)

Radiology Diagnostic role

X-ray U/S CE-CT

Radiology X-ray

Air in the duodenal C loop Sentinel loop sign Colon cutoff sign All these signs are non specific

Radiology CE-CT

Enlargement of the pancreas (focal/diffuse)

Irregular enhancement Shaggy Pancreatic contour Thickening of fascial planes fluid collections.

Intraperitoneal / retroperitoneal Retroperitoneal air

Radiology

U/S Diagnosis of gallstones F/U of pseudocysts. Dx pseudoaneurysms EAUS vs. EUS

PROGNOSIS

Prognosis Course either mild or severe

Mild = edematous pancreatitis Severe = necrotic pancreatitis No such thing as moderate pancreatitis

Prognosis Serum markers CT Systemic complications Prognostic scores

Ranson Apache II Modified Glasgow Atlanta

Atlanta Consensus1992

Prognostic scores Ranson’s

Published in 1974 Predictor of morbidity/mortality

<2 0% mortality 3-5 10-20% >7 >50% mortality

Critique of Ranson’s 11 parameters 48 hours No predictor value beyond 48hrs Too pessimistic for today’s healthcare system

Prognostic scores APACHE II

Immediate Acute and chronic parameters Complicated >7 = severe pancreatitis

Prognostic biochemical markers Biochemical markers of prognosis

Ideally High sensitivity High specificity Discriminate severe from mild Immediate Widely available

Amylase & lipase Highly sens./spec. Lack prognostic value

Prognostic biochemical markers

Alternatives CRP 2 macroglobulin PMN elastase 1 antitrypsin Phospholipase A2

“CRP seems to be the marker of choice in these settings”

CRP >150 is diagnostic of severe pancreatitis

Prognostic biochemical markers Other markers

IL-6 Urinary TAP

These showed great promise in models and clinical trials

Failed in larger scale trials

CT scan (prognostic aspect) “CT scanning with bolus IV contrast has

become the gold standard for detecting and assessing the severity of pancreatitis”

“Currently, IV bolus contrast enhanced CT scanning is routinely performed on patients who are suspected of harboring severe pancreatitis, regardless of their Ranson’s or APACHE scores” Schwartz’s

CT scan (prognostic aspect)

CT scan (prognostic role) Balthazar CT-severity index (CTSI)

CTSI considers degree of necrosis Also considers the CT grade A final score is given and correlates with

mortality and complication development

CT scan (prognostic role) Balthazar grading

Grade A - Normal-appearing pancreas 0 Grade B - Enlargement of the pancreas 1 Grade C - Pancreatic gland abnormalities a with

peripancreatic fat infiltration 2 Grade D - A single fluid collection 3 Grade E - Two or more fluid collections 4

CT scan (prognostic role) Grade of necrosis and the points

assigned per grade are as follows: None 0 points Grade 0.33 2 points Grade 0.5 4 points Grade > 0.5 6 points

CT scan (prognostic role) Overall prognostic outlook:

CTSI Mortality Complication

0-3 3% 8%

4-6 6% 35%

7-10 17% 92%

Is CT superior???

“Computed Tomography Severity Index, APACHE II Score, and Serum CRP Concentration for Predicting the Severity of Acute Pancreatitis”*

n=55 CTSI,APACHE and CRP had p <0.01

Prognosis Recommendation for assessing

severity: Mild is defined as:

No systemic complications Low APACHE/Ranson scores CE-CT findings (Balthazar) CRP level <150

Santorini1999

MANAGEMENT

MANAGEMENT Management depends on severity We will consider management of

edematous pancreatitis separately from necrotizing pancreatitis for purpose of simplification

MANAGEMENT OF MILD PANCREATITIS

Management (mild) Core of treatment based on

Physiological monitoring Metabolic support Maintenance of fluids and electrolytes

Management (mild) NG suction H2 blockers

Gastric acid reaching the duodenum will activate pancreatic secretion???

Large studies failed to show any benefit

Management (mild)

Management (mild) What is the role of anti-secretory

agents? Atropin Calcitonin Somatostatin Glucagon Flurouracil

Unproven benefit*

Management (mild) Pancreatitis is an autodigestive process Role of protease inhibitors?

Aprotinin Gabexate mesylate Camostate Phospholipase A2 inhibitors FFP

No benefit

Management (mild) Pancreatitis is an inflamatory process Role of anti-inflamatory drugs?

Indomethacin Prostaglandin inhibitors Interleukin-10

No measurable benefit

Management (mild) Vascular injury is mediated by platelet

aggregating factor What’s the role of PAF inhibitors?

PAF acetylhydrolase Lexipafant

Great results in models Great results in small clinical trials Failed in larger studies

Verdict: useless

Management (mild) Question to audience: When dealing with acute pancreatitis,

do u start Abx therapy? (hands please) “Antibiotic therapy has not proved to be

of value in the absence of signs or documented sources of infection”

Management (mild) Mainstay of management is supportive

NPO IVF

When to resume oral intake? Absence of pain Absence of tenderness Patient feeling hungry

On average takes about 3-7 days Sips of water and build up to low protein low

fat diet

Management (mild) Any drug therapy for acute pancreatitis?

