Acute Severe Pancreatitis

Pancreatitis

Dr Anoop.k.rAsst profGeneral medicineMMCH CALICUT

22 years old maleSudden onset of epigastric pain radiating to backNo significant past historyNo drugs, no alcohol, no heavy meals

On examination:In painPulse 82/min, B.P.120/80RR: 16/min, no cyanosisAbdomen: Tenderness +, no guarding, No rigidity, peristalses +

? Acute pancreatitis: DiagnosisInvestigationsBloodAmylaseLipase

Diagnosis

Amylase and lipase are the cornerstone lab parameters for the diagnosis.

"It is usually not necessary to measure both amylase and lipase (3).

DiagnosisLipase may be preferable It remains normal in some nonpancreatic conditions that increase serum amylase including macroamylasemia, parotitis, and some carcinomas. Lipase is thought to be more sensitive and specific and superior to amylase[3, 4, 5]In one large study, there were no patients with pancreatitis who had an elevated amylase with a normal lipase [5].

DiagnosisLipase starts to rise by 4-8 hours, peaks in 24 hours and normalizes by 8- 14 days.

Amylase and LipaseHigher the numerical value more certain is the diagnosis.Although severe pancreatitis could also exist without significant rise in these enzymes.Numerical value of these enzymes have no prognostic value and neither they reflect severity

Diagnosis: ImagingUSG is cornerstone CT MREUS/ ERCP100 acute pancreatitis.20% severe= 2020% of severe become infected= 4Infection usually sets in 2nd week or 3rd weekSurgeons would want to delay surgery till about 4 weeksInfected necrosis will always be clinically manifest

So why CT scan in first week ????

Issues: Assessing severity at the bedside

Clinical featuresScoring systems

Clinical features useful in assessing severityToxic LookSevere painPersistent tachycardiaBreathlessness and CyanosisSub-normal temperatureShock

Normal lookMild painNormal Pulse rateNormal Oxygen saturationAdequate urine outputFlat and soft and movable abdomen

Bedside index of severity in acute pancreatitis (BISAP) scoreThis calculator evaluates the following Clinical Criteria:BUN >25 mg/dL (8.9 mmol/L)Impairment of mental status with a Glasgow coma score 60 years oldPleural effusionEach determinant is given one pointThe MedCalc 3000 module Bedside index of severity in acute pancreatitis (BISAP) score is available in MedCalc 3000 Complete Edition.

SIRS is defined as 2 or more of the following variables;Fever of more than 38C (100.4F) or less than 36C (96.8F)Heart rate of more than 90 beats per minuteRespiratory rate of more than 20 breaths per minute or arterial carbon dioxide tension (PaCO2) of less than 32mm HgAbnormal white blood cell count (>12,000/L or < 4,000/L or >10% immature [band] forms)

BISAP Score BISAP Score Observed Mortality0 0.1%1 0.4%21.6%33.6%47.4%59.5%Wu et al, Gut 2008

Comparison of BISAP, Ranson's, APACHE-II, and CTSI scores in predicting organ failure, complications, and mortality in acute pancreatitis.Papachristou GI, Muddana V, Yadav D, O'Connell M, Sanders MK, Slivka A, Whitcomb DC. Am J Gastroenterol. 2010 Feb;105(2):435-41; quiz 442. doi: 10.1038/ajg.2009.622. Epub 2009 Oct 27

CONCLUSIONS: BISAP score is an accurate means for risk stratification in patients with AP. Its components are clinically relevant and easy to obtain. The prognostic accuracy of BISAP is similar to those of the other scoring systems.

Determinants of revised Atlanta classificationLocalPancreatic or peripancreatic fluid collectionSterileInfected NecrosisSterileInfectedPseudocyst and walled-off necrosis (sterile or infected).Organ failure

Local ComplicationsInfection

Revised Atlanta......Acute pancreatitis identified two phases of the disease: early and late. Severity is classified as mild, moderate or severe. Mild: the most common form, has no organ failure, local or systemic complications and usually resolves in the first week. Moderate: Presence of transient organ failure, local complications or exacerbation of co-morbid disease. Severe: Persistent organ failure >48 h. Local complications are peripancreatic fluid collections, pancreatic and peripancreatic necrosis (sterile or infected),

The presence of one determinant can modify the effect of another such that the presence of both infected (peri)pancreatic necrosis and persistent organ failure have a greater effect on severity than either determinant alone. The derivation of a classification based on the above principles results in 4 categories of severity-mild, moderate, severe, and critical.

