Acute Pancreatitis Managementdoccdn.simplesite.com/d/a8/e9/287104482457151912... · Member of...

Acute Pancreatitis Management

Imam Sofii, MD

Staff of General Surgery, Sardjito General Hospital/

Gadjah Mada University Yogyakarta Indonesia

Member of Indonesian College of Surgeon

Leppaniemi A, Tolonen M, Tarasconi A, et al. WSES Guideline for the Management of severe acute pancreatitis. 2019

• Atlanta (1998) and Revise Atlanta Classification (RAC, 2012).

• British Society of Gastroenterology.

• American Collage of Gastroenterology.

• International Association of Pancreas.

• World Congress of Gastroenterology.

Guidelines

Definition

• Acute pancreatitis is an inflammatory

condition of the pancreas, clinically

characterized by acute abdominal pain and

elevated levels of pancreatic enzymes in the

blood

• Auto digestion of pancreatic substance by

inappropriately activated pancreatic enzymes

( especially trypsinogen )



• Clinical sign and symptom.

• Mild to severe (critical).

• Laboratory support.

• Organ failure impact (transient/persistent, single/multiple)

• Imaging support.

• Local complication pattern.

• Acute peripancreatic fluid collections

• Pancreatic pseudo cyst

• Acute necrotic collections

• Walled-off pancreatic necrosis

Diagnosis of acute pancreatitis

Acute Pancreatitis ( 2 of the following )

• Abdominal pain ( acute onset of a persistent, severe, epigastric pain often

radiating to the back )

• Serum lipase activity ( or amylase ) at least 3 times greater than the upper.

• Characteristics findings of acute pancreatitis on computed tomography or

magnetic resonance imaging

Mild acute pancreatitis

• No organ failure, local or systemic complications

Key Term Diagnosis


Moderately severe acute pancreatitis

• Organ failure that resolves within 48 hour and or

• Local or systemic complications without persistent organ failure

Severe acute pancreatitis

• Persistent organ failure >48 hours

Interstitial edematous acute pancreatitis

• Acute inflammation of the pancreatic parenchyma and peripancreatic tissues,

but without recognizable necrosis


Key Term Diagnosis

Necrotizing acute pancreatitis • Inflammation associated with pancreatic parenchymal necrosis and/or peri-

pancreatic necrosis

Organ failure and systemic complications of acute pancreatitis

• Respiration : PaO2/FiO2 ≤ 300

• Cardiovascular : systolic blood pressure <90 mmHg ( off inotropic support) not

fluid responsive, or pH <7.3

• Renal serum creatinine ≥ 170 µmol/L Leppaniemi A, Tolonen M, Tarasconi A, et al. WSES Guideline for the Management of severe acute pancreatitis. 2019

Key Term Diagnosis

Local complications of acute pancreatitis

• Acute peripancreatic fluid collections

• Pancreatic pseudo cyst

• Acute necrotic collections

• Walled-off pancreatic necrosis

Shah AP, Mourad MM, Bramhall SR. Acute Pancreatitis: Current Perspectives on Diagnosis and Management. 2018

Key Term Diagnosis

• Serum lipase has a slightly higher sensitivity for detection of acute

pancreatitis than serum amylase because elevation occur earlier and last

longer.

• Sensitivity serum lipase vs serum amylase:

• day 1 : 100% vs 95%

• day 2-3 : 85 vs 68%

• Biliary stone and alcohol overuse are the causes of acute pancreatitis in

70-80% of cases.



• USG has sensitivity and specificity > 95% in detection of gallstones.

• MRCP is useful in identifying CBD stones and delineating pancreatic

and biliary tract anatomy.

• Sensitivity and specificity of MRCP to diagnose biliary obstruction

were 95% and 97%. To detection biliary stones, sensitivity was 92%.

• CT is useful to distinguish between interstitial acute pancreatitis and necrotizing

acute pancreatitis, and to rule out local complication. However, these distinctions

typically occur more than 3-4 days from onset of symptoms (limited use on

admission).



