Acute pancreatitis

What to treat locally and what to refer to a specialist unit

London Cancer Pancreas Update

London - 12th July 2017

R. Valente, S. Zlatkov

Prevalence

• In England, more than 25,000 people admitted to hospital every year for acute pancreatitis

Mechanism

Causes

• 90% alcohol and gallstones

• Other causes • Hyperlipidemia

• Hypercalcemia

• Trauma

• Heredity

• Drugs, venoms

• Iatrogenic (ERCP)

Management of suspected pancreatitis

• Pancreatitis is a serious condition with a potential mortality rate of 10–25% [BMJ Best Practice, 2015]

• Has a worsening prognosis if diagnosis is delayed, and is not amenable to treatment in primary care. [Working Party of the British

Society of Gastroenterology et al, 2005]

• Urgent admission is needed, without delay, for investigations and ongoing specialist management. [Johnson, C.D.

et al., 2014]

AP Clinical key manifestation

• Can be very broad, from mild to severe

• Most commonly mild. Usually self-limiting.

• 15% organ failure involving cardiovascular, renal, and/or respiratory systems: SAP.

• SAP generally divided into two phases 1. Inflammatory response for approximately 1 week. Pancreatic

edema and multiple-organ failure resolve or advance to peripancreatic ischemia and necrosis.

2. Necrotizing process, for weeks to months. Mortality usually associated with secondary infection.

Primary care

• Admit urgently if the person has suspected acute pancreatitis, for further management.

• Do not delay admission by taking blood samples or ordering imaging in primary care!

Secondary care - Goals of initial assessment 1

• Determine the cause

• Remove any ongoing stimulus fueling pancreatitis

• Identify which patients will progress to SAP

Secondary care - Goals of initial assessment 2

• History focussed on identifying the cause • Alcohol, cholelithiasis, hyperlipidemia, prior pancreatitis,

medications. Ages and number of family members afflicted with AP.

• Physical examination • Vital signs, oxygen saturation, and urine output. • Depressed mentation, tachycardia, tachypnea, and low oxygen

saturation are concerning signs of SAP.

• Abdominal examination • upper abdominal tenderness, particularly in the epigastrium,

peritonitis.

• GAS / LAC • FBC, LFT, AMY/LIP, BUN/CREA

Secondary care 1 - Initial treatment

• Resuscitation with intravenous fluids (maintain perfusion)

• Supplemental oxygen (maintain oxygenation) • Pain relief • Antibiotics for treatment of associated cholangitis or

acute infections (i.e. chest or urinary tract infection) • Early nutritional support

• Oral feeding mild acute pancreatitis if no nausea, vomiting, or abdominal pain.

• Enteral feeding otherwise preferable and possible in the majority of people.

• Parenteral feeding is reserved when enteral nutrition is not possible.

Secondary care 2 – Initial investigations

• Lipase or amylase levels

• Assessment for prognostic features to identify those at risk of a potentially severe attack

• Imaging techniques, such as computed tomography, magnetic resonance imaging, or ultrasonography

Secondary care 3

• If pancreatitis and organ dysfunction usually managed in a high-dependency unit or intensive therapy unit

• If acute pancreatitis caused by suspected or proven gallstones, management may include:

• ERCP to relieve the obstruction, within 72 hours of the onset of

pain, for those with cholangitis.

• Cholecystectomy during the same admission. If protracted course of severe disease, cholecystectomy may be delayed until clinically appropriate

AP Natural history

Adapted from Nicholson LJ, Curr Gastroenterol Rep 13(4):336–343, 2011.

Classification 1 – Revised Atlanta criteria

• Two phases • Early <=1 week

• Late > 1 week

• Severity (48h) • Mild

• Moderate

• Severe Banks et al, Gut 2014

Clinical course – Revised Atlanta criteria

• Mild • No organ failure

• Local or systemic complications

• Usually resolves in the first week

• Moderate • Transient organ failure,

• Local complications

• Or Exacerbation of co-morbid disease

• Severe • Persistent organ failure >48 h Banks et al, Gut 2014

RLH Cause and severity (2015/16)

0

5

10

15

20

25

30

35

Severe

Mild

Local complications

• Peripancreatic fluid collections (sterile or infected): 60%, 30% >3

• Pancreatic and peripancreatic necrosis (sterile or infected)

• Pseudocyst and walled-off necrosis (sterile or infected)

• Gastric outlet dysfunction

• Splenic and portal vein thrombosis

• Colonic necrosis

Banks et al, Gut 2014

SV – SMV – PV Thrombosis - Treatment

Risk of bleeding Risk of

thrombus progression

New thrombotic onset

Other signs of procoagulability

Liver / bowel ischaemia

Sentinel bleed

Extent of necrosis

Infection (pseudoaneuirism)

Natural history

Adapted from Nicholson LJ, Curr Gastroenterol Rep 13(4):336–343, 2011.

