Acute Pancreatitis

Acute Pancreatitis - Panel discussion

Panelists

Dr Ganesan Tanjore

Dr Manoharan Chennai

Dr Palaniappan Chennai

Dr Amarnath Chennai

Case 1 ..• Mrs P , 29 year old lady in the third trimester of

pregnancy had an episode of severe upper abdominal and back pain lasting for about 10 hours

• S Amylase : 1045 IU • Ultrasound abdomen : showed cholelithiasis, normal

bile ducts and pancreas.

• No other tests were performed. Pain settled with tablets • She went on to have a normal delivery and delivered a

normal boy baby.

Are serum amylase and Lipase reliable markers for acute pancreatitis

in pregnancy?

Dr Ganesan

Serum amylase in pregnancy

In a study of amylase activity in 200 pregnant women:

• Serum amylase rises gradually during pregnancy until the twenty-fifth week and thereafter falls slightly

• Serum amylase values in normal pregnant women during the second and third trimesters may exceed those in normal men and nonpregnant women

Kaiser R et al Am J Obstet Gynaecol. 1975 1;122(3):283-6

Amylase & Lipase in pregnancyStudy on amylase & lipase in pregnant & nonpregnant women :

• Serum amylase activity was similar in pregnant women and nonpregnant women during all trimesters of pregnancy.

• Serum lipase activity was significantly lower during the first trimester of pregnancy compared to nonpregnant women

- Serum lipase activity was not statistically different between pregnant and nonpregnant women during the second and third trimesters Karsenti D et al Am J Gastroenterol. 2001;96:697–699

Serum amylase and lipase levels are reliable markers of AP during pregnancy

What is the best Imaging modality for evaluating bile duct for choledocholithiasis

in pregnancy ? Why?

Dr Amarnath

Best Imaging modality for evaluating bile duct for choledocholithiasis in pregnancy ?

A Abdominal Ultrasound

B CT scan abdomen

C MRCP

D ERCP

E Endoscopic Ultrasound

.

• Abdominal Ultrasound is insensitive for the detection of common bile duct stones or sludge

• CT is not preferred in all trimesters of pregnancy in view of a radiation risk to the fetus.

• ERCP is not preferred as a diagnostic test because of radiation risk to fetus


• MRCP is a good technique to evaluate CBD

- Concerns of thermal injury to the fetus in first trimester

- Small ductal stones located in the distal CBD could be missed

by MRCP. Gallstone pancreatitis is generally associated with

small gallbladder stones and sludge.

- Claustrophobia remains the major barrier

• EUS is the best imaging study to evaluate CBD in pregnancy.

C S Pitchumani et al WJ G 2009 Dec 7; 15(45): 5641–5646


Is it safe to do therapeutic ERCP in pregnancy ? Any Precautions to be taken?

Dr Palaniappan

Safety of ERCP in pregnancy• ERCP risks to mother and fetus appear to be acceptable when

performed for therapy (demonstrated in 350 cases during pregnancy)

- Justifiable indications include jaundice, cholangitis, gallstone pancreatitis

• Precautions to be taken :

- Minimise fetal radiation exposure

( Lead apron on pelvis ; Minimal fluoroscopy time; No X-ray)

- safest during the second trimester of pregnancy.

• Informed consent about minimal fetal radiation risks

Friedel D et al World J Gastrointest Endosc. 2014 May 16; 6(5): 156–167.

Management of symptomatic cholelithiasis in pregnancy

Conservative management vs lap Cholecystectomy?

Dr Manoharan

Management of symptomatic cholelithiasis in pregnancy Non-operative management vs lap

Cholecystectomy

• Retrospective study of symptomatic cholelithiasis in pregnancy :

- 78.6 % who had non-operative management had recurrent

symptoms prior to Lap Cholecystectomy

- 50 % repeat hospitalizations prior to surgery.

• Given the safety of antepartum LC and the frequency of recurrent

symptoms and hospitalizations, early surgical intervention

during pregnancy may be the optimal strategy

Jorge AM et al Gastrointest Surg 2015

What is the best time to perform Lap cholecystectomy in pregnancy ? Why?