Diagnosis of local complication and acute pancreatitis

Local complication that can be recognized on abdominal CT scan:

• Peripancreatic fluid collections, gastrointestinal and biliary complications

(e.q.obstruction)

• Solid organ involvement (e.q. splenic infarct)

• Vascular complications (e.q.pseudoaneurysms, splenic vein thrombosis)

• Pancreatic ascites.



Diagnosis of local complication and acute pancreatitis

FNA has been established as an accurate, safe & reliable technique for identification of :

• Infected acute peripancreatic fluid collection (APFCS)

• Pancreatic pseudocysts

• ANCS (Acute necrotic collections)

• WOPN (Walled-off pancreatic necrosis)

FNA should not be performed in the absence of a clinically or radiologically suspected infection

• Small necrosis.

• Associated infection into a previously sterile.


• Laboratory (CRP, Hematocrit, BGA, etc)

• Ranson score

• APACHE II

• BISAP

• SOFA

• Modified Marshal score.

• …

Assessment of severity

Level serum CRP above 14 286 nmol/L (150 mg/dL) at

48 hours help discriminate severe

from mild disease.

At 48 hours, serum CRP level above 14 286 nmol/dL (150 mg/dL)

have sensitivity, specificity, positive predictive value and negative

predictive value of 80%, 76%, 67%, and 8%, respectively, for severe

acute pancreatitis.

Level serum CRP > 17 143 nmol/dL (180 mg/dL) with in first

72 hours have been correlated with the

presence of necrosis (sensitivity and specificity both > 80

APACHE II scores at admission and during 72

hours < 8 (mortality < 4%).

APACHE II score within first 24 hours

had positive predictive value of 43% and negative predictive

value of 86% for severe acute pancreatitis.

APACHE II score ≧ 8 (mortality 11-18%).

If APACHE II score decreases within the first 48 hours strongly

predicts mild acute pancreatitis, if increases within the first 48 hours

strongly predict severe acute pancreatitis.



Ranson score was found to be poor predictor of severity in a meta-analysis of 110 studies

A diagnosis of severe acute pancreatitis should also made if a patient exhibits signs of persistent

organ failure for more than 48 hours despite adequate iv fluid resuscitation (Revision Atlanta

Classification).

Transient organ failure (resolving in 48 h) : mortality was 1%.

Transient organ failure + local complication :

mortality was 29%

Persistent organ failure (lasting >48 h) :

mortality was 35%

Persistent organ failure + local complication :

mortality was 77%




Management

Risk Factors Assessment

Monitoring Response to Initial Therapy

Clinical Risk Classification

Acute Pancreatitis Approach I G E T S M A S H E D


• Mild to Moderate.

• No doubt.

• Severe.

• Organ failure or infectious local

complication.

• Critical.

• Organ failure and infectious local

complication

Clinical risk classification Monitoring initial treatment

• Global monitoring assessment.

• GCS, VS, UO

• Organ monitoring assessment.

• Organ function

• Cell monitoring assessment.

• Lactate, BE


• Fluid resuscitation.

• Lose in third space.

• Intravascular pressure.

• Intraabdominal pressure (IAP).

• Pain.

• Nutrition support.

• Fasting.

• Oral/enteral feeding

• Parenteral.

Management

• Metabolic complication.

• Antibiotic rules.

• Monitoring and assessment.

• ERCP role.

• Early vs delay ERCP (cholecystectomy)

• One vs two stage.

• Surgery rule.

• Minimally invasive.

• Open surgery (stage laparotomy)

Supportive care

• Resuscitation with RL. After 24 hours of resuscitation there was an 84% reduction in

the incidence of SIRS and significant reduction in CRP from 9905 nmol/L (104 mg/dL to

5143 nmol/L (54 mg/dL) over normal saline.

• Necrotizing acute pancreatitis developed in all patients who received inadequate fluid

replacement as measured by a rise in hematocrit at 24 hours.

