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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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