Dr Manoharan

Best time to perform Lap cholecystectomy in pregnancy

Cholecystectomy during the second trimester is safe for both the mother and the fetus

• In first trimester organogenesis is incomplete and spontaneous abortions may occur

• In third trimester the uterus is big and may obscure the surgical view for laparoscopic approach. Pre-term labour may also be precipitated

Case 1 ..• Two months after delivery ( 09/11/2014) she

presented to our hospital with severe epigastric pain radiating to back and vomiting of 24 hours duration; No fever

Examination : Mild jaundice

Pulse Rate: 135/mt ; BP : 110/70 mmHg

Respiratory rate : 16/mt; Pa O2 : 97% (room air)

- Abdomen : tender epigastrium; No mass ; No fluid

- Respiratory System : Dullness on percussion & decreased air entry in both lung bases

Case 1 .. Investigations • Blood tests : (09/11/14)

- Amylase 2695 IU/ml ; Lipase : 24280 IU/ml

- CRP : 407mg/L

- Hb : 16.4 ; PCV : 49.2 ; WBC TC 10700/cmm

- S. Creatinine : 0.64; Na 144; K 3.8; Cl 111; HCO3 23

- LFT : 4.2/2.9/7.1/4.1/320/629/300 ; Gamma GT 1092

- Ca :9.5; Phosphorus : 2.5 ; Triglyceride : 202

• Imaging studies:

- Ultrasound abdomen: Dilated Intra & extrahepatic bile ducts; No CBD calculi seen; Gall bladder showed multiple calculi; Pancreas was enlarged with heterogenous echotexture; Rest normal

• Chest X-ray : Bilateral pleural effusion

Diagnosis

Acute Biliary pancreatitis

How to grade severity of pancreatitis ? ( Revised Atlanta classification)

What is the need to grade severity ?

Dr Ganesan

Mild acute pancreatitis• No organ failure• No local or systemic complications

Moderately severe acute pancreatitis• Organ failure that resolves within 48 h (transient organ failure)

and/or• Local or systemic complications without persistent organ failure

Severe acute pancreatitis

Persistent organ failure (>48 h) • Single organ failure• Multiple organ failure

Banks P A GUT 2013 Jan;62(1):102-11

Severity of acute pancreatitis

Why assess severity – determines mortality

• Mild acute pancreatitis

- Almost nil

• Moderate Severe acute pancreatitis

- 2% ( Vege SS Am J gastro 2009)

• Severe acute pancreatitis

- mortality reported to be as great as 36–50%

Case 1.. Treatment

• Analgesics – Tramadol

• Aggressive fluid resuscitation

• Antibiotics : Meropenem 1g Q8h in view of ERCP in obstructed bile duct

• Naso Jejunal feed started

Fluid resuscitation

When to start?

What fluid?

How much ?

Dr Ganesan

Fluid resuscitation in acute pancreatitis• Vigorous fluid resuscitation is the cornerstone of therapy in

the management of AP and should be started early ( day 1) -

- Non-aggressive fluid resuscitation group experienced higher mortality (17.9%) as compared to aggressive fluid resuscitation group (0% mortality)

Gardner TB, Vege SS et al. Pancreatology. 2009;9:770-776

• Few recent studies have suggested that aggressive fluid therapy increases morbidity and mortality (Intra-abdominal hypertension and respiratory complications)

• There may be a need to restrict fluid infusion in those patients who have renal dysfunction or cardiac dysfunction

• Concept of controlled aggressive fluid resuscitation

Which fluid ?• Crystalloids :

- Normal saline- Ringer Lactate- Hypertonic saline

• Colloids : - Hydroxy Ethyl Starch - Albumin

• Combination of crystalloids and colloids (ratio of 1:3)

Lack of high level evidence to guide choice of fluid

• Crystalloids are recommended by AGA

• Among crystalloids RL preferred over NS

• Colloids in cases of low hematocrit (<25%) and low serum albumin (<2.0g/dl).

