SlideShare a Scribd company logo

Gastrocon 2016 - Dr S.K Sinha's observation on Acute Pancreatitis

‱Download as PPT, PDF‱
‱
A
ApolloGleaneagls

A detailed case studies of patients having acute pancreatitis

Health & Medicine
1 of 145
Acute Pancreatitis S K Sinha Professor Department of Gastroenterology PGIMER, Chandigarh
Index Case 24May 2016 40 yrs old male, alcohol abuser presented with â–șPain abdomen for 3 hours Upper abd, non-colicky, severe, radiating to back Associated vomiting, multiple time bilious Associated abd distension + â–șPast, Family History : Not significant â–șPersonal History: 80-100 gms of alcohol/day for 15-16 yrs
GPE – Pulse 122 , BP 140/82 mmHg, RR 24/min Abdomen â–șLiver 3 cm, soft to firm â–șSpleen not palpable â–șDiffuse tenderness & guarding in whole abdomen â–șBowel sound sluggish Chest: reduced breath sound at bases CVS, CNS – NS Possibilities: Index Case
Index case: Investigations Hb -15.5 TLC – 14000 DLC – N 76 L 22 Platelets – 355 Urea : 55 Creatininine : 1.2 Bil – 1.5 SGOT – 55 SGPT – 62 ALP 130 (ULN – 128) TP – 7.6 Albumin – 4.9 Amylase – 155 (40-140) Lipase – 96 (0-50) Abd X-ray: No evidence of pneumoperitoneum USG abdomen – Bulky pancreas, GB sludge
Issue 1 What is the practically acceptable criteria for diagnosis of acute pancreatitis?
Acute pancreatitis: Diagnosis At least two of the following â–șAbdominal pain consistent with the disease â–șSerum amylase and / or lipase greater than three times the upper limit of normal â–șCharacteristic findings from abdominal imaging CECT and / or MRI should be reserved for â–șPatients in whom the diagnosis is unclear â–șWho fail to improve clinically within the first 48 – 72 h after hospital admission â–șTo evaluate complications ACG Guideline. Am J Gastroenterol 2013; 108:1400–1415
Issue 2 Which enzyme assay is preferable : amylase or lipase or combination of two? â–șRelative accuracy â–șFalse negative and false positive
Pattern of rise â–șRises within a few hours, may return to normal within 5 days â–șSensitivity in AP – approx 80% Acute pancreatitis with no rise in amylase â–șHypertriglyceridemia â–șAlcohol related AP â–șAcute on chronic pancreatitis High amylase but no pancreatitis â–șMacroamylasemia â–șRenal failure â–șdiseases of the salivary glands â–șExtrapancreatic abdominal conditions with inflammation â–șGynaecological diseases Serum amylase estimation: Pitfalls
Amylase vs Lipase Barbieri JS. Journal of Hospital Medicine 2016;11 :366-68
Pancreatic enzyme testing in AP Amylase testing offers no additional value to lipase testing Dual testing is not superior to Lipase testing alone Neither have prognostic value Pancreatic enzymes should not be repeated after making the diagnosis of acute pancreatitis Barbieri JS. Journal of Hospital Medicine 2016;11 :366-68
Index case Repeat Lipase at 24 hours : 480 IU Diagnosis of Acute pancreatitis was made Treatment â–șIV fluid â–șAnalgesia
Issue 3 Fluid for initial resuscitation/therapy of acute pancreatitis? â–șDoes initial aggressive fluid resuscitation matter? â–șWhich the preferred or currently recommended crystalloid fluid in initial management of acute of pancreatitis? â–șHow to monitor fluid resuscitation? Non-invasively – clinical/lab parameter Invasively How frequently the fluid therapy should be monitored?
Fluid therapy in acute pancreatitis Aggressive hydration, defined as 250 – 500 ml per hour of isotonic crystalloid solution unless contraindicated Early aggressive intravenous hydration is most beneficial during the first 12 – 24 hrs In a patient with severe volume depletion, manifest as hypotension and tachycardia, more rapid repletion (bolus) may be needed ACG Guideline. Am J Gastroenterology 2013
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 BUN CVP/USG monitoring of IVC Fluid therapy in acute pancreatitis ACG Guideline. Am J Gastroenterology 2013
IV line secured, started on RL NPO Injectable PPI – Pantoprazole 80 mg followed by 40 mg BD Inj Metoclopramide 10 mg IV stat Analgesic: Buscopan + Diclofenac injection – pain reduced in intensity but did not subside Index case: Investigations
Issue 4 Which narcotic analgesic should be used in acute pancreatitis?
Effect of narcotics on Sphincter of Oddi pressure Sphincter pressure at base line Sphincter pressure 20 min after inj Morphine 8.90±9.11 20.51±13.46 Pethidine 7.06±5.07 6.68±4.32 Tramadol 7.01±5.50 6.39±5.37 Pentazocine 6.42±5.10 11.34±8.40 Wu SD. World J Gastroenterol 2004;10(19):2901-2904
Effect of narcotics on Sphincter of Oddi pressure Staritz M et al. Gut, 1986, 27, 567-569
Morphine and pentazocine increase SO and CBD pressure Pethidine does not increase SO or bile duct pressure Tramadol and Buprenorphine increase SO pressure minimally Tramadol has the same analgesic effect as morphine. But it has little effect on the respiratory system and circulation system Effect of narcotics on Sphincter of Oddi pressure Wu SD. World J Gastroenterol 2004;10(19):2901-2904
Pain persisted in lower intensity – was put on Inj Tramadol sos, Buprenorphine patch was given Started having fever from Day 3 – Temp upto 38.5 degrees C Bowel not moved Tachypnea – RR 24-30, O2 – 0.30 Repeat Labs on day 4 â–șS/Electrolytes, RFT – N â–șLFT – Bil – N, Mild rise of transaminases â–șHb 12.9 gms TLC -13500 DLC – N 70 L 26 Index case: Course
Issue 5 How do we define severity of acute pancreatitis? â–șMild/moderate/severe
Revised Atlanta Definitions 2012 Interstitial oedematous pancreatitis â–șAcute inflammation of the pancreatic parenchyma and peripancreatic tissues, but without recognisable tissue necrosis â–șCECT criteria Pancreatic parenchyma enhancement by intravenous contrast agent No findings of peripancreatic necrosis Necrotizing pancreatitis â–șInflammation associated with pancreatic parenchymal necrosis and/or peripancreatic necrosis â–șCECT criteria Lack of pancreatic parenchymal enhancement by intravenous contrast agent and/or Presence of findings of peripancreatic necrosis
Mild acute pancreatitis â–șNo organ failure â–șNo local or systemic complications Moderately severe acute pancreatitis â–șOrgan failure that resolves within 48 h â–șTransient organ failure and/or â–șLocal or systemic complications without persistent organ failure Severe acute pancreatitis â–șPersistent organ failure (>48 h) Single organ failure Multiple organ failure Severity of acute pancreatitis
Parameters Score 0 1 2 3 4 PaO2/ FiO2 ratio >400 301–400 201–300 101– 200 ≀101 Serum creatinine, mg/dl) <1.4 1.4–1.8 1.9–3.6 3.6–4.9 >4.9 Cardiovascular (systolic blood pressure, mm) >90 <90, fluid responsive <90, not fluid responsive <90, pH<7.3 <90, pH<7. 2 Modified Marshall scoring system for organ dysfunction A score of 2 or more in any system defines the presence of organ failure.
Organ failure in acute pancreatitis Shock â–ș(systolic blood pressure < 90 mm Hg), Pulmonary insufficiency â–ș (PaO 2 < 60 mm Hg), Renal failure â–șcreatinine > 2 mg / dl after rehydration Gastro intestinal bleeding â–ș > 500 ml of blood loss/ 24 h Bradley EL et al. Arch Surg 1993 ; 128 : 586 –
Local complications of AP
APFC (acute peripancreatic fluid collection)
Pancreatic pseudocyst
Acute necrotic collection
Acute necrotic collection
Infected pancreatic necrosis
WON (walled-off necrosis)
Issue 6 Is this patient having severe acute pancreatitis or likely to have severe acute pancreatitis? How to identify patients with severe acute pancreatitis?
Ranson’s Criteria for acute pancreatitis
Glasgow criteria for acute pancreatitis
APACHE II scoring system for acute pancreatitis
Japanese society severity score Variables â–șBE level < -3 mEq/L or shock â–șPaO2 < 60 mm Hg (room air) or respiratory failure â–șBlood urea nitrogen level > 40 mg/dL or creatinine level > 2 mg/dL â–șLactate dehydrogenase level > 2 folds of upper normal limit â–șPlatelet count < 105/mm3 â–șCalcium level < 7.5 mg/dL â–șC-reactive protein level > 15 mg/dL â–șSystemic inflammatory response syndrome score > 3 â–șAge > 70 years old Pancreas 2014, 43:487-89
BISAP: Bedside index for severity in acute pancreatitis Blood urea nitrogen >25 mg/dL Impaired mental status (Glasgow coma scale score<15) SIRS : SIRS is defined as two or more of the following: â–șTemperature of <36℃ or >38℃ â–șRespiratory rate >20 breaths/min or PaCO2<32 mmHg â–șPulse>90 beats/min â–șWBC<4×109 or >12×109/L or >10% immature bands Age>60 yr Pleural effusion detected on imaging
Clinical findings predicting a severe course Patient characteristics â–ș Age > 55 years, Obesity (BMI > 30 kg / m2 ) â–ș Altered mental status Comorbid disease The systemic infl ammatory response syndrome (SIRS) â–șPresence of > 2 of the following criteria: pulse > 90 beats / min, respirations > 20 / min, PaCO 2 > 32 mm Hg, temperature > 38 ° C or < 36 ° C, WBC count > 12,000 or < 4,000 cells / mm3 , 10 % immature neutrophils (bands) Laboratory findings â–ș BUN > 20 mg/dl, Rising BUN, HCT > 44 %, Rising HCT, Elevated creatinine Radiology findings â–ș Pleural effusions, Pulmonary infiltrates, Multiple or extensive extrapancreatic collections ACG Guideline 2013. Am J Gastroenterol 2013
Comparison of different scores Park JY. Hepatobiliary Pancreat Dis Int 2013
Issue 7 – Imaging in AP CECT of abdomen in acute pancreatitis â–șWhat are the findings which should especially be taken into consideration? â–șWhat is accuracy of CT scan? â–șShould all patients be subjected to CT scan examination? â–șWhen should CT scan be done? â–șWhat is the ideal timing? â–șDoes accuracy depend on timing and technique? â–șWhat are the risks involved with CT scan examination? â–șWhat are the modalities to reduce the risk?
Contrast CT scan of abdomen CECT provides over 90 % sensitivity and specificity for the diagnosis of AP ( 20 ). Routine use of CECT in patients with AP is unwarranted If a patient fails to improve after 48 – 72 CECT or MRI imaging is recommended to assess local complications CT and MRI are comparable in the early assessment of AP â–șMRCP can detect CBD stones upto 3 mm Timing of CT scan â–șFor assessment of severity and local complications: after 3-5 days â–șWhen diagnosis in doubt: any time ACG Guideline. Am J Gastroenterol 2013; 108:1400–1415
CT severity index of acute pancreatitis Balthazar CT Score â–șA -Normal â–ș B -Focal or diffuse enlargement of the pancreas, including irregularities of contour and inhomogeneous attenuation â–ș C - Pancreatic gland abnormalities in grade B plus per pancreatic inflammation â–ș D - Grade C plus a single fluid collection â–ș E - Grade C plus 2 or more fluid collections and/or the presence of gas in or adjacent to the pancreas Necrosis â–șNone – score 0 â–șLess than 30% - score 2 â–ș30-50% - score 4 â–ș> 50% - score 6
Mortele KJ et al. AJR 2004;183:1261–1265 Modified CT Severity Index
CECT abdomen: CTSI – 8/10 MCTSI – 10/10 Patient having low grade fever - ? Start antibiotics Nutritional support???? Index case: Course
Issue 8 – Antibiotic prophylaxis in AP Antibiotics in acute panreatitis â–șShould prophylactic antibiotics be given to all patients with acute pancreatitis? â–șShould prophylactic antibiotics be given to all patients with severe acute pancreatitis? â–șWhat are the commonly acceptable indications of emperical use of antibiotics? â–șWhat the antibiotics preferred for prophylactic or emperical use? â–șWhen to start and when to stop?
Prophylactic antibiotics in AP “It is very difficult to study this very very challenging question and it is likely to remain enigma for quite some time” Alphonso Brown, Gastroenterology 2004
Last 15 years â–șMultiple trials â–șIncluded mainly severe pancreatitis â–șMany randomized trials, only one double blind randomized trial â–șVariable results â–șAntibiotics : Imipenem, Cephalosporins, Ciprofloxacin/Metronidazole Prophylactic antibiotics in SAP Gastroenterology 2004
Author Agent Durat ion Panrcreatic infection Mortality Antibi otics Control Antibi otics Control Pederzoli Imipenem 14 12.1 30.3 7.3 12.1 Sainio Cefuroxime 14 30.0 40.0 3.3 23.3 Delcenseri e Ceftazidime, Amika, Metro 10 0 25 9.1 25 Schwarz Ofloxacin, Metro 10 61.5 53.8 0 23 Nordback Imipenem/cila statin Not state d 8.0 42.4 8.0 15.1 Isenman Cipro, metro 14 12.0 8.9 5.1 7.1 Prophylactic antibiotics in AP
Prophylactic antibiotics in AP
Antibiotics in acute pancreatitis Routine use of prophylactic - not recommended Prophylactic antibiotic in necrotizing pancreatitis - not recommended Antibiotics should be given for an extra-pancreatic infection Infected necrosis should be considered in patients with pancreatic or extrapancreatic necrosis who deteriorate or fail to improve after 7 – 10 days of hospitalization. â–ș In these patients, either (i) initial CT-guided fine-needle aspiration (FNA) for Gram stain and culture to guide use of appropriate antibiotics or â–șEmpiric use of antibiotics after obtaining necessary cultures for infectious agents, without CT FNA, should be given ACG Guideline . Am J Gastroenterology 2013
