Acute pancreatitis What to treat locally and what to …...Acute pancreatitis What to treat locally...
Transcript of Acute pancreatitis What to treat locally and what to …...Acute pancreatitis What to treat locally...
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