Agarwal A et al World J Gastroenterol. 2014 28; 20 : 18092–18103.

Wu et al Clin Gastroenterol Hepatol 2011;9:710-717

Which fluid ?

Fluid resuscitation – Volume & rate• De-Madaria et al analyzed 247 patients depending

on the fluid received in the initial 24 h. - Administration of > 4 L during the initial 24 h was found to be associated with persistent organ failure and acute collections- administration between 3 - 4 L was associated with an excellent outcomeDe-Madaria et al Am J Gastroenterol. 2011;106:1843-1850.

• Mild pancreatitis 125 ml/hr Moderately severe pancreatitis 250 ml/hr Severe acute pancreatitis 300ml/hr

Ulinastatin in severe acute pancreatitis – Does it work?

Ulinastatin in mild or severe acute pancreatitis.

• Ulinastatin inhibits pro-inflammatory markers ( NFkB) as well as coagulation and fibrinolysis.

• Randomized, double-blind, placebo-controlled, multi-centre trial across 15 centres in India

- 135 randomized subjects, 129 completed the study;

- Alcohol was the cause in majority (81%)

- Ulinastatin prevents new organ dysfunction and reduces mortality in subjects with severe pancreatitis

Abraham P et al J Assoc Phycians India 2013 Aug;61(8):535-8

Probiotics in Severe Acute Pancreatitis ?

Use of probiotics in the treatment of severe acute pancreatitis: a

systematic review and meta-analysis of randomized controlled trials.

Probiotics showed neither beneficial nor adverse effects on the clinical outcomes of patients with predicted SAP

Gou S et al Crit Care 2014 :18(2):R57

Case 1..

(10/11/14)• ERCP : Cholangiogram showed mild

dilatation of bile duct, No calculi

- Spincterotomy performed

- Double pigtail plastic stent inserted

• Bile sent for culture

Do all patients with biliary pancreatitis need evaluation of bile duct ?

Are there predictors for CBD stones in ABP

Dr Palaniappan

Predictors for CBD stones in ABP

• Cholangitis (likelihood ratio 18.3)

• Jaundice and ultrasound evidence of stones in the common bile duct (likelihood ratio > 10 in each case)

• A dilated common bile duct on ultrasound hyperbilirubinemia had likelihood ratios between 4 -7

• More modest predictors included an elevated alkaline

phosphatase level, pancreatitis, cholecystitis

Is ERCP required for all patients with ABP

• ERCP is indicated for all patients with cholangitis

• 60% of the patients with gall stones & cholestasis subjected to conservative treatment did not have choledocholithiasis during elective surgery (cholecystectomy and intraoperative cholangiography ) performed during the same hospitalization.

(Oria A et al Ann Surg. 2007;245:10–17.)

• Waiting for 3-5 days in patients with cholestasis will reduce the number of ERCP by 60 % (morbidity & mortality of ERC avoided)

- If no improvement after 3-5 days , EUS/ MRC and ERCP if there are CBD stones

Does prophylactic CBD stent before cholecystectomy have any impact on the rate of biliary complications?

Dr Palaniappan

Is prophylactic CBD stent required during ERCP ?

• 162 patients with choledo-chocystolithiasis underwent ERCP with ES and were divided to two subgroups.

- Group A ( 52 patients) with stent insertion and group B (110 patients) with no stent insertion

• Prevalence of cholangitis, cholecystitis and

emergency cholecystectomy similar in both groups

Verzhbitsky et al Surg Endosc 2013 Dec;27(12):4620-4

Case 1..

13/11/14.• Developed fever ( 102F) with tachycardia (127/mt)

and tachypnea ( resp rate : 30/mt)

• Cultures :

- Bile culture : No growth

- Blood culture x2 : No growth

• LFT : 1.0/0.4/5.0/2.6/49/87/108; Gamma GT : 211

What are possible causes of fever, tachycardia & tachypnea in this scenario?

What to do next ?

Dr Ganesan Dr Manoharan

Pathogenesis of acute pancreatitis

Inflammation Infection

Contrast enhanced CT scan

Dr Amarnath

Case 1..