In patients with infected necrosis, antibiotics known to penetrate pancreatic necrosis, such as carbapenems, quinolones, and metronidazole, may be useful in delaying or sometimes totally avoiding intervention, thus decreasing morbidity and mortality Duration of antibiotics : ?? Routine administration of antifungal agents along with prophylactic or therapeutic antibiotics is not recommended Antibiotics in acute pancreatitis ACG Guideline . Am J Gastroenterology 2013
Prophylactic antibiotics in AP Mild pancreatitis : Not recommended SAP: The prophylactic administration of antibiotics may improve the prognosis, if carried out in the early phases of pancreatitis (within 72 h of onset). (2B) Prophylactic antifungals are not recommended. (1C) Japanese Guideline. J Hepatobiliary Pancreat Sci (2015) 22:405–432
Antibiotics Efficacy factor Imipenem 0.98% Ofloxacin 0.87% Ciprofloxacin 0.86% Ceftriaxone 0.79% Cefotaxime 0.78% Tobramycin 0.22% Netilmycin 0.21% Efficacy factor of antibiotics in SAP Trop GE 1998
Issue 9 – Nutrition in acute pancreatitis Feeding in acute pancreatitis â–șWhich is the preferred route – enteral or parenteral? â–șWhen to start feeding”? â–șMild to moderate pancreatitis â–șSevere acute pancreatitis â–șWhich is preferred feeding formula – elemental/polymeric/Immune feeding? â–șWhich is the preferred enteral feeding route – nasogastric or nasoduodenal or nasojejunal?
Nutrition in acute pancreatitis In mild AP, oral feedings can be started once there is no nausea and vomiting, and abdominal pain â–șlow-fat solid diet appears as safe as a clear liquid diet In severe AP, enteral nutrition is recommended to prevent infectious complications. Parenteral nutrition â–șenteral route is not available, not tolerated, or not meeting caloric requirements Nasogastric delivery and nasojejunal delivery of enteral feeding appear comparable in efficacy and safety
Nutrition in acute pancreatitis Petrov M et al. ISRN Inflammation 2013 Reduced risk of infective complications and possibly reduced mortality with enteral feeding in severe acute pancreatitis
Nutrition in acute pancreatitis Petrov M et al. ISRN Inflammation 2013 Most of the patients with SAP are able to tolerate enteral feeding and nutritional goal is achieved in most patients
Enteral feeding formula Elemental â–șComprising amino acids or oligopeptides, maltodextrins, and medium—chain and long-chain triglycerides; Polymeric â–șComprising nonhydrolyzed proteins, maltodextrins, and oligofructosaccharides, as well as long-chain triglycerides; Immune-enhancing â–șComprising substrates that have been hypothesised to modulate the activity of the immune system, for example, immunonutrition (glutamine, arginine, and omega-3 fatty acids), probiotics, fibre-enriched formulation.
Nutrition in Acute pancreatitis Enteral nutrition – â–șCurtails of acute inflammation of the pancreas â–șReduces septic complications Nasojejunal tube feeding improves outcomes in SAP Safety and efficacy of nasogastric tube feeding in SAP Early NG feeding may have benefits even in mild-to- moderate acute pancreatitis Optimal enteral feeding formulations – more information is required Petrov M et al. ISRN Inflammation 2013
Put on IV antibiotics – Piperacillin+ Tazobactum for 14 days Nasojejunal tube placed – feeding attempted â–șDistension of abdomen â–șSOB Feeding had to be stopped temporarily O2 supplementation CXR was unremarkable IAP was measured Index case: Course
Issue 10 : IAP monitoring in acute pancreatitis Role of intra-abdominal pressure monitoring in acute pancreatitis? â–șHow to define abdominal compartment syndrome? â–șHow to monitor for abdominal compartment syndrome? â–șHow to treat abdominal compartment syndrome?
Abdominal compartment syndrome IAH – IAP> 12 mmHg ACS – IAP> 20 mmHg Causes â–șInflammatory fluid collection, inflammatory mass â–șParalytic ileus and distension of bowel â–șAscites Consequences â–șReduced renal and abd perfusion â–șIschemic bowel complication â–șRespiratory impairment Remedial measure â–șDecompression of stomach & bowel â–șAscitic tap/ placement of drains â–șMechanical ventilation with muscle relaxants â–șRestrict fluid if possible Mentula P et al. World Journal of Emergency Surgery 2014, 9:15
NJ feeding could be established after 5 days NJ feeding was given for two weeks Oral feeding in third week – gradually built up â–șFullness and bloating – post meals â–șNo vomiting Palpable lump abdomen, No fever , No vomiting Labs: normal RFT, LFT, Mild leucocytosis Discharged in 5th week Index case: Course
Re-evaluation during 7 – 8 th week â–șMild abdominal pain/discomfort, post prandial bloating â–șNo fever â–șTolerating oral diet, low fat â–șExamination: large upper abdominal lump, mild tenderness Index case: Course
Issue 11 : Management of Non-Infected Necrosis Pancreatic necrosis without infection â–șWhat are factors which determine the outcome? â–șWhat should be the preferred approach in management?
Management of local complication of AP Japanese Guideline 2015
Sterile pancreatic necrosis Debridement for sterile necrosis is recommended if â–șAssociated with gastric outlet obstruction â–șBile duct obstruction Asymptomatic pancreatic and / or extrapancreatic necrosis does not mandate intervention regardless of size, location, and extension.
10th week of illness â–șGradual increase in upper abdominal pain over 3-4 days â–șFever – High grade â–șVomitng off and on â–șShortness of breath â–șExamination Palpable upper abominal lump, tender Reduced breath sound at lung bases â–șLabs RFT, LFT – N HMG – Hb 10.5 gm, TLC – 24000, DLC – N88%, L 12 PCT – 3.9 Index case: Course
Issues 12: Infected Pancreatic Necrosis Pancreatic necrosis - With evidence of infection â–șShould all patients be referred for surgery? â–șWhat are the factors which determine the outcome? â–șHow to select the cases for non-surgical management? â–șWhat is the optimum timing for surgery?
Issue Infections in acute pancreatits â–șWhat are the common sites of infection in patients with acute pancreatitis? â–șWhat are the risk factors for infected pancreatic necrosis? â–șTiming of pancreatic infection â–șMethods of diagnosis â–șOrganisms â–șWhat are the common organisms? â–șWhat is the source of these organisms â–șHow common are the anaerobes? â–șHow common is fungal infection ?
Risk of pancreatic infection Risk depends upon â–șSeverity of pancreatitis Ranson’s score < 3 : 5.3% Ranson’s score > 5 : 58% â–șExtent of necrosis <30% : 5-10% 30 – 50% : 10-20% > 50% : 30 – 70% â–șBacterial colonization of gut Br J Surgery 1999
Surgical necrosectomy Medical series Guided FNA First week 11.1% 22.2% Second week 17.7% 33.3% Third week 22.2% 22.2% Fourth week 48% 22.2% Timing of pancreatic infection Gastroenterology 1986, 1987
Bacteriology of pancreatic infection Organism Frequenc y E coli 35% K pneumoniae 24% Enterococcus 24% Staphylococcus 14% Pseudomonas 11% Proteus 8% Aerobic streptococci 7% Enterobacter 7% Bacteroides 6% Compiled data No of series : 45 Total patients > 1100 Am Surgeon 2000
Fungal infection in pancreatic necrosis Risk factors â–șBroad spectrum antibiotics â–șAbdominal surgery â–șMale sex, Age > 40 years â–șCentral venous access , Hypotension at admission â–șHigh APACHE II score â–șRenal failure , TPN, Respiratory failure at admission â–șMechanical ventilation â–șERCP/ Pancreatic stenting â–șDiabetes mellitus â–șPercutaneous drainage â–șDuration of hospital stay > 4 weeks Kochhar R, JGH 2013
Fungal infection in pancreatic necrosis
Impact of pancreatic infection Increased mortality Increased morbidity â–șIncreased risk of renal failure â–șIncreased risk of GI bleed â–șIncreased risk of respiratory failure â–șIncreased cardiovascular complication Longer hospital stay Increased probability of surgery Increased cost of therapy
Infected necrosis Sterile necrosis Cardiovascular complication 31.0% 7.3% Pulmonary insufficiency 40.0% 14.3% Renal insufficiency 42.2% 21.7% Sepsis/SIRS 35.6% 8.7% G I bleeding 17.8% 5.8% Gastroenterology 1996 Impact of pancreatic infection
Infection in pancreatic necrosis When to suspect â–șTiming : second or third week â–șClinical feature Recurrence of pain abdomen Worsening of organ system function Increasing temperature Increasing TLC New onset ileus Am Surgeon 2000
Methods of diagnosis â–șPlain X-Ray â–șUltrasonography, CT â–șBlood culture â–șGallium scan â–șIn111 labelled leucocyte scan â–șUSG/CT guided FNA â–șPET CT Infection in pancreatic necrosis Gut 2005, Gastroenterology2004
Methods of diagnosis â–șPlain X-Ray â–șUltrasonography, CT â–șBlood culture â–șGallium scan â–șIn111 labelled leucocyte scan â–șUSG/CT guided FNA â–șPET CT Infection in pancreatic necrosis Gut 2005, Gastroenterology2004
USG/CT guided FNA Needle should not pass through a bowel Each suspected area should be sampled, multiple passes may be required Multiple sessions may be required Samples for gram’s stain, aerobic & anaerobic bacterial culture, fungal smear & culture Rapid inoculation, use of transport medium
USG/ CT guided FNA Complications : rare Results : High PPV, high NPV â–șTotal patients : 60 â–șTotal aspirations : 92 Grams stain + : 41 Culture + : 42 â–șFinal diagnosis Infected : 42 Uninfected : 50 Gastroenterology 1997
Infected pancreatic necrosis Antibiotics alone can lead to resolution of infection and, in select patients, avoid surgery altogether â–ș16/28 pts improved with antibiotics Unstable patients with infected necrosis needs consideration for urgent debridement â–șa course of antibiotics before intervention to allow the inflammatory reaction to become better organized â–șIf pt fails to improve : Necrosectomy Endoscopic/radiologic/video-assisted retroperitoneal/ laparoscopic approach/ combination
Cochrane review â–șThe minimally invasive step-up approach resulted in fewer adverse events, serious adverse events, less organ failure, and lower costs compared to open necrosectomy. No evidence to suggest that early open necrosectomy is superior or inferior to peritoneal lavage or delayed open necrosectomy Endoscopic minimally invasive step-up approach resulted in fewer adverse events than the video-assisted minimally invasive step-up approach but increased the number of procedures required for treatment Infected pancreatic necrosis
Treatment of Infected pancreatic necrosis Before demarcation of necrosis develops (< 4 weeks), it is almost impossible to remove all necrotic tissue without causing hemorrhage. Early surgical debridement â–șHigh risk of hemorrhage â–șIncreased organ dysfunction and death. Necrosectomy within the first two weeks - 75% mortality Necrosectomy after 6-8 weeks – Mortality 5% Multiple organ dysfunction increases mortality
Because high mortality is associated with early surgery , it is recommended that surgery for infected necrosis should be postponed as late as possible, preferable later than four week from disease onset â–șRole of percutaneous drain – single or multiple â–șMinimally invasive surgery/ endoscopic procedure Infected pancreatic necrosis
Infected pancreatic necrosis Supportive care for organ failure Nutrition Antibiotics : as per sensitivity and local data Drainage and necrosectomy â–șOpen surgical â–șLaparoscopic â–șRadiological â–șEndoscopic
USG guided aspiration â–șPus culture – E coli sensitive to Imipenem, Meropenem and Colistin Was started on Meropenem PCD was places – upgraded to 16 F Percutaneous endoscopic necrosectomy – 2 sessions Patient became afebrile after first session ERCP – Disrupted MPD, stented Index case: Course
Necrosectomy for infected necrosis Best surgical method not defined â–șNo direct comparison available Open surgical necrosectomy is the gold standard and standard of care Percutaneous and endoscopic necrosectomy are emerging modalities Local expertise and quality of ICU care matters
Percutaneous drainage of necrosis/collection
Endoscopic drainage/necrosectomy Baron & Kozarek. Clin Gastro Hepatol 2012
Endoscopic necrosectomy Baron & Kozarek. Clin Gastro Hepatol 2012
Issue 13 ERCP in acute biliary pancreatitis â–șWhat are the indications for ERCP in acute biliary pancreatitis? Urgent indications Semi-elective indications â–șDoes timing of ERCP matter? â–șWhat is the preferred ERCP intervention – stent or NBD or sphincterotomy or CBD clearance? â–șPatient taken up for ERCP but no stone on cholangiogram – what to do next?
Diagnosis of Biliary Pancreatitis
ERCP in acute biliary pancreatitis Indications â–șSuspected bile-duct stones as the cause of pancreatitis established clinically, and one of the following: Cholangitis (fever, jaundice, sepsis) Persistent biliary obstruction (conjugated bilirubin level >5 mg/dl Clinical deterioration (worsening pain, increasing white-cell count, worsening vital signs) Stone detected in the common bile duct on imaging ACG Guideline. Am J Gastroenterology 2013
