2 ObjectivesIdentify clinical presentation and etiologies of acute pancreatitisRecognize the importance of severity of pancreatitis in determining management and outcomesUnderstand the indications for imaging and antibiotics in acute pancreatitis
3 Key MessagesEarly aggressive hydration is critical in the management of acute pancreatitis.Imaging with contrasted CT or MRI is indicated at hours in patients with severe disease.Early enteral nutrition improves outcomes in patients with severe pancreatitis.Severity scores can be used to triage patients at risk for complications.
5 EtiologiesGallstones % (increased ALT >150 is 50% sensitive and 96% specific) *womenAlcohol – 30% *menHypertriglyceridemiaHypercalcemiaPost-ERCP -3% of diagnostic, 25% if SOD studiesDrugs – direct toxic, immunologic, ischemic causes – cocaine, HCTZGenetic mutationsTraumaInfection – Viruses (mumps, hep B, CMV, HIV), Bacteria (mycoplasma, legionella, salmonella), fungi, parasitesIdiopathic %Autoimmune (although usually presents mimicking neoplasm)Scorpion biteSOD dysfunction? Pancreatic divisum?
6 Pathophysiology Activation of trypsin in acinar cells Activating multiple pancreatic digestive enzymes (synthesized but not secreted)Leak into interstitial space and systemic circulationIntrapancreatic InflammationMediated by cytokines/inflammatory markersSIRSExtrapancreatic InflammationARDSMultiple organ failure (MOF)Respiratory, cardiovascular, renal
7 Diagnosis Requires 2 of the following 3 features Characteristic abdominal painEpigastric, band-like radiating to back, assoc n/vAmylase and/or lipase >/= 3 times the upper limitAmylase rises in 6-12 hrs, elevated 3-5 daysLipase sensitivity %; more specific than amylaseCharacteristic CECT (contrast enhanced CT) findings (or MRI/US)Edema, peripancreatic fat stranding, necrosis, calcifications, pancreatic heterogeneity
8 ImagingPlain XR – unremarkable or have “sentinel loop” (localized ileus) or “colon cutoff sign” in severe diseaseCXR – pleural effusion suggests increased risk of complicationsAbd ultrasound: diffuse, hypoechoic pancreas, useful for gallstones, not good for necrosisCT scan – useful for complications and for severity assessmentWhen to CT? indicated if need to assess for necrosis (severe disease) at hoursOral and IV contrast preferred (to diagnose necrosis, calcifications, stones, mass)MRCP – best for delineating fluid collections, necrosis, ducts, looking for choledocholithiasis
9 ManagementDetermine etiology – history, LFTs, TGs, calcium, abdominal ultrasound for stonesDetermine severity and send severe to ICUFLUIDS FLUIDS FLUIDS – Initial bolus, then cc/hr x 48 hours if cardiac fx normalIncreasing BUN at 24 hrs predicts mortalityMonitor glucose and lytes (Ca, Mg)No daily amylase/lipase; no correlation with severityPain managementNutrition – start oral feeds when pain improving, no ileus in mild dz
10 NutritionNeed for nutrition and pancreatic rest in severe pancreatitis or anyone NPO > 5 daysEarly enteral nutrition (at hrs) reduces mortality, multi-system organ failure, infections and need for operative interventions compared to TPNMaintains intestinal barrier, prevents translocationHigh protein, low fat formula
11 Antibiotics ACG – prophylactic antibiotics not recommended AGA – abx should be restricted to pts with >30% pancreatic necrosis by CT and should be used for less than 14 daysMeropenem or imipenem are drugs of choiceCT guided aspiration/culture recommended if infected pancreatic necrosis is suspected (fevers, sepsis, increasing WBC)
12 Classification of Acute Pancreatitis Interstitial edematousAcute inflammation of pancreatic parenchyma and peripancreatic tissueNecrotizing Acute Pancreatitis5-10% of patientsPancreatic or peripancreatic necrosisAppears as non-enhancing areaEarly CECT may underestimate (wait 48-72h)
13 Severity of Pancreatitis Mild AcuteNo organ failure, local or systemic complicationsModerately SevereTransient organ failure (OF) <48hLocal or systemic complications w/o persistent OFSevere AcutePersistent organ failure (>48h)Mortality ~36-50%; higher w infected necrosis
14 Severity scores Most cases mild, 15-25% severe Depends on presence and duration of organ failureEarly risk stratification (median time to ICU transfer is 24 hours after admission)APACHE II most widely used – score >8=severeBISAP – simple, can be done earlyBUN, AMS, SIRS, Age>60, pleural effusion>3 points indicates increased risk of deathRanson’s criteria
15 Ranson’s Criteria At admission At 48 hrs out Age > 55 WBC > 16 Glu > 200AST > 250LDH > 350Ca < 8HCT fall > 10%PO2 < 60BUN increase > 5Base deficit > 4 mEq/LSequestration of fluids > 6LCriteria MetMortality0-22%3-415%5-640%7-8100%
16 ComplicationsPancreatic necrosis – becomes infected in about 30%; usually monomicrobial (Ecoli, Pseudomonas, Kleb)AbscessesPseudocysts-Drainage prior to maturation (6 wks) can lead to complicationsSplenic vein thrombosis (up to 19% of pts)Anticoagulation may be needed for complicationsAbdominal compartment syndromeARDS, shock, renal failure, GI bleeding
17 Definitions of Pancreatic and Peripancreatic Fluid Collections APFC: Acute Peripancreatic Fluid CollectionAssoc w intersitial panc; no necrosisHomogenous; no definable wall; adjac to pancreasPancreatic PseudocystWell circumscribed, homogenous, with wallMaturation usually >4 weeks after acute pancANC: Acute Necrotic CollectionOnly in setting of necrotizing pancHeterogenous, no wall, intra and/or extra pancreaticWON: Walled Off NecrosisHeterogenous, well defined wall, intra/extraMaturation >4 weeks after acute necrotizing panc
18 Gallstone pancreatitis – early ERCP or surgery? Early ERCP or surgery to remove bile duct stones may decrease severity of pancreatitisERCP within 72 hours in pts with cholangitis OR concern for stone (stone on imaging, dilated CBD, jaundice, rising LFTs)All patients with gallstone panc should have cholecystectomy25-30% risk of recurrent panc, cholecystitis or cholangitis in <18 wksRecent retrospective of mild gallstone panc who had lap chole within 48 hrs of admissionNo increase in morbidity or mortalityDecreased hospital stay and ERCPConsider early consult in appropriate patients
19 ReferencesBanks P et al. Practice Guidelines in Acute Pancreatitis. Am J Gastroenterol 2006; 101:Banks P et al. Classification of acute pancreatitis-2012:revision of the Atlanta classification and definitions by international consensus. Gut 2013; 62:Al-Omran M et al. Enteral versus Parenteral Nutrition for Acute Pancreatitis (Review). Cochrane Database of Systematic Reviews 2010, Issue1Falor et al. Early Laparoscopic Cholecystectomy for Mild Gallstone Pancreatitis. Arch Surg 147: Nov 2012Van Santvoort et al. Early Endoscopic Retrograde Cholangiopancreatography in Predicted Severe Acute Biliary Pancreatitis: A Prospective Multicenter Study. Annals of Surgery (1); July 2009Wu, Bechien. Prognosis in Acute Pancreatitis. CMAJ: 183 (6); April 2011
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