“None of the evaluated medical treatments is recommended (level A)”*

Meta-analysis considering gabexate mesylate, octreiotide, aprotinin and lexipafant

MANAGEMENT OF SEVERE PANCREATITIS

Management (severe) Severe pancreatitis:

> Ranson / APACHE CRP >150 Systemic complications Necrosis on CE-CT Hemodynamic compromise

Management (severe) Complications

Local Phlegmon Abcess Pseudocyst Ascitis pseudoanurysm Adjacent organ

envolvment

Systemic pulmonary Cardiac Hematological GI Renal Metabolic CVS Fat necrosis

Pseudocyst

Management (severe) Sterile necrosis

Absence of retroperitoneal air on CT Prognosis

0% mortality without complications 38% with single sys. complication

Management (severe) How to approach sterile necrosis?:

No sys. Comp., no infec. (i.e. uncomplicated) supportive

Sys. Comp. + infection? ( mild complication) CT guided aspiration gram stain/culture Abx

Mult. Sys comp + toxicity/shock (frank complication) surgical debridment

SEVERITY

Management (severe) Role of prophylactic Abx?

Previously thought to have no role in sterile necrosis Prophylaxis indicated whenever there is necrosis Drugs with proven benefit

Imipenem Flagyl 3rd gen. Cephalosporins

Abx prophylaxis reduced:* Sepsis by 21.1% Mortality by 12.3%

Management (severe) Role of Antifungal medication

Candida is a common inhabitant of upper GI tract

Risk of secondary infection Empiric fluconazole?

Clansy TE “current management of necrotizing pancreatitis”*

Management (severe) Nutritional support

NPO with resumption of diet when fit If NPO > 7 days… TPN vs. Jujenal tube feeding?

TPN: gastric mucosal atrophy bacterial translocation

Jujenal tube feeding: induces pancreatic secretion Inconclusive studies:

Jujenal T. feeding is superior*

Management (severe) Benefit of enteral feeding

Prospective randomized trial n=34 Severe acute pancreatitis “enteral feeding modulates the inflamatory

and sepsis response in acute pancreatitis”*

Management (severe) NG vs. NJ feeding

Prospective randomized trial N=50 Mortality as endpoint

No statistically significant benefit of NJ*

NG mortality NJ mortality

18.5% 31.8%

Management (severe) Something very important has been

missing in the presentation… Where is pain management? Also missing from the research scene

Specific considerations of biliary pancreatitis

Management (severe) Specific consideration of biliary

pancreatitis: Majority of stones will pass within hours Some might impact Patient at risk of subsequent stone obst.

NECROSECTOMY

Management (severe) If hyperbili is dropping:

Lap chole with surgical duct clearance <72 hours vs. >72 (within admission) If patient critical ERCP stone clearance Routine ERCP NOT ADVOCATED

Management (severe) If hyper bili persists:

confirm presence of stone before ERCP (MRCP, EUS)

Suggested algorithm

Conclusion Acute pancreatitis is a hot area for

research Advances at the cellular level show

promise to “halt”pancreatitis Most patients need just supportive care No indication for Antibiotics in mild type Severe pancreatitis needs antibiotics Surgical management ►gallstones /

complications

Your comments….

Pancreatic Psudocyst

Definition:Pseudocysts are encapsulated localized collection of pancreatic enzyme, inflammatory fluid and necrotic debris on pancreas or in part or the whole of the lesser sac. They are distinguished from other types of pancreatic cysts by their lack of an epithelial lining.

Causes Acute or chronic pancreatitis

abdominal trauma.

Duct obstruction.

Presenting symptoms

Epigastric pain

Nausea

Vomiting

Weight loss

Mild Fever

Jaundice

Physical Examination•The sensitivity of physical examination findings is limited.

•Tender abdomen.•Palpable mass in the abdomen with an indistinct lower edge.•The upper limit is not palpable .

Physical Examination•The sensitivity of physical examination findings is limited.

•tender abdomen.•palpable mass in the abdomen with an indistinct lower edge.•The upper limit is not palpable .

Physical Examination•Its usually resonant to percussion because it is covered by the stomach.•It moves very slightly with respiration.•it is not possible to elicit fluctuation or a fluid thrill. •Peritoneal signs suggest rupture of the cyst or infection

Differential diagnosis:•Acute pancreatic fluid collections.•Serous cystadenoma of the pancreas•Mucinous cystadenoma of the pancreas•Mucinous cystadenocarcinoma•Pancreatic retention cyst

Investigations:

•Lab studies

•Imaging studies

• E.R.C.P

Serum tests: Amylase and lipase levels are

often elevated but may be normal

Bilirubin and LFT findings may be elevated if the biliary tree is involved.

Lab Studies Analysis of the cyst fluid may help

differentiate pseudocysts from tumors.