Contraindications â–șAbsolute Unstable medical condition precluding safe administration of moderate sedation or general anesthesia Decision by competent patient not to provide consent for the procedure Endoscopist with inadequate training in ERCP â–șRelative (may be overcome) Anatomical condition (gastroduodenal disease or surgical alteration) that would impede endoscopic access to the major papilla; Clinically significant or uncorrectable coagulopathy ERCP in acute biliary pancreatitis ACG Guideline. Am J Gastroenterology 2013
UK guideline 2005 â–șEarly ERCP (within 72 hours after admission to the hospital) in all patients with predicted or actual severe biliary pancreatitis AGA 2007 â–șUrgent ERCP (within 24 hours after admission) if cholangitis â–șEarly ERCP (within 72 hours after admission) if suspicion of persistent bile-duct stones ACG 2013 â–șPatients with AP and concurrent acute cholangitis should undergo ERCP within 24 h of admission â–șERCP is not needed early in most patients with gallstone pancreatitis who lack laboratory or clinical evidence of ongoing biliary obstruction ERCP in acute biliary pancreatitis
ERCP in acute pancreatitis Sphincterotomy and CBD clearance â–șEvidence of CBD stone, biliary obstruction : at any time during course â–șSuspicion or evidence of cholangitis : at any time during course â–șPersistent biliary obstruction â–ș? Any case of biliary pancreatitis taken up for ERCP
ERCP in acute pancreatitis “While laparoscopic cholecystectomy is the gold standard to avoid recurrence in patients with gall stone related pancreatitis, ERCP and sphincterotomy are accepted alternatives in patients who are unfit for surgery” Gut 2005
Issue 14 Timing of cholecystectomy after an episode of acute biliary pancreatitis? â–ș What is the risk of recurrence over time?
Risk of delayed cholecystectomy Jee SL. Asian Journal of Surgery 2016
Summary AP – disease with unpredictable severity Significant morbidity and mortality in severe disease Team approach is crucial in management Enteral nutrition is preferable to parenteral nutrition Radiological interventions may play a crucial role in stabilizing a critically ill patient Endoscopic interventions are indicated in a select group of patient Early surgery is associated with higher complication rate compared with late surgery Specific treatment should be instituted when applicable
Open surgical necrosectomy Various techniques â–șOpen packing â–șPlanned re-laparotomies â–șClosed packing â–șClosed continuous lavage
Author No. of patients Pts with infected necrosis Mortality Re- laparotomy Bradley 1993 71 100% 15% 1-5/pt Branum 1998 50 84% 12% 2-13/pt Bosscha 1998 28 100% 39% 17/pt Nieuwenh uijs 2003 38 47% Surgical necrosectomy : Open packing
Author No. of patients Pts with infected necrosis Mortality Re- laparotomy Beger 1988 95 39% 8% 27% Farkas 1996 123 100% 7% Buchler 2000 29 93% 24% 22% Buchler 2001 42 93% 21% 17% Nieuwenh uijs 2003 21 33% Surg. necrosectomy : closed continuous lavage
AP: Magnitude of problem Incidence : 4.9 – 73.4 cases per lac population Incidence is increasing Mortality: minimal decrease over years Severity of pancreatitis â–șMild : 70 -80% No local or systemic complication Usually no necrosis Recovery in 3 – 7 days â–șSevere : 20 -30 % Local or systemic complications Necrosis usual Infection : 20 – 70% Gut 2005, Am J Gastro 2013
Course of acute pancreatitis Overall mortality: 5 – 10% Almost all mortality in severe cases Two phases of illness â–șEarly phase - within 7 days: largely unrelated to infection, mostly cytokine mediated SIRS Organ failure â–șLate phase – after 7 days, largely related to infection and consequences of organ failure Local complications Fluid collections, necrosis – sterile or infected Acute pseudocyst Walled off pancreatic necrosis Organ failure - persistent Tanner S et al. Am J Gastroenterol 2013
Cochior D et al. Chirurgia (2013) 108: 631-642 Course of acute pancreatitis
Initial assessment and risk stratification Hemodynamic status be assessed immediately upon presentation â–șAggressive hydration, defined as 250-500 ml per hour of isotonic crystalloid solution preferably Ringer Lactate Exceptions: Cardiovascular and renal comorbidity â–șHigher infusion rate in those with hypotension or tachycardia â–șAssess fluid requirement every 6 hours for 48 hours – aim to decrease BUN Risk assessment : â–șStratify patients into higher- and lower-risk categories to assist triage, such as admission to an intensive care setting Patients with organ failure: â–șadmitted to an ICU or HDU
APFC (acute peripancreatic fluid collection) Peripancreatic fluid associated with interstitial oedematous pancreatitis with no associated peripancreatic necrosis. This term applies only to areas of peripancreatic fluid seen within the first 4 weeks after onset of interstitial oedematous pancreatitis and without the features of a pseudocyst. CECT criteria â–șOccurs in the setting of interstitial oedematous pancreatitis â–șHomogeneous collection with fluid density â–șConfined by normal peripancreatic fascial planes â–șNo definable wall encapsulating the collection â–șAdjacent to pancreas (no intrapancreatic extension)
Pancreatic pseudocyst An encapsulated collection of fluid with a well defined inflammatory wall usually outside the pancreas with minimal or no necrosis. This entity usually occurs more than 4 weeks after onset of interstitial oedematous pancreatitis to mature. CECT criteria â–șWell circumscribed, usually round or oval â–șHomogeneous fluid density â–șNo non-liquid component â–șWell defined wall; that is, completely encapsulated â–șMaturation usually requires >4 weeks after onset of acute pancreatitis; occurs after interstitial oedematous pancreatitis
ANC (acute necrotic collection) A collection containing variable amounts of both fluid and necrosis associated with necrotising pancreatitis; the necrosis can involve the pancreatic parenchyma and/or the peripancreatic tissues CECT criteria â–șOccurs only in the setting of acute necrotizing pancreatitis â–șHeterogeneous and non-liquid density of varying degrees in different locations (some appear homogeneous early in their course) â–șNo definable wall encapsulating the collection â–șLocation—intrapancreatic and/or extrapancreatic
WON (walled-off necrosis) A mature, encapsulated collection of pancreatic and/or peripancreatic necrosis that has developed a well defined inflammatory wall. WON usually occurs >4 weeks after onset of necrotising pancreatitis. CECT criteria â–șHeterogeneous with liquid and non-liquid density with varying degrees of loculations (some may appear homogeneous) â–șWell defined wall, that is, completely encapsulated â–șLocation—intrapancreatic and/or extrapancreatic â–șMaturation usually requires 4 weeks after onset of acute necrotising pancreatitis
Etiology work up Initial work up: â–șAlcohol, Gall stones, Hypercalcemia, hypertriglyceridemia idiopathic acute pancreatitis, â–șEUS - to assess for occult microlithiasis, neoplasms and chronic pancreatitis. â–șIf EUS is negative, (secretin-stimulated) MRCP is advised For rare morphologic abnormalities - CT of the abdomen If etiology remains unidentified, especially after a second attack of idiopathic pancreatitis - genetic counseling (not necessarily genetic testing) ACG Guideline. Am J Gastroenterology 2013
Abdominal compartment syndrome IAH – IAP> 12 mmHg ACS – IAP> 20 mmHg Causes â–șInflammatory fluid collection, inflammatory mass â–șParalytic ileus and distension of bowel â–șAscites Consequences â–șReduced renal and abd perfusion â–șIschemic bowel complication â–șRespiratory impairment Remedial measure â–șDecompression of stomach & bowel â–șAscitic tap/ placement of drains â–șMechanical ventilation with muscle relaxants â–șRestrict fluid if possible Mentula P et al. World Journal of Emergency Surgery 2014, 9:15
Interventions in local complications
Acute pancreatitis Antibiotics prophylaxis for prevention of infection in necroting pancreatitis
EUS and acute pancreatitis Fusaroli P et al. World J Gastroenterol 2012; 18(32): 4243-4256
Role of EUS in acute pancreatitis EUS may prevent ERCP in 71% of patients with AP and offers a complication-free alternative EUS seems superior to MRCP (51% vs 20%) in the evaluation of AP Cholelithiasis and biliary sludge (24%) are the most frequent EUS diagnoses, and pancreas divisum (8%) is the most frequent MRCP diagnosis EUS can diagnose underlying chronic pancreatitis Treatment of local complication – fluid collection, FNA, necrosectomy, pseudocyst drainage
Hypertriglyceridemia induced acute pancreatitis Tsuang W et al. Am J Gastroenterol 2009
Hypertriglyceridemia induced acute pancreatitis Tsuang W et al. Am J Gastroenterol 2009
Management of Acute Pancreatitis Da Cost DW et al. BJS 2014;101:65-79
Da Cost DW et al. BJS 2014;101:65-79 Management of Acute Pancreatitis
Japanese Guideline 2015 Urinary trypsinogen-2 dipstick may be useful for minimally invasive method and rapid diagnosis of acute pancreatitis. The prophylactic administration of antibiotics in severe acute pancreatitis and necrotizing pancreatitis may improve the prognosis, if carried out in the early phases of pancreatitis (within 72 h of onset). (2B) Intravenous hyperalimentation is not recommended for mild cases. (1B) In severe cases, it is more significant as a measure to prevent infection rather than as a route of nutrition support. If initiated in the early phase, enteral nutrition can reduce
In principle, it is recommended that enteral feeding tubes be inserted into the jejunum through the Treitz ligament. However, if a feeding tube cannot be inserted into the jejunum, nutrients can be infused into the duodenum or stomach instead. (2B) No life-saving effect has been observed from peritoneal lavage for acute pancreatitis The sequential measurement of IAP is recommended for cases with â–șexcessive fluid infusion, high severity, â–șrenal and respiratory complications, â–șfluid accumulation in multiple areas as observed by CT, Japanese Guideline 2015
When there is persistent or recurrent IAP≧12mmHg, â–șgastrointestinal decompression, â–șintra-abdominal decompression, â–șimprovement of abdominal wall compliance, â–șappropriate fluid infusion and circulation management Surgical decompression should be considered only when internal treatment is not effective for patients with IAP>20mmHg and where the additional complication of organ failure is of concern Routine use of FNA is not required for diagnosis, and clinical signs and CT should be used for a comprehensive determination. Japanese Guideline 2015
If possible, therapeutic intervention for infected pancreatic necrosis should be performed after 4 weeks of onset, when the necrosis has been sufficiently walled off, or in other words, during WON period for infected pancreatic necrosis, percutaneous (retroperitoneal) drainage or endoscopic transluminal drainage should be first given, and if no improvement is achieved, necrosectomy should then be performed Japanese Guideline 2015
Japanese Guideline 2015
Japanese Guideline 2015
Japanese Guideline 2015
Author No. of patients Pts with infected necrosis Mortality Re- laparotomy Planned re- laparotomies Sarr 1991 23 75% 17% 2-5/pt Tsiotos 1998 72 79% 25% 1-7/pt Closed packing Fernandez 1998 64 56% 6% 17% Surgical necrosectomy
Surgical method Author No. of pts Fistula (pancreatic/ enteric) Bleeding Open packing Bradley 1993 71 46 7% Branum 1998 50 88% (72%/16%) Bosscha 1998 28 25% 50% Planned re-lap Sarr 1991 23 26%/52% 26% Tsiotos 1998 72 19% 27% 18% Closed packing Fernandez 1998 64 53%/16% 3% Closed cont. lavage Farkas 1996 123 13%/1% 2% Buchler 2001 42 19% 5% Open necrosectomy : complications
Author No . Infected (%) Mort ality Succes sful Sepsis Complic ation Percut aneous Geeinwiese r 1997 29 100 27% 69% 86% Fistula 7% Freeny 1998 34 100 12% 47% 74% None Echenique 1998 20 100 0% 20% Fistula 50% Gouzi 1999 32 81 15% 65% Fistula 52% Endos copic Baron 1996 11 27 0% 81% Bleeding 9%, Fistula 36% Percutaneous or endoscopic drainage
Author No. Infected(%) Mortality Bleeding/ Fistula Fagniez 1989 40 97% 33% 45% / 45% Villazan 1991 18 100% 22% 6% /32% Van Vyve 1993 20 20% 25% Nakasaki 1999 8 100% 25% 13% / ? Retroperitoneal laparotomy
Decontamination group (n=50) Control group (n=55) Mortality 22% 35% Infected necrosis 18% 38% Laparotomy 32% 46% Laparotomy/pt 0.9 3.1 Selective decontamination in SAP Ann Surgery 1995
Probiotics in acute pancreatitis Four RCTs (n=428) were included in the review. Sample size ranged from 25 to 296 participants. The present study showed that enteral feeding with probiotics could not reduce rates of infected necrosis and mortality. Future studies were required Langenbeck's Archives of Surgery 2009; 394(1): 171-177