Acute Pancreatitis: ManagementIssueFluid replacementVigorous hydration to optimize outcomes has been increasingly recognized. The ACG guidelines stress, Patients with evidence of significant third-space losses require aggressive fluid resuscitation. Many patients sequester substantial amounts of fluid into the retroperitoneal space, producing very high fluid requirements. Intravascular volume depletion may lead to tachycardia, hypotension, renal failure, hemoconcentration, and generalized circulatory collapse. More than 6 L of fluid sequestration within the first 48 hours is considered a marker of increased severity, according to the Ranson criteria

Acute Pancreatitis:Issues:Antibiotics

Time frame:Severe pancreatitis can be observed in 1520 % of all cases. The first two weeks after onset of symptoms are characterized by the systemic inflammatory response syndrome (SIRS). Pancreatic necrosis develops within the first 4 days after the onset of symptoms to its full extent, Infection of pancreatic necrosis develops most frequently in the 2nd and 3rd week

Authors' conclusions: No benefit of antibiotics in preventing infection of pancreatic necrosis or mortality was found, except for when imipenem (a betalactam) was considered on its own, where a significantly decrease in pancreatic infection was found. None of the studies included in this review were adequately powered. Further better designed studies are needed if the use of antibiotic prophylaxis is to be recommended

Acute PancreatitisIssues:Nutrition

Background facts..Nutritional management during acute pancreatitis has the purpose to avoid a negative influence on the outcome and to preserve the morphofunctional integrity of the gut, preventing bacterial translocation. Preventing SIRS

When the course of the disease is longer and the severity is higher, an early artificial nutritional support is advisable. Caloric needs thought to be useful are 25-30 kcal/kg/d; 40-60% of nutrient mixture should consist of carbohydrates and 20-30% of lipids. Proteins should be approximately 1.0-1.5 g/kg/d

McClave SA, Chang WK, Dhaliwal R, Heyland DK. Nutrition support in acute pancreatitis: a systematic review of the literature. JPEN J Parenter Enteral Nutr. 2006 Mar-Apr;30(2):143-56.

Fears.Enteral diets stimulate enzyme secretion unless delivered below the jejunum.

Authors' conclusions: In patients with acute pancreatitis, enteral nutrition significantly reduced mortality, multiple organ failure, systemic infections, and the need for operative interventions compared to those who received TPN. In addition, there was a trend towards a reduction in length of hospital stay. These data suggest that EN should be considered the standard of care for patients with acute pancreatitis requiring nutritional support.

Nutrition Support in Acute Pancreatitis: A Systematic Review of the LiteratureStephen A. McClave, Wei-Kuo Chang, Rupinder Dhaliwal, Daren K. Heyland, JPEN J Parenter Enteral Nutr MARCH-APRIL 2006 vol. 30 no. 2 143-156 doi: 10.1177/0148607106030002143Patients with acute severe pancreatitis should begin EN early because such therapy modulates the stress response, promotes more rapid resolution of the disease process, and results in better outcome. In this sense, EN is the preferred route and has eclipsed PN as the new gold standard of nutrition therapy. When PN is used, it should be initiated after 5 days. Individual variability allows for a wide range of tolerance to EN, even in severe pancreatitis

Acute PancreatitisIssues:Intervention in form of ERCP

Emergency ERCP in APIn persistent and severe biliary pancreatitis, when an obstructing gallstone lodged at the ampulla of Vater

Any role of early Surgery?Except in the unusual situation of fulminating acute pancreatitis with organ failure and a rapidly progressive downhill course soon after admission to the hospital, most patients should not undergo operation during the first week of their illness.When clinical deterioration is rapid and surgery is undertaken during the first week, these patients have a high mortality rate. The outcome is better when surgery is postponed at least until the second week or later, when the margins of the pancreatic necrosis have become better defined, and the acute inflammation has subsided somewhat.

Acute PancreatitisIssue: Surgery: Background factsMore than 80% of deaths amongst patients with acute pancreatitis are caused by infected necrosisAggressive surgical treatment required in such casesPatients with infected necrosis require emergent surgery.

Common Organisms

Enteric Gram Negative organisms like E.coliGram positive organismsAnaerobesFungal Infection is a late event usually following prolonged antibiotic therapyDaziel D J. Doolas A. Pancreatic abscess and pancreatic necrosis: current concepts and controversies. Problems in General Surgery, vol 7 (3) pp 415-27. 1990

Diagnosis of infected necrosisMost reliably by CT or ultrasound-guided fine needle aspiration (FNA) with Gram staining and culture of the aspirate. The material should be sent for bacterial and fungal culture. Some patients with infection have only a low grade fever and a WBC