Acute Pancreatitis
University Hospital Berne, Clinic for Visceral Surgery and Medicine
Jan Hendrik
Niess
How do you diagnose acute pancreatitis (AP)?
Presence of two of the following three criteria
- abdominal pain consistent with disease
- lipase or serum amylase greater than three times
upper the normal limit
- characteristic findings of abdominal imaging
What abdominal imaging modality needs to be
performed in early AP?
- Transabdominal ultrasound
- Search for biliary aetiology
- needs to be performed on admission (since sludge can develop
during AP evolution)
- sensitivity for GB lithiasis 95%
- sensitivity for CBD lithiasis 30-80%
- (pancreatic swelling only in 25 – 50%; bowel gases may mask the
pancreatic region)
What problems does CE-CT have at early AP?
- High sensitivity (90%) and specificity for AP
- In most cases AP can be diagnosed without imaging modality
- Has a low sensitivity and specificity for the detection of lithiasis
- Necrosis are not marked at early time points (prior to 48 to 72h)
When should CE-CT carried out?
In patients not improving with 72 hours (persistent pain, fever, nausea,
unable to begin oral feeding) to assess local complications
What is the aetiology of AP?
• Gallstones (40-70%)
• Alcohol (25-35%)
• Medications (http://www.mucosalimmunology.ch/images/content/PPT-presentations_free_access/bible_class/Drug-inducedpancreatitis.pdf)
• (i.e. azathioprine, furosemide, valproic acid)
• Primary and secondary hypertriglyceridemia ( > 1,000 mg/dl)
• Hypercalcemia and hyperparathyroidism
• Autoimmune
• Infectious (coxackie, mumps, CMV, HSV, HAC, HBV, HCV)
• Post -ERCP
• SPINK, PRSS1, CFTR mutations
• Congenital anomaly of the pancreas (Pancreas divisum)
• 5-14% pf patients with a benign or malign mass present with AP
Work-up of patients with AP?
- Ultrasound at admission
- Lab tests
- Ca2+
- ALT, AST, Bili g-GT
- Fasting TG (if > 1000 mg/dl, repeat 4 weeks after resolution of AP)
- Immunoglobulins
- Consider genetic testing in young patients (< 30 years) and with a
positive family history of pancreatic diseases.
- Consider anomalies of the pancreas
- Consider in patients > 40 years a benign or maligne mass as cause
for the pancreatitis
- Abdominal imaging after resolution of pancreatitis
How can severe AP predicted?
- There is no lab parameter, which predicts severe AP
- AP-specific scoring systems (BISAP, APACHE etc.) are of importance for clinical
studies, but have limited value within the first 48 hours of AP
- Clinical assessment is most important in monitoring AP patients
Patient characteristics
Age > 55 years
Obesity (BMI > 30 kg/m2)
Altered mental status
Comorbidities
How can severe AP predicted?
The systemic inflammatory response syndrome (SIRS)
Pulls > 90 beats/min
Respiration > 20/min
Temperature <36; > 38
Laboratory findings
blood urea nitrogen (BNU) > 20 mg/dl
Haematocrit > 44
Radiology findings
pleural effusions
pulmonary infiltrates
Multiple or extrapancreatic collections
How is AP managed ?
Fluid management
• Aggressive hydration 250-500 ml per hour of isotonic crystalloid
solution. Most efficient in the first 12-24 hours, and may have little
benefit beyond
• Lactated Ringer’s solution may be the preferred isotonic crystalloid
replacement fluid.
• Fluid requirements should be reassessed at frequent intervals
within 6 h of admission and for the next 24 – 48 h. The goal of
aggressive hydration should be to decrease the blood urea nitrogen
Pain control
How should antibiotics used ?
Consider
Mortality
Sterile necrosis 10%
Infected necrosis 30%
but it takes approximately 7 to 10 days before necrosis will become infected
This means
- Antibiotics should be given for the treatment of extrapancreatic infections
(cholangitis, pneumonia, urinary tract infections ……..).
- Routine use of prophylactic antibiotics in patients with severe
AP is not recommended (any longer)
- There are only few antibiotics that penetrate into necrotic regions
(carbapenems, quinolones, metronidazole and 4th generation cephalosporins)
- Consider the development of pancreatitis for the choice of the antibiotic used
for the treatment of extrapancreatic infections in early AP
How should nutrition be managed in AP patients?
N Engl J Med. 2014 Nov 20;371(21):1983-93
• Intravenous fluids in the first 72 hours
If patients actively asks for food an oral diet can be offered
• Start on demand oral diet after 72 hours
• If an oral diet is not tolerated within 96 hours after onset of pancreatitis,
then place a naso-enteral feeding tube for nutrition
What is the management of necrosis?
Sterile necrosis: conservative management; no drainage or necrosectomy to prevent
iatrogenic infection
(Exceptions: compartment syndrome, bowel ischemia, acute bleeding, gastrointestinal
or biliary obstruction)
Infected necrosis (confirmed or suspicious) - gas inclusion in CT
- fine needle aspiration and microbiology
conservative treatment with broad spectrum antibiotics for at least 3 to 4 weeks
if possible (wait for the encapsulation and demarcation of necrosis)
Invasive approaches for the treatment of
infected necrosis?
• Percutaneous catheter drainage
• Endoscopic transluminal drainage
• Minimally invasive retroperitoneal necrosectomy
• Minimally invasive laparoscopic necrosectomy
• Endoscopic (transluminal) necrosectomy
• Open necrosectomy
CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2012;10:1190–1201
Minimale invasive retroperitoneal necrosectomy
Endoscopic transluminal drainage and necrosectomy
CLINICAL GASTROENTEROLOGY
AND HEPATOLOGY 2012;10:1190–1201
Axios
Stent System
Gastrointestinal Endoscopy
2012; 75:870–876
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