Recommended

Liver trauma
Liver traumaLiver trauma
Liver traumaJunaid Sofi
 
Liver trauma
Liver traumaLiver trauma
Liver traumaJibran Mohsin
 
Colorectal injuries
Colorectal injuriesColorectal injuries
Colorectal injuriesSharath !!!!!!!!
 
Liver trauma
Liver traumaLiver trauma
Liver traumasyed ubaid
 
Ashraf 2017 abdominal trauma
Ashraf 2017 abdominal traumaAshraf 2017 abdominal trauma
Ashraf 2017 abdominal traumaAshraf Mohamed
 
Liver Trauma (Liver Injury)
Liver Trauma (Liver Injury)Liver Trauma (Liver Injury)
Liver Trauma (Liver Injury)Dmitriy Shamrai
 
Liver trauma
Liver traumaLiver trauma
Liver traumaMonsif Iqbal
 
Mesenteric ischemia
Mesenteric ischemiaMesenteric ischemia
Mesenteric ischemiaRawan Aljawi
 

Recommended

Liver trauma
Liver traumaLiver trauma
Liver traumaJunaid Sofi
 
Liver trauma
Liver traumaLiver trauma
Liver traumaJibran Mohsin
 
Colorectal injuries
Colorectal injuriesColorectal injuries
Colorectal injuriesSharath !!!!!!!!
 
Liver trauma
Liver traumaLiver trauma
Liver traumasyed ubaid
 
Ashraf 2017 abdominal trauma
Ashraf 2017 abdominal traumaAshraf 2017 abdominal trauma
Ashraf 2017 abdominal traumaAshraf Mohamed
 
Liver Trauma (Liver Injury)
Liver Trauma (Liver Injury)Liver Trauma (Liver Injury)
Liver Trauma (Liver Injury)Dmitriy Shamrai
 
Liver trauma
Liver traumaLiver trauma
Liver traumaMonsif Iqbal
 
Mesenteric ischemia
Mesenteric ischemiaMesenteric ischemia
Mesenteric ischemiaRawan Aljawi
 
CHOLANGIOCARCINOMA
CHOLANGIOCARCINOMA CHOLANGIOCARCINOMA
CHOLANGIOCARCINOMA Shambhavi Sharma
 
liver injury
liver injuryliver injury
liver injuryHaseeb Manzoor
 
Acute pancreatitis
Acute pancreatitisAcute pancreatitis
Acute pancreatitisRifhan Kamaruddin
 
Acute abdomen
Acute abdomenAcute abdomen
Acute abdomenHidayat Shariff
 
Acute pancreatitis
Acute pancreatitisAcute pancreatitis
Acute pancreatitisNote Noteenote
 
Splenic injuries
Splenic injuriesSplenic injuries
Splenic injuriesGuna Sekar
 
Acute Diverticulitis.pptx
Acute Diverticulitis.pptxAcute Diverticulitis.pptx
Acute Diverticulitis.pptxjim kuok
 
Acute pancreatitis
Acute pancreatitisAcute pancreatitis
Acute pancreatitisAtit Ghoda
 
Liver Transplantation present scenario in India
Liver Transplantation present scenario in IndiaLiver Transplantation present scenario in India
Liver Transplantation present scenario in IndiaM.G.M.Medical College and M.Y. Group of Hospitals,Indore (M.P.),India
 
01 blunt abdominal trauma
01 blunt abdominal trauma01 blunt abdominal trauma
01 blunt abdominal traumaDang Thanh Tuan
 
Acute liver failure Managemt
Acute liver failure ManagemtAcute liver failure Managemt
Acute liver failure ManagemtPratap Tiwari
 
Acute Pancreatitis
Acute Pancreatitis Acute Pancreatitis
Acute Pancreatitis Palatty Jinto
 
Colonic trauma, colon injury, colorectal trauma
Colonic trauma, colon injury, colorectal traumaColonic trauma, colon injury, colorectal trauma
Colonic trauma, colon injury, colorectal traumakhaled Mestareehy
 
Blunt trauma abdomen
Blunt trauma abdomenBlunt trauma abdomen
Blunt trauma abdomenAshish Tripathi
 
Surgical Jaundice: A synopsis
Surgical Jaundice: A synopsisSurgical Jaundice: A synopsis
Surgical Jaundice: A synopsisCHRIS ALUMONA
 
Acute Pancreatitis
Acute PancreatitisAcute Pancreatitis
Acute PancreatitisSimmedic UKM
 
Liver resection indications &amp; methods
Liver resection indications &amp; methodsLiver resection indications &amp; methods
Liver resection indications &amp; methodsDr Harsh Shah
 
Pancreatic Trauma
Pancreatic TraumaPancreatic Trauma
Pancreatic TraumaJibran Mohsin
 
Bile duct injuries in Laparocsopic cholecystectomy
Bile duct injuries in Laparocsopic cholecystectomyBile duct injuries in Laparocsopic cholecystectomy
Bile duct injuries in Laparocsopic cholecystectomyUCMS-TH Bhairahwa, NEPAL
 
Splenic injuries ppt by manjusb
Splenic injuries ppt by manjusbSplenic injuries ppt by manjusb
Splenic injuries ppt by manjusbmanjusb61
 
Pancreatitis
PancreatitisPancreatitis
PancreatitisNandinii Ramasenderan
 
Management of acute pancreatitis
Management of acute pancreatitisManagement of acute pancreatitis
Management of acute pancreatitisSubhasish Deb
 

More Related Content

What's hot

Acute pancreatitis
Acute pancreatitisAcute pancreatitis
Acute pancreatitisNote Noteenote
 
Splenic injuries
Splenic injuriesSplenic injuries
Splenic injuriesGuna Sekar
 
Acute Diverticulitis.pptx
Acute Diverticulitis.pptxAcute Diverticulitis.pptx
Acute Diverticulitis.pptxjim kuok
 
Acute pancreatitis
Acute pancreatitisAcute pancreatitis
Acute pancreatitisAtit Ghoda
 
01 blunt abdominal trauma
01 blunt abdominal trauma01 blunt abdominal trauma
01 blunt abdominal traumaDang Thanh Tuan
 
Acute liver failure Managemt
Acute liver failure ManagemtAcute liver failure Managemt
Acute liver failure ManagemtPratap Tiwari
 
Acute Pancreatitis
Acute Pancreatitis Acute Pancreatitis
Acute Pancreatitis Palatty Jinto
 