• Pain control is an important part of the supportive management of patients with

pancreatitis. Multi modal analgesic regimen is recommended, including narcotics,

NSAID and acetaminophen.

Management


Nutrition

• Current recommendation from 32 RCTs is to commence oral feeding

• Serial RCT shown that early oral/enteral feeding in patients with acute pancreatitis is

not associated adverse effect and may be associated with substantial decreases in

pain, opiod usage and food intolerance.

• Current recommendation from 32 RCTs is to commence oral feeding

at time of admission if tolerated or within the first 24 hours.

• Oral feeding on admission for mild acute pancreatitis significant decrease in LOS

from 6 to 4 days compared with holding oral food and fluid (Eckerwall et al).

Management


Nutrition

• Low fat diet was shown to be preferable to clear fluids on admission for mild acute

pancreatitis owing to higher caloric intake with no associated adverse effects.

• There is no evidence to suggest that a low fat diet is preferable to a regular diet.

• Meta-analysis 8 RCT (348 patients) EN vs TPN for acute pancreatitis showed reduced

mortality (RR 0.5), multiorgan failure (RR 0.55), systemic infection (RR 0.39), operative

intervention (RR 0.44), local septic complication (RR 0.74), complication (RR 0.74)

Management


Prophylactic antibiotic

• 7 RCT (404 patients) comparing prophylactic antibiotic vs placebo in CT proven

necrotizing acute pancreatitis : no statistically significant reduction of mortality

with therapy (8.4% vs 14.4%), no significant reduction in infection rates of

pancreatic necrosis (19.7% vs 24.4 %). Non pancreatic infection rates (23.7% vs

36%), overall infection (37.5% vs 51.9%).

• Overuse of antibiotics is associated with the increase risk of antibiotic-associated

diarrhea and Clostridium difficile colitis

Management

Most patients with sterile necrosis

• response to conservative medical management.

Patients with sterile necrosis, there have been several retrospective reports suggesting that :

• a delay in surgical necrosectomy and at times a total avoidance of surgery

results in less morbidity and mortality than early surgical debridement.

When sterile necrosis is debrided surgically

• a common sequel is the development of infected and the need for additional

surgery. Leppaniemi A, Tolonen M, Tarasconi A, et al. WSES Guideline for the Management of severe acute pancreatitis. 2019

Management of local complication acute pancreatitis

Management of local complication acute pancreatitis

In RCT, that compared early to late surgery in small number of patients with sterile necrosis :

• there was a trend toward greater mortality among those operated within the

first 3 days after admission.

Antibiotics should be prescribed only in patients with infected necrosis

• confirmed by FNA or if there is gas within a collection visualized on CT scan.

Antimicrobial therapy should be tailored to FNA culture speciation and sensitiveties.


Management of local complication and acute pancreatitis

The most commonly isolated bacteria from pancreatic necrosis :

• E.coli, Enterobacter cloacae, Enterococcus faecalis, Bacteriodes fragilis.

The mortality of patients with infected pancreatic necrosis is higher than 30%, and up to 80% of fatal outcomes in patients with acute pancreatitis

• due to septic complication resulting from pancreatic infection.



Recommedation empiric antimicrobial therapy :

• Imipenem and ertapenem have both been shown to penetrate pancreatic

tissue and pancreatic fluid at levels exceeding the minimum inhibitory

concentration (MIC) for the most commonly seen bacteria after as little as a

single iv dose.

The other empiric antimicrobial therapy

• Moxifloxacin (dose > 400 mg).



The NOM of infected pancreatic necrosis associated with MOF has a mortality

• Mortality is up to 100%. Surgical treatment of patients with infected pancreatic necrosis is associated with mortality

• as low as 10-30% in some specialized centres.

Patients with confirmed or suspected infected necrosis :

• Open necrosectomy

• Percutaneous drainage.

• Minimally invasive retroperitoneal necrosectomy. Surgical Infections. Volume 16, Number 1, 2015

ERCP should be performed early (within 24-48 h) in patients with

acute gallstone pancreatitis

associated with bile duct obstruction or

cholangitis.

in unstable patients percutaneous

transhepatic gallbladder drainage if ERCP is not

feasible.