Prediction of severity - Early Scoring

• Clinical • Ranson (Needs repetition 48h)

• Glasgow Imrie (rapid, on lab tests)

• BISAP

• Procalcitonin

• CT (>72 hours) • Balthazaar score

• CT Severity Index (CTSI)

• Mortele score

- BUN > 25 - Impaired

mental status - SIRS - Age - Pleural effusion

Wu et al. The early prediction of mortality in acute pancreatitis (2008)

Glasgow – Imrie on Discharge summary

Natural history

Adapted from Nicholson LJ, Curr Gastroenterol Rep 13(4):336–343, 2011.

CT imaging Revised Atlanta criteria

• Interstitial edematous pancreatitis

CT imaging Revised Atlanta criteria

• Necrotizing pancreatitis

• Acute peripancreatic fluid collection (APFC)

CT imaging Revised Atlanta criteria

• Necrotizing pancreatitis

• Acute peripancreatic fluid collection (APFC)

CT imaging Revised Atlanta criteria • Walled-off collection

• Pseudocyst (6 weeks)

CT imaging Revised Atlanta criteria

• Infected necrotic collection

Tertiary referral A reasonable pathway

HPB referral

Assessment

On-demand care

Remote management

Transfer: HPB admission

Ward

HDU/ITU

Ward

Outpatients

1. Transfer imaging via PACS

2. HPB involvement: phone & email on clinical condition

3. Imaging expert review

4. Registrar / Consultant documented discussion

Estimating need of HPB intervention failure to progress or deterioration:

- Serial imaging - SIRS response

- Organ support

What to treat locally and what to refer to a specialist unit?

What to treat locally and what to refer to a specialist unit

• Failure to progress without dedicated MDT team.

• Concern without dedicated ITU support

• Need for intervention unavailable locally • IR (Drainage, Embolisation, PTBD)

• Endoscopy (ERCP, Drainage)

• Surgery • VARD, open necrosectomy

• Decompression of ACS

• Haemorrage salvage

AP RLH admissions 2015 - 2016

[VALUE] 74

2

76

94 Admissions

Transfer A&E Elective

Length of stay

Median 6 (1-143)

Treatment of infected necrosis

• A step-up approach starting with minimal invasive drainage techniques and endoscopic necrosectomy

• Significant reduction of morbidity and mortality in necrotising pancreatitis compared to a primarily surgical intervention

Intervention at RLH – 2015/16

72

14

2

2

1

1

20

Intervention

No

IR

IR + End

IR + Surg

End

Surg

Endoscopic versus surgical step up approach

Endoscopic transluminal drainage (ETD) and endoscopic transluminal necrosectomy (ETN

Percutaneous catheter drainage (PCD) and video-assisted retroperitoneal débridement (VARD)

TENSION trial

VARD

• Video assisted retroperitoneal debridement

IACS & Decompressive laparotomy

• No consistent guidelines

• Needs aggressive medical treatments before

• 31 mmHg

• Decompress puss under pressure

• When medical treatments to reduce it fail

• Alternative: superficial laparotomy

Boone et al. Am. Surg. 2013

IACS & Superficial laparotomy

Leppaniemi et al 2006

Summary 1 - Management recommendations at diagnosis

1. Liver function tests and US < 24h of admission (Gallstones?)

2. Initial management: fluid resuscitation and supplemental oxygen

3. Severe acute pancreatitis: >48h organ failure (>30% mortality)

4. If symptoms > 7 days: CT to assess extension of necrosis

5. If gallstones: cholecystectomy or sphyncterotomy < 2 weeks of resolution of symptoms

6. Necrotising pancreatitis should be managed by a specialist team including surgeons, endoscopists, interventional radiologists, and intensivists

Johnson et al. BMJ 2014

Tertiary referral A reasonable pathway

HPB referral

Assessment

On-demand care

Remote management

Transfer: HPB admission

Ward

HDU/ITU

Ward

Outpatients

1. Transfer imaging via PACS

2. HPB involvement: phone & email on clinical condition

3. Imaging expert review

4. Registrar / Consultant documented discussion

Estimating need of HPB intervention failure to progress or deterioration:

- Serial imaging - SIRS response

- Organ support

Thank you