Colonic trauma, colon injury, colorectal trauma
Colonic trauma, colon injury, colorectal traumaColonic trauma, colon injury, colorectal trauma
Colonic trauma, colon injury, colorectal traumakhaled Mestareehy
 
Blunt trauma abdomen
Blunt trauma abdomenBlunt trauma abdomen
Blunt trauma abdomenAshish Tripathi
 
Surgical Jaundice: A synopsis
Surgical Jaundice: A synopsisSurgical Jaundice: A synopsis
Surgical Jaundice: A synopsisCHRIS ALUMONA
 
Acute Pancreatitis
Acute PancreatitisAcute Pancreatitis
Acute PancreatitisSimmedic UKM
 
Liver resection indications &amp; methods
Liver resection indications &amp; methodsLiver resection indications &amp; methods
Liver resection indications &amp; methodsDr Harsh Shah
 
Pancreatic Trauma
Pancreatic TraumaPancreatic Trauma
Pancreatic TraumaJibran Mohsin
 
Bile duct injuries in Laparocsopic cholecystectomy
Bile duct injuries in Laparocsopic cholecystectomyBile duct injuries in Laparocsopic cholecystectomy
Bile duct injuries in Laparocsopic cholecystectomyUCMS-TH Bhairahwa, NEPAL
 
Splenic injuries ppt by manjusb
Splenic injuries ppt by manjusbSplenic injuries ppt by manjusb
Splenic injuries ppt by manjusbmanjusb61
 

What's hot (20)

CHOLANGIOCARCINOMA
CHOLANGIOCARCINOMA CHOLANGIOCARCINOMA
CHOLANGIOCARCINOMA
 
liver injury
liver injuryliver injury
liver injury
 
Acute pancreatitis
Acute pancreatitisAcute pancreatitis
Acute pancreatitis
 
Acute abdomen
Acute abdomenAcute abdomen
Acute abdomen
 
Acute pancreatitis
Acute pancreatitisAcute pancreatitis
Acute pancreatitis
 
Splenic injuries
Splenic injuriesSplenic injuries
Splenic injuries
 
Acute Diverticulitis.pptx
Acute Diverticulitis.pptxAcute Diverticulitis.pptx
Acute Diverticulitis.pptx
 
Acute pancreatitis
Acute pancreatitisAcute pancreatitis
Acute pancreatitis
 
Liver Transplantation present scenario in India
Liver Transplantation present scenario in IndiaLiver Transplantation present scenario in India
Liver Transplantation present scenario in India
 
01 blunt abdominal trauma
01 blunt abdominal trauma01 blunt abdominal trauma
01 blunt abdominal trauma
 
Acute liver failure Managemt
Acute liver failure ManagemtAcute liver failure Managemt
Acute liver failure Managemt
 
Acute Pancreatitis
Acute Pancreatitis Acute Pancreatitis
Acute Pancreatitis
 
Colonic trauma, colon injury, colorectal trauma
Colonic trauma, colon injury, colorectal traumaColonic trauma, colon injury, colorectal trauma
Colonic trauma, colon injury, colorectal trauma
 
Blunt trauma abdomen
Blunt trauma abdomenBlunt trauma abdomen
Blunt trauma abdomen
 
Surgical Jaundice: A synopsis
Surgical Jaundice: A synopsisSurgical Jaundice: A synopsis
Surgical Jaundice: A synopsis
 
Acute Pancreatitis
Acute PancreatitisAcute Pancreatitis
Acute Pancreatitis
 
Liver resection indications &amp; methods
Liver resection indications &amp; methodsLiver resection indications &amp; methods
Liver resection indications &amp; methods
 
Pancreatic Trauma
Pancreatic TraumaPancreatic Trauma
Pancreatic Trauma
 
Bile duct injuries in Laparocsopic cholecystectomy
Bile duct injuries in Laparocsopic cholecystectomyBile duct injuries in Laparocsopic cholecystectomy
Bile duct injuries in Laparocsopic cholecystectomy
 
Splenic injuries ppt by manjusb
Splenic injuries ppt by manjusbSplenic injuries ppt by manjusb
Splenic injuries ppt by manjusb
 

Viewers also liked

Management of acute pancreatitis
Management of acute pancreatitisManagement of acute pancreatitis
Management of acute pancreatitisSubhasish Deb
 
Evidence Based Treatment of Acute Pancreatitis 2013
Evidence Based Treatment of Acute Pancreatitis 2013Evidence Based Treatment of Acute Pancreatitis 2013
Evidence Based Treatment of Acute Pancreatitis 2013Waleed Mahrous
 
Acute pancreatitis.ppt
Acute pancreatitis.pptAcute pancreatitis.ppt
Acute pancreatitis.pptIbrahim Odeh
 
Acute Pancreatitis (According to American College of Gastroenterology 2013 gu...
Acute Pancreatitis (According to American College of Gastroenterology 2013 gu...Acute Pancreatitis (According to American College of Gastroenterology 2013 gu...
Acute Pancreatitis (According to American College of Gastroenterology 2013 gu...Jibran Mohsin
 
Acute pancreatitis 2015
Acute pancreatitis 2015Acute pancreatitis 2015
Acute pancreatitis 2015samirelansary
 
Acute and Chronic Pancreatitis
Acute and Chronic PancreatitisAcute and Chronic Pancreatitis
Acute and Chronic Pancreatitismarcosmachado
 
ACUTE AND CHRONIC PANCREATITIS
ACUTE AND CHRONIC PANCREATITISACUTE AND CHRONIC PANCREATITIS
ACUTE AND CHRONIC PANCREATITISabhilasha chaudhary
 
Acute pancreatitis nikhil
Acute pancreatitis nikhilAcute pancreatitis nikhil
Acute pancreatitis nikhilMohit Aggarwal
 
ACUTE PANCREATITIS ,INTRODUCTION, AETIOPATHOLOGY
ACUTE PANCREATITIS ,INTRODUCTION, AETIOPATHOLOGYACUTE PANCREATITIS ,INTRODUCTION, AETIOPATHOLOGY
ACUTE PANCREATITIS ,INTRODUCTION, AETIOPATHOLOGYArkaprovo Roy
 
Pancreatitis
PancreatitisPancreatitis
Pancreatitisankita0809
 
Pancreatitis (acute and chronic )
Pancreatitis (acute and chronic )Pancreatitis (acute and chronic )
Pancreatitis (acute and chronic )MEEQAT HOSPITAL
 
CLINICAL FEATURES OF ACUTE PANCREATITIS
CLINICAL FEATURES OF ACUTE PANCREATITISCLINICAL FEATURES OF ACUTE PANCREATITIS
CLINICAL FEATURES OF ACUTE PANCREATITISArkaprovo Roy
 
Pancreatitis
PancreatitisPancreatitis
PancreatitisRita Batta
 
Acute pancreatitis by Mohammed Hussien
Acute pancreatitis by Mohammed HussienAcute pancreatitis by Mohammed Hussien
Acute pancreatitis by Mohammed HussienKafrelsheiekh University
 
Acute liver failure
Acute liver failureAcute liver failure
Acute liver failureJyoti Kathwal
 
Acute pancreatitis
Acute pancreatitisAcute pancreatitis
Acute pancreatitisMohamed Soliman
 
Acute pancreatitis
Acute pancreatitisAcute pancreatitis
Acute pancreatitisspecialclass
 

Viewers also liked (20)

Pancreatitis
PancreatitisPancreatitis
Pancreatitis
 
Management of acute pancreatitis
Management of acute pancreatitisManagement of acute pancreatitis
Management of acute pancreatitis
 
Evidence Based Treatment of Acute Pancreatitis 2013
Evidence Based Treatment of Acute Pancreatitis 2013Evidence Based Treatment of Acute Pancreatitis 2013
Evidence Based Treatment of Acute Pancreatitis 2013
 
Acute pancreatitis.ppt
Acute pancreatitis.pptAcute pancreatitis.ppt
Acute pancreatitis.ppt
 
Acute Pancreatitis (According to American College of Gastroenterology 2013 gu...
Acute Pancreatitis (According to American College of Gastroenterology 2013 gu...Acute Pancreatitis (According to American College of Gastroenterology 2013 gu...
Acute Pancreatitis (According to American College of Gastroenterology 2013 gu...
 
Acute pancreatitis 2015
Acute pancreatitis 2015Acute pancreatitis 2015
Acute pancreatitis 2015
 
Acute and Chronic Pancreatitis
Acute and Chronic PancreatitisAcute and Chronic Pancreatitis
Acute and Chronic Pancreatitis
 
Acute pancreatitis SP
Acute pancreatitis SPAcute pancreatitis SP
Acute pancreatitis SP
 
ACUTE AND CHRONIC PANCREATITIS
ACUTE AND CHRONIC PANCREATITISACUTE AND CHRONIC PANCREATITIS
ACUTE AND CHRONIC PANCREATITIS
 
Acute pancreatitis nikhil
Acute pancreatitis nikhilAcute pancreatitis nikhil
Acute pancreatitis nikhil
 
PANCREATITIS
PANCREATITISPANCREATITIS
PANCREATITIS
 
ACUTE PANCREATITIS ,INTRODUCTION, AETIOPATHOLOGY
ACUTE PANCREATITIS ,INTRODUCTION, AETIOPATHOLOGYACUTE PANCREATITIS ,INTRODUCTION, AETIOPATHOLOGY
ACUTE PANCREATITIS ,INTRODUCTION, AETIOPATHOLOGY
 
Pancreatitis
PancreatitisPancreatitis
Pancreatitis
 
Pancreatitis (acute and chronic )
Pancreatitis (acute and chronic )Pancreatitis (acute and chronic )
Pancreatitis (acute and chronic )
 
CLINICAL FEATURES OF ACUTE PANCREATITIS
CLINICAL FEATURES OF ACUTE PANCREATITISCLINICAL FEATURES OF ACUTE PANCREATITIS
CLINICAL FEATURES OF ACUTE PANCREATITIS
 
Pancreatitis
PancreatitisPancreatitis
Pancreatitis
 
Acute pancreatitis by Mohammed Hussien
Acute pancreatitis by Mohammed HussienAcute pancreatitis by Mohammed Hussien
Acute pancreatitis by Mohammed Hussien
 
Acute liver failure
Acute liver failureAcute liver failure
Acute liver failure
 
Acute pancreatitis
Acute pancreatitisAcute pancreatitis
Acute pancreatitis
 
Acute pancreatitis
Acute pancreatitisAcute pancreatitis
Acute pancreatitis
 

Similar to Gastrocon 2016 - Dr S.K Sinha's observation on Acute Pancreatitis

Pancreatitis scm
Pancreatitis scmPancreatitis scm
Pancreatitis scmarnab ghosh
 
Dr. Amit Annand Acute Pancreatitis.pptx
Dr. Amit Annand Acute Pancreatitis.pptxDr. Amit Annand Acute Pancreatitis.pptx
Dr. Amit Annand Acute Pancreatitis.pptxdramit13
 
pancreatitis anoop k r
pancreatitis anoop k rpancreatitis anoop k r
pancreatitis anoop k ranoop k r
 
Git j club ap16.
Git j club ap16.Git j club ap16.
Git j club ap16.Shaikhani.
 