Contrast enhanced CT scan: (15/11/14)• CBD with stent in situ• Extensive fluid collection in lesser sac,

pelvis and left paracolic pouch;

- No air pockets• Extra pancreatic fat necrosis• Bilateral pleural effusion

Case 1..

• Urine culture : ( 17/11/14)

- Growth of > 100,000cfu/ml of Enterococci faeceum;

- Sensitive only to Teicoplanin,Linezolid, Vancomycin & Tigecycline

• Teicoplanin added following which fever, tachycardia & tachypnea subsided in 3 days.

Extra pancreatic infections in acute pancreatitis

• Half of bacterial cultures of pancreatic necrosis are of non-enteric origin, raising the possibility of other sources of infection

• Systematic review of 19 studies with 1741 patients- Incidence of Extra-pancreatic infectious complication was 32% with the commonest being respiratory infection (9.2%) and bacteraemia (8.4%)

Brown LA et al Pancreatology 2014 Nov-Dec;14(6):436-43

What is the best approach to manage a patient with biliary pancreatitis - cholelithiasis &

Choledocholithiasis ? Give reasons

A ERCP & Spincterotomy , followed by Lap Cholecystectomy

B Lap Cholecystectomy followed by ERCP &

Spincterotomy C Lap Cholecystectomy with Lap CBD exploration

D ERCP & Spincterotomy alone

Dr Palaniappan & Dr Manoharan

• Study on 5,079 patients with severe gallstone pancreatitis :

• Recurrent pancreatitis after :- ES alone 6.7 %- Cholecystectomy alone 4.4 %- ES followed by cholecystectomy 1.2 % (p < 0.05)

• Gallstones related complications in patients treated with ES alone were similar to patients who received no definitive treatment (12.2 vs. 9.4 %)

• ES alone only in patients where surgery cannot be performed

Mustafa A Surg Endosc 2014 Jan;28(1):127-33

Approach to manage a patient with biliary pancreatitis

• Single-stage management is equivalent to two-stage management

- Similar post-op morbidity, mortality, conversion to open procedure and length of hospital stay

• Patient's condition, operator's expertise and local

resources should be taken into account in making treatment decisions

Lu J et al World J Gastroenterol 2012 28;18(24):3156-66

L C with Lap CBD exploration vs ES followed by L C

A B P – Timing of cholecystectomy - Index admission or later date ?

Dr Manoharan

Timing of cholecystectomy - Index admission or later date?

• After biliary pancreatitis, cholecystectomy is recommended at :- Same hospital stay for mild pancreatitis - After an interval of 6 wk following an episode of severe pancreatitis

Acute Pancreatitis Guidelines Working Group IAP/APA Pancreatology. 2013;13:e1–15

Case 1 ..

• Patient was discharged at request on 21/11/14 and and advised to return for Lap cholecystectomy.

• Patient was readmitted in first week of December with abdominal pain & vomiting. No fever or jaundice

- S. Amylase : 98 IU; Lipase 120 IU : CRP : 24.7

- LFT : 1.2/0.3/8.2/4.1/21/30/81.Gamma GT : 32

• CECT abdomen : Dr Amarnath

Case 1..• CECT abdomen :

- Significant improvement over last CT.

- Fluid collection reduced in peripancreatic and left pararenal space.

- Edematous gall bladder wall suggestive of cholecystitis.

• Abdominal pain settled with analgesics

• She underwent Lap cholecystectomy and had uneventful recovery. The biliary stent was removed 2 weeks after surgery

Summary

• Issues in management of acute biliary pancreatitis in pregnancy

• Aggressive fluid resuscitation in SAP

• Extrapancreatic infections in SAP

• Management strategies in biliary pancreatitis- Endoscopic - Surgical

Thank You Panelists

Dr Ganesan Tanjore

Dr Manoharan Chennai

Dr Palaniappan Chennai

Dr Amarnath Chennai

Acute Pancreatitis

Health & Medicine

Transcript of Acute Pancreatitis