Attempt to exclude tumors in any patient who does not have a clear history of pancreatitis.

Analysis of cyst fluid Carcinoembryonic antigen (CEA) and

carcinoembryonic antigen-125 (CEA-125) tumor marker levels are low in pseudocysts and elevated in tumors.

Fluid viscosity is low in pseudocysts and elevated in tumors.

Amylase levels are usually high in pseudocysts and low in tumors.

Cytology is occasionally helpful in diagnosing tumors, but a negative result does not exclude tumors.

Abdominal CT scan CT scan is the investigation of

choice in pancreatic pseudocysts. It has a sensitivity of 90-100% and is not operator dependent.

The usual finding on CT scan is a large cyst cavity in and around the pancreas.

Multiple cysts may be present.

Abdominal CT scan The pancreas may appear irregular or

have calcifications. Pseudoaneurysms of the splenic artery,

bleeding into a pseudocyst, biliary and enteric obstruction, and other complications may be noted on CT scan.

The CT scan provides a very good appreciation of the wall thickness of the pseudocyst, which is useful in planning therapy.

Abdominal ultrasound:

While cystic fluid collections in and around the pancreas may be visualized via ultrasound,

the technique is limited by operator skill, the patient's habitus, and overlying bowel gas.

As such, ultrasound is not the study of choice for diagnosis.

MRMR is not necessary for the diagnosis of pseudocysts; however, it is useful in detecting a solid component to the cyst and in differentiating between organized necrosis and a pseudocyst.

MRIA solid component makes catheter drainage difficult; therefore, in the setting of acute necrotizing pancreatitis with resultant pseudocyst, an MRI may be very important before a planned catheter drainage procedure.

Endoscopic Retrograde Cholangiopancreatography

(ERCP) is not necessary in diagnosing pseudocysts; however, it is useful in planning drainage strategy.

Complications Infection of the pseudocyst patients develop fever or an elevated WBC count.

Treat infection with antibiotics and urgent drainage.

Gastric outlet obstruction, manifesting as nausea and vomiting, is an indication for drainage.

Complications Rupture

A controlled rupture into an enteric organ occasionally causes GI bleeding.

On rare occasions, a profound rupture into the peritoneal cavity causes peritonitis

Continue

Bleeding is the most feared complication and is

caused by the erosion of the pseudocyst into a vessel. Consider the possibility of bleeding in

any patient who has a sudden increase in abdominal pain coupled with a drop in hematocrit level or a change in vital signs.

Continue

Bleeding is the most feared complication and

is caused by the erosion of the pseudocyst into a vessel. Therapy is emergent surgery or

angiography with embolization of the bleeding vessel.

Management: 4X4, 5X5, 6X6 All cysts do not require treatment. In

many cases the pseudocysts may improve and go away on their own.

In a patient with a small (less than 5cm) cyst that is not causing any symptoms, careful observation of the cyst with periodic CT scans is indicated.

Management: If a pseudocyst is persistent over

many months or causing symptoms then treatment of the cyst is required.

External DrainageCatheter drainage:•Percutaneous catheter drainage is the procedure of choice for treating infected pseudocysts,• allowing for rapid drainage of the cyst and identification of any microbial organism. A high recurrence and failure rate exist.

Continue Percutaneous catheter drainage

is contraindicated in patients who are poorly compliant and cannot manage a catheter at home.

It is also contraindicated in patients with strictures of the main pancreatic duct and in patients with cysts containing bloody or solid material.

Internal drainage:•The majority of patients who require treatment for their pseudocysts are treated by surgery.

Internal drainage:In the surgical procedure a connection is created between the cyst and an adjacent intestinal organ to which the cyst is adherent to such as the stomach. This connection allows the cyst to drain into the stomach.

Continue Cysto-gastrostomy a connection is created between the back wall of the

stomach and the cyst , the cyst drains into the stomach.

Cysto-jejunostomy: a connection is created between the cyst and the

small intestine. Cysto-duodenostomy:a connection is created between the duodenum and

the cyst. During surgical drainage procedure biopsy of cyst

wall must be done to rule out a cystic carcinoma.

Endoscopic technique In this procedure a gastroenterologist

drains the pseudocyst through the stomach by creating a small opening between the cyst and the stomach during endoscopy.

Endoscopic technique In selected patients this treatment can

successfully treat pseudocyst. The disadvantage of this technique is that

if there is dead tissue in the pseudocyst cavity or if the cyst is very large then infection or recurrence of pseudocyst with this technique may occur.

Insertion of a pancreatic stent:

In this technique the gastroenterologist may insert a drain into the cyst during an ERCP.

If the drain is placed directly into the cyst then the fluid from the cyst is drained into the intestine through this tube.

Prognosis Most pseudocysts resolve without

interference, and patients do well without intervention.

Outcome is much worse for patients who develop complications or who have the cyst drained.

Prognosis The failure rate for drainage

procedures is about 10%, the recurrence rate is about 15%, and the complication rate is 15-20%.

THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow),...

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