Acute pancreatitis ‫‏
Acute pancreatitis ‫‏Acute pancreatitis ‫‏
Acute pancreatitis ‫‏MEEQAT HOSPITAL
 
Capurso G. Le Pancreatiti Acute: quelle vere e quelle false. ASMaD 2014
Capurso G. Le Pancreatiti Acute: quelle vere e quelle false. ASMaD 2014Capurso G. Le Pancreatiti Acute: quelle vere e quelle false. ASMaD 2014
Capurso G. Le Pancreatiti Acute: quelle vere e quelle false. ASMaD 2014Gianfranco Tammaro
 
Cirrhotic Ascites Review
Cirrhotic Ascites Review Cirrhotic Ascites Review
Cirrhotic Ascites Review Brian Lee
 
Acute pancreatitis
Acute pancreatitisAcute pancreatitis
Acute pancreatitisRajesh Mandal
 
Case pancretitis
Case pancretitisCase pancretitis
Case pancretitisKamal Mergani
 
8 Severe Acute Pancreatitis
8 Severe Acute Pancreatitis8 Severe Acute Pancreatitis
8 Severe Acute PancreatitisDang Thanh Tuan
 
Acute pancreatitis final
Acute pancreatitis finalAcute pancreatitis final
Acute pancreatitis finalIndhu Reddy
 
Pancreatitis severity score.pptx
Pancreatitis severity score.pptxPancreatitis severity score.pptx
Pancreatitis severity score.pptxmanzoorbhat7
 
Acute pancreatitis
Acute pancreatitis Acute pancreatitis
Acute pancreatitis rks sivasankar
 
Chitlada upper gi bleeding 2
Chitlada upper gi bleeding 2Chitlada upper gi bleeding 2
Chitlada upper gi bleeding 2Aimmary
 
Acute pancreatitis
Acute pancreatitisAcute pancreatitis
Acute pancreatitisRahul Garg
 
Acute pancreatitis
Acute pancreatitisAcute pancreatitis
Acute pancreatitisBhupendra Shah
 
Gastrocon 2016 - Hepatorenal Syndrome
Gastrocon 2016 - Hepatorenal SyndromeGastrocon 2016 - Hepatorenal Syndrome
Gastrocon 2016 - Hepatorenal SyndromeApolloGleaneagls
 

Similar to Gastrocon 2016 - Dr S.K Sinha's observation on Acute Pancreatitis (20)

Pancreatitis scm
Pancreatitis scmPancreatitis scm
Pancreatitis scm
 
Dr. Amit Annand Acute Pancreatitis.pptx
Dr. Amit Annand Acute Pancreatitis.pptxDr. Amit Annand Acute Pancreatitis.pptx
Dr. Amit Annand Acute Pancreatitis.pptx
 
pancreatitis anoop k r
pancreatitis anoop k rpancreatitis anoop k r
pancreatitis anoop k r
 
Acute pancreatitis
Acute pancreatitisAcute pancreatitis
Acute pancreatitis
 
Git j club ap16.
Git j club ap16.Git j club ap16.
Git j club ap16.
 
Acute pancreatitis ‫‏
Acute pancreatitis ‫‏Acute pancreatitis ‫‏
Acute pancreatitis ‫‏
 
Capurso G. Le Pancreatiti Acute: quelle vere e quelle false. ASMaD 2014
Capurso G. Le Pancreatiti Acute: quelle vere e quelle false. ASMaD 2014Capurso G. Le Pancreatiti Acute: quelle vere e quelle false. ASMaD 2014
Capurso G. Le Pancreatiti Acute: quelle vere e quelle false. ASMaD 2014
 
Cirrhotic Ascites Review
Cirrhotic Ascites Review Cirrhotic Ascites Review
Cirrhotic Ascites Review
 
Acute pancreatitis
Acute pancreatitisAcute pancreatitis
Acute pancreatitis
 
Case pancretitis
Case pancretitisCase pancretitis
Case pancretitis
 
8 Severe Acute Pancreatitis
8 Severe Acute Pancreatitis8 Severe Acute Pancreatitis
8 Severe Acute Pancreatitis
 
Acute pancreatitis final
Acute pancreatitis finalAcute pancreatitis final
Acute pancreatitis final
 
Pancreatitis severity score.pptx
Pancreatitis severity score.pptxPancreatitis severity score.pptx
Pancreatitis severity score.pptx
 
pancreatitis
pancreatitispancreatitis
pancreatitis
 
Acute pancreatitis
Acute pancreatitis Acute pancreatitis
Acute pancreatitis
 
Chitlada upper gi bleeding 2
Chitlada upper gi bleeding 2Chitlada upper gi bleeding 2
Chitlada upper gi bleeding 2
 
Acute pancreatitis
Acute pancreatitisAcute pancreatitis
Acute pancreatitis
 
Acute pancreatitis
Acute pancreatitisAcute pancreatitis
Acute pancreatitis
 
Gastrocon 2016 - Hepatorenal Syndrome
Gastrocon 2016 - Hepatorenal SyndromeGastrocon 2016 - Hepatorenal Syndrome
Gastrocon 2016 - Hepatorenal Syndrome
 
Sepsis Treatment
Sepsis TreatmentSepsis Treatment
Sepsis Treatment
 

More from ApolloGleaneagls

Gastrocon 2016 - Pregnancy & Liver Disease
Gastrocon 2016 - Pregnancy & Liver DiseaseGastrocon 2016 - Pregnancy & Liver Disease
Gastrocon 2016 - Pregnancy & Liver DiseaseApolloGleaneagls
 
Gastrocon 2016 - Drug Induced Liver Disease
Gastrocon 2016 - Drug Induced Liver DiseaseGastrocon 2016 - Drug Induced Liver Disease
Gastrocon 2016 - Drug Induced Liver DiseaseApolloGleaneagls
 
Endoscopic management of Post liver transplant - Bilary Complications
Endoscopic management of Post liver transplant - Bilary ComplicationsEndoscopic management of Post liver transplant - Bilary Complications
Endoscopic management of Post liver transplant - Bilary ComplicationsApolloGleaneagls
 
Gastrocon 2016 - Acute Liver Failure
Gastrocon 2016 - Acute Liver FailureGastrocon 2016 - Acute Liver Failure
Gastrocon 2016 - Acute Liver FailureApolloGleaneagls
 
Gastrocon 2016 - Dr G.N Ramesh describes how to diagnose NETs
Gastrocon 2016 - Dr G.N Ramesh describes how to diagnose NETsGastrocon 2016 - Dr G.N Ramesh describes how to diagnose NETs
Gastrocon 2016 - Dr G.N Ramesh describes how to diagnose NETsApolloGleaneagls
 
Gastrocon 2016 - GI Cancer
Gastrocon 2016 - GI CancerGastrocon 2016 - GI Cancer
Gastrocon 2016 - GI CancerApolloGleaneagls
 
Evolution of pediatric gastroenterology - Dr Anupam Sibal
Evolution of pediatric gastroenterology - Dr Anupam SibalEvolution of pediatric gastroenterology - Dr Anupam Sibal
Evolution of pediatric gastroenterology - Dr Anupam SibalApolloGleaneagls
 
Corrosive esophageal injury
Corrosive esophageal injuryCorrosive esophageal injury
Corrosive esophageal injuryApolloGleaneagls
 
Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases
Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI DiseasesGastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases
Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI DiseasesApolloGleaneagls
 

More from ApolloGleaneagls (9)

Gastrocon 2016 - Pregnancy & Liver Disease
Gastrocon 2016 - Pregnancy & Liver DiseaseGastrocon 2016 - Pregnancy & Liver Disease
Gastrocon 2016 - Pregnancy & Liver Disease
 
Gastrocon 2016 - Drug Induced Liver Disease
Gastrocon 2016 - Drug Induced Liver DiseaseGastrocon 2016 - Drug Induced Liver Disease
Gastrocon 2016 - Drug Induced Liver Disease
 
Endoscopic management of Post liver transplant - Bilary Complications
Endoscopic management of Post liver transplant - Bilary ComplicationsEndoscopic management of Post liver transplant - Bilary Complications
Endoscopic management of Post liver transplant - Bilary Complications
 
Gastrocon 2016 - Acute Liver Failure
Gastrocon 2016 - Acute Liver FailureGastrocon 2016 - Acute Liver Failure
Gastrocon 2016 - Acute Liver Failure
 
Gastrocon 2016 - Dr G.N Ramesh describes how to diagnose NETs
Gastrocon 2016 - Dr G.N Ramesh describes how to diagnose NETsGastrocon 2016 - Dr G.N Ramesh describes how to diagnose NETs
Gastrocon 2016 - Dr G.N Ramesh describes how to diagnose NETs
 
Gastrocon 2016 - GI Cancer
Gastrocon 2016 - GI CancerGastrocon 2016 - GI Cancer
Gastrocon 2016 - GI Cancer
 
Evolution of pediatric gastroenterology - Dr Anupam Sibal
Evolution of pediatric gastroenterology - Dr Anupam SibalEvolution of pediatric gastroenterology - Dr Anupam Sibal
Evolution of pediatric gastroenterology - Dr Anupam Sibal
 
Corrosive esophageal injury
Corrosive esophageal injuryCorrosive esophageal injury
Corrosive esophageal injury
 
Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases
Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI DiseasesGastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases
Gastrocon 2016 - Dr Pankaj Dhawan on Surveillance in GI Diseases
 

Recently uploaded

Call Girls In Andheri East Call 9920874524 Book Hot And Sexy Girls
Call Girls In Andheri East Call 9920874524 Book Hot And Sexy GirlsCall Girls In Andheri East Call 9920874524 Book Hot And Sexy Girls
Call Girls In Andheri East Call 9920874524 Book Hot And Sexy Girlsnehamumbai
 
Glomerular Filtration and determinants of glomerular filtration .pptx
Glomerular Filtration and determinants of glomerular filtration .pptxGlomerular Filtration and determinants of glomerular filtration .pptx
Glomerular Filtration and determinants of glomerular filtration .pptxDr.Nusrat Tariq
 
Call Girls Kanakapura Road Just Call 7001305949 Top Class Call Girl Service A...
Call Girls Kanakapura Road Just Call 7001305949 Top Class Call Girl Service A...Call Girls Kanakapura Road Just Call 7001305949 Top Class Call Girl Service A...
Call Girls Kanakapura Road Just Call 7001305949 Top Class Call Girl Service A...narwatsonia7
 
Call Girls Whitefield Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Whitefield Just Call 7001305949 Top Class Call Girl Service AvailableCall Girls Whitefield Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Whitefield Just Call 7001305949 Top Class Call Girl Service Availablenarwatsonia7
 
Russian Call Girls Chickpet - 7001305949 Booking and charges genuine rate for...
Russian Call Girls Chickpet - 7001305949 Booking and charges genuine rate for...Russian Call Girls Chickpet - 7001305949 Booking and charges genuine rate for...
Russian Call Girls Chickpet - 7001305949 Booking and charges genuine rate for...narwatsonia7
 
Call Girls ITPL Just Call 7001305949 Top Class Call Girl Service Available
Call Girls ITPL Just Call 7001305949 Top Class Call Girl Service AvailableCall Girls ITPL Just Call 7001305949 Top Class Call Girl Service Available
Call Girls ITPL Just Call 7001305949 Top Class Call Girl Service Availablenarwatsonia7
 
Call Girl Koramangala | 7001305949 At Low Cost Cash Payment Booking
Call Girl Koramangala | 7001305949 At Low Cost Cash Payment BookingCall Girl Koramangala | 7001305949 At Low Cost Cash Payment Booking
Call Girl Koramangala | 7001305949 At Low Cost Cash Payment Bookingnarwatsonia7
 
Bangalore Call Girls Marathahalli 📞 9907093804 High Profile Service 100% Safe
Bangalore Call Girls Marathahalli 📞 9907093804 High Profile Service 100% SafeBangalore Call Girls Marathahalli 📞 9907093804 High Profile Service 100% Safe
Bangalore Call Girls Marathahalli 📞 9907093804 High Profile Service 100% Safenarwatsonia7
 