Cholecystectomy performed during the

index admission in patient who have mild

acute pancreatitis

patient who have severe acute pancreatitis ,

cholecystectomy delayed until clinical resolution.

If cholecystectomy is contraindicated in

patients because of medical comorbidities :

ERCP and sphincterectomy should be considered prior to

discharge in patient with acute gall stone pancreatitis.

Management of patient with acute gallstone pancreatitis

Surgical Infections. Volume 16, Number 1, 2015

Case 1

• A 39 yo male with a history of gallstones 1 year ago, came to the emergency room

complaining of epigastric abdominal pain for the past 2 days.

• He describes the pain as constant and radiating to his back.

• He also complains of nausea and has vomited several times.

• His vital signs are BP 90/60 mm Hg, HR 110 x/mnt, resp. 24x/mnt, temp. 39°C.

• Physical exam reveals abdominal distension and diffuse tenderness to palpation,

worse over the epigastrium, but no guarding or rigidity.

• He is jaundiced and has no Grey-Turner or Cullen signs.

Laboratory (on admission) • HB 11 gr%

• Ht 33%

• WBC count of 16,400 cells/cm3

• Serum glucose 230 mg/dL

• Lipase 8,200 U/L,

• amylase 5,800 U/L

• AST of 124 IU/L

• ALT of 119 IU/L).

• LDH 411 IU/L

• CRP 160 ml/dl.

• AFP 320 U/L

• Total billirubin 3,4 mg/dl, direct bill 2,2 mg/dl

• Creatinine 2,4 mg/dl, ureum 59 mg/dl.

• BGA: pH 7.31, PaO2 of 72 mm Hg, BE -6.

RAC

• Clinical sign and symptom.

• Laboratory result.

• CT scan, USG?, MRCP?

Risk factor classification.

Severity classification.

• ?

A contrast-enhanced CT scan of the abdomen and pelvis:

• Stranding, inflammation, and edema within the peripancreatic

area and extending inferiorly along the paracolic until tail of the

pancreas.

• Necrosis and represents approximately 10% of the pancreatic

parenchyma.

• There was no free air.

Treatment

• Initial assessment and resuscitation.

• Monitoring initial treatment 48 hours.

• Success

• Fail

• Nutrition?

• AB?

• Repeated Ct scan?

• Rule of ERCP?

• Rule of surgery?

• A 39 yo male came to the

emergency room complaining of

abdominal pain after stab wound

accident 1 hour before.

• Primary survey: Airway, Breathing,

and Disability were clear but

Circulation not clear.

• Secundary survey: ‘klitih accident’

one hour before.

Case 2

• USG: free fluid collection in the hepatorenal, splenorenal, and

perivesical spaces.

• Operation report:

• Laceration of pancreatic body grade II

• Rupture of the liver grade II

• Rupture of gastroduodenal artery

• Postoperative:

o Drain seroushemorragic 100 cc a day and increase day by day.

• Second look for source and infection control.

o Deep SSI

o Fibrin and pancreatic juice (caseous).

o Open wound and VAC treatment.

Conclusion

• Acute pancreatitis is an inflammatory condition of the pancreas, auto digestion of

pancreatic substance.

• Misdiagnosis may happen anywhere and anytime.

• The success factors of management are risk classification, specific stage of acute

pancreatitis, and monitoring initial assessment, that do comprehensive and

multidiscipline approach team.

• Surgical management is a challenge to necrotizing pancreatitis increase morbidity and

mortality.

o Appropriate in infectious local complication.

o Persistent systemic organ failure involvement.

TERIMA KASIH

Acute Pancreatitis Managementdoccdn.simplesite.com/d/a8/e9/287104482457151912... · Member of...

Documents

Transcript of Acute Pancreatitis Managementdoccdn.simplesite.com/d/a8/e9/287104482457151912... · Member of...