Call Girls Hebbal Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Hebbal Just Call 7001305949 Top Class Call Girl Service AvailableCall Girls Hebbal Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Hebbal Just Call 7001305949 Top Class Call Girl Service Availablenarwatsonia7
 
Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...
Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...
Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...narwatsonia7
 
Housewife Call Girls Hsr Layout - Call 7001305949 Rs-3500 with A/C Room Cash ...
Housewife Call Girls Hsr Layout - Call 7001305949 Rs-3500 with A/C Room Cash ...Housewife Call Girls Hsr Layout - Call 7001305949 Rs-3500 with A/C Room Cash ...
Housewife Call Girls Hsr Layout - Call 7001305949 Rs-3500 with A/C Room Cash ...narwatsonia7
 
Glomerular Filtration rate and its determinants.pptx
Glomerular Filtration rate and its determinants.pptxGlomerular Filtration rate and its determinants.pptx
Glomerular Filtration rate and its determinants.pptxDr.Nusrat Tariq
 
Kolkata Call Girls Services 9907093804 @24x7 High Class Babes Here Call Now
Kolkata Call Girls Services 9907093804 @24x7 High Class Babes Here Call NowKolkata Call Girls Services 9907093804 @24x7 High Class Babes Here Call Now
Kolkata Call Girls Services 9907093804 @24x7 High Class Babes Here Call NowNehru place Escorts
 
call girls in green park DELHI 🔝 >àŒ’9540349809 🔝 genuine Escort Service đŸ”âœ”ïžâœ”ïž
call girls in green park DELHI 🔝 >àŒ’9540349809 🔝 genuine Escort Service đŸ”âœ”ïžâœ”ïžcall girls in green park DELHI 🔝 >àŒ’9540349809 🔝 genuine Escort Service đŸ”âœ”ïžâœ”ïž
call girls in green park DELHI 🔝 >àŒ’9540349809 🔝 genuine Escort Service đŸ”âœ”ïžâœ”ïžsaminamagar
 
Low Rate Call Girls Mumbai Suman 9910780858 Independent Escort Service Mumbai
Low Rate Call Girls Mumbai Suman 9910780858 Independent Escort Service MumbaiLow Rate Call Girls Mumbai Suman 9910780858 Independent Escort Service Mumbai
Low Rate Call Girls Mumbai Suman 9910780858 Independent Escort Service Mumbaisonalikaur4
 
call girls in Connaught Place DELHI 🔝 >àŒ’9540349809 🔝 genuine Escort Service ...
call girls in Connaught Place DELHI 🔝 >àŒ’9540349809 🔝 genuine Escort Service ...call girls in Connaught Place DELHI 🔝 >àŒ’9540349809 🔝 genuine Escort Service ...
call girls in Connaught Place DELHI 🔝 >àŒ’9540349809 🔝 genuine Escort Service ...saminamagar
 
College Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort Service
College Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort ServiceCollege Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort Service
College Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort ServiceNehru place Escorts
 
Russian Call Girls in Pune Riya 9907093804 Short 1500 Night 6000 Best call gi...
Russian Call Girls in Pune Riya 9907093804 Short 1500 Night 6000 Best call gi...Russian Call Girls in Pune Riya 9907093804 Short 1500 Night 6000 Best call gi...
Russian Call Girls in Pune Riya 9907093804 Short 1500 Night 6000 Best call gi...Miss joya
 
VIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service Lucknow
VIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service LucknowVIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service Lucknow
VIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service Lucknownarwatsonia7
 
Call Girls Service in Bommanahalli - 7001305949 with real photos and phone nu...
Call Girls Service in Bommanahalli - 7001305949 with real photos and phone nu...Call Girls Service in Bommanahalli - 7001305949 with real photos and phone nu...
Call Girls Service in Bommanahalli - 7001305949 with real photos and phone nu...narwatsonia7
 

Recently uploaded (20)

Call Girls In Andheri East Call 9920874524 Book Hot And Sexy Girls
Call Girls In Andheri East Call 9920874524 Book Hot And Sexy GirlsCall Girls In Andheri East Call 9920874524 Book Hot And Sexy Girls
Call Girls In Andheri East Call 9920874524 Book Hot And Sexy Girls
 
Glomerular Filtration and determinants of glomerular filtration .pptx
Glomerular Filtration and determinants of glomerular filtration .pptxGlomerular Filtration and determinants of glomerular filtration .pptx
Glomerular Filtration and determinants of glomerular filtration .pptx
 
Call Girls Kanakapura Road Just Call 7001305949 Top Class Call Girl Service A...
Call Girls Kanakapura Road Just Call 7001305949 Top Class Call Girl Service A...Call Girls Kanakapura Road Just Call 7001305949 Top Class Call Girl Service A...
Call Girls Kanakapura Road Just Call 7001305949 Top Class Call Girl Service A...
 
Call Girls Whitefield Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Whitefield Just Call 7001305949 Top Class Call Girl Service AvailableCall Girls Whitefield Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Whitefield Just Call 7001305949 Top Class Call Girl Service Available
 
Russian Call Girls Chickpet - 7001305949 Booking and charges genuine rate for...
Russian Call Girls Chickpet - 7001305949 Booking and charges genuine rate for...Russian Call Girls Chickpet - 7001305949 Booking and charges genuine rate for...
Russian Call Girls Chickpet - 7001305949 Booking and charges genuine rate for...
 
Call Girls ITPL Just Call 7001305949 Top Class Call Girl Service Available
Call Girls ITPL Just Call 7001305949 Top Class Call Girl Service AvailableCall Girls ITPL Just Call 7001305949 Top Class Call Girl Service Available
Call Girls ITPL Just Call 7001305949 Top Class Call Girl Service Available
 
Call Girl Koramangala | 7001305949 At Low Cost Cash Payment Booking
Call Girl Koramangala | 7001305949 At Low Cost Cash Payment BookingCall Girl Koramangala | 7001305949 At Low Cost Cash Payment Booking
Call Girl Koramangala | 7001305949 At Low Cost Cash Payment Booking
 
Bangalore Call Girls Marathahalli 📞 9907093804 High Profile Service 100% Safe
Bangalore Call Girls Marathahalli 📞 9907093804 High Profile Service 100% SafeBangalore Call Girls Marathahalli 📞 9907093804 High Profile Service 100% Safe
Bangalore Call Girls Marathahalli 📞 9907093804 High Profile Service 100% Safe
 
Call Girls Hebbal Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Hebbal Just Call 7001305949 Top Class Call Girl Service AvailableCall Girls Hebbal Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Hebbal Just Call 7001305949 Top Class Call Girl Service Available
 
Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...
Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...
Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...
 
Housewife Call Girls Hsr Layout - Call 7001305949 Rs-3500 with A/C Room Cash ...
Housewife Call Girls Hsr Layout - Call 7001305949 Rs-3500 with A/C Room Cash ...Housewife Call Girls Hsr Layout - Call 7001305949 Rs-3500 with A/C Room Cash ...
Housewife Call Girls Hsr Layout - Call 7001305949 Rs-3500 with A/C Room Cash ...
 
Glomerular Filtration rate and its determinants.pptx
Glomerular Filtration rate and its determinants.pptxGlomerular Filtration rate and its determinants.pptx
Glomerular Filtration rate and its determinants.pptx
 
Kolkata Call Girls Services 9907093804 @24x7 High Class Babes Here Call Now
Kolkata Call Girls Services 9907093804 @24x7 High Class Babes Here Call NowKolkata Call Girls Services 9907093804 @24x7 High Class Babes Here Call Now
Kolkata Call Girls Services 9907093804 @24x7 High Class Babes Here Call Now
 
call girls in green park DELHI 🔝 >àŒ’9540349809 🔝 genuine Escort Service đŸ”âœ”ïžâœ”ïž
call girls in green park DELHI 🔝 >àŒ’9540349809 🔝 genuine Escort Service đŸ”âœ”ïžâœ”ïžcall girls in green park DELHI 🔝 >àŒ’9540349809 🔝 genuine Escort Service đŸ”âœ”ïžâœ”ïž
call girls in green park DELHI 🔝 >àŒ’9540349809 🔝 genuine Escort Service đŸ”âœ”ïžâœ”ïž
 
Low Rate Call Girls Mumbai Suman 9910780858 Independent Escort Service Mumbai
Low Rate Call Girls Mumbai Suman 9910780858 Independent Escort Service MumbaiLow Rate Call Girls Mumbai Suman 9910780858 Independent Escort Service Mumbai
Low Rate Call Girls Mumbai Suman 9910780858 Independent Escort Service Mumbai
 
call girls in Connaught Place DELHI 🔝 >àŒ’9540349809 🔝 genuine Escort Service ...
call girls in Connaught Place DELHI 🔝 >àŒ’9540349809 🔝 genuine Escort Service ...call girls in Connaught Place DELHI 🔝 >àŒ’9540349809 🔝 genuine Escort Service ...
call girls in Connaught Place DELHI 🔝 >àŒ’9540349809 🔝 genuine Escort Service ...
 
College Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort Service
College Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort ServiceCollege Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort Service
College Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort Service
 
Russian Call Girls in Pune Riya 9907093804 Short 1500 Night 6000 Best call gi...
Russian Call Girls in Pune Riya 9907093804 Short 1500 Night 6000 Best call gi...Russian Call Girls in Pune Riya 9907093804 Short 1500 Night 6000 Best call gi...
Russian Call Girls in Pune Riya 9907093804 Short 1500 Night 6000 Best call gi...
 
VIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service Lucknow
VIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service LucknowVIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service Lucknow
VIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service Lucknow
 
Call Girls Service in Bommanahalli - 7001305949 with real photos and phone nu...
Call Girls Service in Bommanahalli - 7001305949 with real photos and phone nu...Call Girls Service in Bommanahalli - 7001305949 with real photos and phone nu...
Call Girls Service in Bommanahalli - 7001305949 with real photos and phone nu...
 

Gastrocon 2016 - Dr S.K Sinha's observation on Acute Pancreatitis

  • 1. Acute Pancreatitis S K Sinha Professor Department of Gastroenterology PGIMER, Chandigarh
  • 2. Index Case 24May 2016 40 yrs old male, alcohol abuser presented with â–șPain abdomen for 3 hours Upper abd, non-colicky, severe, radiating to back Associated vomiting, multiple time bilious Associated abd distension + â–șPast, Family History : Not significant â–șPersonal History: 80-100 gms of alcohol/day for 15-16 yrs
  • 3. GPE – Pulse 122 , BP 140/82 mmHg, RR 24/min Abdomen â–șLiver 3 cm, soft to firm â–șSpleen not palpable â–șDiffuse tenderness & guarding in whole abdomen â–șBowel sound sluggish Chest: reduced breath sound at bases CVS, CNS – NS Possibilities: Index Case
  • 4. Index case: Investigations Hb -15.5 TLC – 14000 DLC – N 76 L 22 Platelets – 355 Urea : 55 Creatininine : 1.2 Bil – 1.5 SGOT – 55 SGPT – 62 ALP 130 (ULN – 128) TP – 7.6 Albumin – 4.9 Amylase – 155 (40-140) Lipase – 96 (0-50) Abd X-ray: No evidence of pneumoperitoneum USG abdomen – Bulky pancreas, GB sludge
  • 5. Issue 1 What is the practically acceptable criteria for diagnosis of acute pancreatitis?
  • 6. Acute pancreatitis: Diagnosis At least two of the following â–șAbdominal pain consistent with the disease â–șSerum amylase and / or lipase greater than three times the upper limit of normal â–șCharacteristic findings from abdominal imaging CECT and / or MRI should be reserved for â–șPatients in whom the diagnosis is unclear â–șWho fail to improve clinically within the first 48 – 72 h after hospital admission â–șTo evaluate complications ACG Guideline. Am J Gastroenterol 2013; 108:1400–1415
  • 7. Issue 2 Which enzyme assay is preferable : amylase or lipase or combination of two? â–șRelative accuracy â–șFalse negative and false positive
  • 8. Pattern of rise â–șRises within a few hours, may return to normal within 5 days â–șSensitivity in AP – approx 80% Acute pancreatitis with no rise in amylase â–șHypertriglyceridemia â–șAlcohol related AP â–șAcute on chronic pancreatitis High amylase but no pancreatitis â–șMacroamylasemia â–șRenal failure â–șdiseases of the salivary glands â–șExtrapancreatic abdominal conditions with inflammation â–șGynaecological diseases Serum amylase estimation: Pitfalls
  • 9. Amylase vs Lipase Barbieri JS. Journal of Hospital Medicine 2016;11 :366-68
  • 10. Pancreatic enzyme testing in AP Amylase testing offers no additional value to lipase testing Dual testing is not superior to Lipase testing alone Neither have prognostic value Pancreatic enzymes should not be repeated after making the diagnosis of acute pancreatitis Barbieri JS. Journal of Hospital Medicine 2016;11 :366-68
  • 11. Index case Repeat Lipase at 24 hours : 480 IU Diagnosis of Acute pancreatitis was made Treatment â–șIV fluid â–șAnalgesia
  • 12. Issue 3 Fluid for initial resuscitation/therapy of acute pancreatitis? â–șDoes initial aggressive fluid resuscitation matter? â–șWhich the preferred or currently recommended crystalloid fluid in initial management of acute of pancreatitis? â–șHow to monitor fluid resuscitation? Non-invasively – clinical/lab parameter Invasively How frequently the fluid therapy should be monitored?
  • 13. Fluid therapy in acute pancreatitis Aggressive hydration, defined as 250 – 500 ml per hour of isotonic crystalloid solution unless contraindicated Early aggressive intravenous hydration is most beneficial during the first 12 – 24 hrs In a patient with severe volume depletion, manifest as hypotension and tachycardia, more rapid repletion (bolus) may be needed ACG Guideline. Am J Gastroenterology 2013
  • 14. 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 BUN CVP/USG monitoring of IVC Fluid therapy in acute pancreatitis ACG Guideline. Am J Gastroenterology 2013
  • 15. IV line secured, started on RL NPO Injectable PPI – Pantoprazole 80 mg followed by 40 mg BD Inj Metoclopramide 10 mg IV stat Analgesic: Buscopan + Diclofenac injection – pain reduced in intensity but did not subside Index case: Investigations
  • 16. Issue 4 Which narcotic analgesic should be used in acute pancreatitis?
  • 17. Effect of narcotics on Sphincter of Oddi pressure Sphincter pressure at base line Sphincter pressure 20 min after inj Morphine 8.90±9.11 20.51±13.46 Pethidine 7.06±5.07 6.68±4.32 Tramadol 7.01±5.50 6.39±5.37 Pentazocine 6.42±5.10 11.34±8.40 Wu SD. World J Gastroenterol 2004;10(19):2901-2904
  • 18. Effect of narcotics on Sphincter of Oddi pressure Staritz M et al. Gut, 1986, 27, 567-569
  • 19. Morphine and pentazocine increase SO and CBD pressure Pethidine does not increase SO or bile duct pressure Tramadol and Buprenorphine increase SO pressure minimally Tramadol has the same analgesic effect as morphine. But it has little effect on the respiratory system and circulation system Effect of narcotics on Sphincter of Oddi pressure Wu SD. World J Gastroenterol 2004;10(19):2901-2904
  • 20. Pain persisted in lower intensity – was put on Inj Tramadol sos, Buprenorphine patch was given Started having fever from Day 3 – Temp upto 38.5 degrees C Bowel not moved Tachypnea – RR 24-30, O2 – 0.30 Repeat Labs on day 4 â–șS/Electrolytes, RFT – N â–șLFT – Bil – N, Mild rise of transaminases â–șHb 12.9 gms TLC -13500 DLC – N 70 L 26 Index case: Course
  • 21. Issue 5 How do we define severity of acute pancreatitis? â–șMild/moderate/severe
  • 22. Revised Atlanta Definitions 2012 Interstitial oedematous pancreatitis â–șAcute inflammation of the pancreatic parenchyma and peripancreatic tissues, but without recognisable tissue necrosis â–șCECT criteria Pancreatic parenchyma enhancement by intravenous contrast agent No findings of peripancreatic necrosis Necrotizing pancreatitis â–șInflammation associated with pancreatic parenchymal necrosis and/or peripancreatic necrosis â–șCECT criteria Lack of pancreatic parenchymal enhancement by intravenous contrast agent and/or Presence of findings of peripancreatic necrosis
  • 23. Mild acute pancreatitis â–șNo organ failure â–șNo local or systemic complications Moderately severe acute pancreatitis â–șOrgan failure that resolves within 48 h â–șTransient organ failure and/or â–șLocal or systemic complications without persistent organ failure Severe acute pancreatitis â–șPersistent organ failure (>48 h) Single organ failure Multiple organ failure Severity of acute pancreatitis
  • 24. Parameters Score 0 1 2 3 4 PaO2/ FiO2 ratio >400 301–400 201–300 101– 200 ≀101 Serum creatinine, mg/dl) <1.4 1.4–1.8 1.9–3.6 3.6–4.9 >4.9 Cardiovascular (systolic blood pressure, mm) >90 <90, fluid responsive <90, not fluid responsive <90, pH<7.3 <90, pH<7. 2 Modified Marshall scoring system for organ dysfunction A score of 2 or more in any system defines the presence of organ failure.
  • 25. Organ failure in acute pancreatitis Shock â–ș(systolic blood pressure < 90 mm Hg), Pulmonary insufficiency â–ș (PaO 2 < 60 mm Hg), Renal failure â–șcreatinine > 2 mg / dl after rehydration Gastro intestinal bleeding â–ș > 500 ml of blood loss/ 24 h Bradley EL et al. Arch Surg 1993 ; 128 : 586 –
  • 27. APFC (acute peripancreatic fluid collection)
  • 33. Issue 6 Is this patient having severe acute pancreatitis or likely to have severe acute pancreatitis? How to identify patients with severe acute pancreatitis?
  • 34. Ranson’s Criteria for acute pancreatitis
  • 35. Glasgow criteria for acute pancreatitis
  • 36. APACHE II scoring system for acute pancreatitis
  • 37. Japanese society severity score Variables â–șBE level < -3 mEq/L or shock â–șPaO2 < 60 mm Hg (room air) or respiratory failure â–șBlood urea nitrogen level > 40 mg/dL or creatinine level > 2 mg/dL â–șLactate dehydrogenase level > 2 folds of upper normal limit â–șPlatelet count < 105/mm3 â–șCalcium level < 7.5 mg/dL â–șC-reactive protein level > 15 mg/dL â–șSystemic inflammatory response syndrome score > 3 â–șAge > 70 years old Pancreas 2014, 43:487-89
  • 38. BISAP: Bedside index for severity in acute pancreatitis Blood urea nitrogen >25 mg/dL Impaired mental status (Glasgow coma scale score<15) SIRS : SIRS is defined as two or more of the following: â–șTemperature of <36℃ or >38℃ â–șRespiratory rate >20 breaths/min or PaCO2<32 mmHg â–șPulse>90 beats/min â–șWBC<4×109 or >12×109/L or >10% immature bands Age>60 yr Pleural effusion detected on imaging
  • 39. Clinical findings predicting a severe course Patient characteristics â–ș Age > 55 years, Obesity (BMI > 30 kg / m2 ) â–ș Altered mental status Comorbid disease The systemic infl ammatory response syndrome (SIRS) â–șPresence of > 2 of the following criteria: pulse > 90 beats / min, respirations > 20 / min, PaCO 2 > 32 mm Hg, temperature > 38 ° C or < 36 ° C, WBC count > 12,000 or < 4,000 cells / mm3 , 10 % immature neutrophils (bands) Laboratory findings â–ș BUN > 20 mg/dl, Rising BUN, HCT > 44 %, Rising HCT, Elevated creatinine Radiology findings â–ș Pleural effusions, Pulmonary infiltrates, Multiple or extensive extrapancreatic collections ACG Guideline 2013. Am J Gastroenterol 2013
  • 40. Comparison of different scores Park JY. Hepatobiliary Pancreat Dis Int 2013
  • 41. Issue 7 – Imaging in AP CECT of abdomen in acute pancreatitis â–șWhat are the findings which should especially be taken into consideration? â–șWhat is accuracy of CT scan? â–șShould all patients be subjected to CT scan examination? â–șWhen should CT scan be done? â–șWhat is the ideal timing? â–șDoes accuracy depend on timing and technique? â–șWhat are the risks involved with CT scan examination? â–șWhat are the modalities to reduce the risk?
  • 42. Contrast CT scan of abdomen CECT provides over 90 % sensitivity and specificity for the diagnosis of AP ( 20 ). Routine use of CECT in patients with AP is unwarranted If a patient fails to improve after 48 – 72 CECT or MRI imaging is recommended to assess local complications CT and MRI are comparable in the early assessment of AP â–șMRCP can detect CBD stones upto 3 mm Timing of CT scan â–șFor assessment of severity and local complications: after 3-5 days â–șWhen diagnosis in doubt: any time ACG Guideline. Am J Gastroenterol 2013; 108:1400–1415
  • 43. CT severity index of acute pancreatitis Balthazar CT Score â–șA -Normal â–ș B -Focal or diffuse enlargement of the pancreas, including irregularities of contour and inhomogeneous attenuation â–ș C - Pancreatic gland abnormalities in grade B plus per pancreatic inflammation â–ș D - Grade C plus a single fluid collection â–ș E - Grade C plus 2 or more fluid collections and/or the presence of gas in or adjacent to the pancreas Necrosis â–șNone – score 0 â–șLess than 30% - score 2 â–ș30-50% - score 4 â–ș> 50% - score 6
  • 44. Mortele KJ et al. AJR 2004;183:1261–1265 Modified CT Severity Index
  • 45.
  • 46.
  • 47. CECT abdomen: CTSI – 8/10 MCTSI – 10/10 Patient having low grade fever - ? Start antibiotics Nutritional support???? Index case: Course
  • 48. Issue 8 – Antibiotic prophylaxis in AP Antibiotics in acute panreatitis â–șShould prophylactic antibiotics be given to all patients with acute pancreatitis? â–șShould prophylactic antibiotics be given to all patients with severe acute pancreatitis? â–șWhat are the commonly acceptable indications of emperical use of antibiotics? â–șWhat the antibiotics preferred for prophylactic or emperical use? â–șWhen to start and when to stop?
  • 49. Prophylactic antibiotics in AP “It is very difficult to study this very very challenging question and it is likely to remain enigma for quite some time” Alphonso Brown, Gastroenterology 2004
  • 50. Last 15 years â–șMultiple trials â–șIncluded mainly severe pancreatitis â–șMany randomized trials, only one double blind randomized trial â–șVariable results â–șAntibiotics : Imipenem, Cephalosporins, Ciprofloxacin/Metronidazole Prophylactic antibiotics in SAP Gastroenterology 2004
  • 51. Author Agent Durat ion Panrcreatic infection Mortality Antibi otics Control Antibi otics Control Pederzoli Imipenem 14 12.1 30.3 7.3 12.1 Sainio Cefuroxime 14 30.0 40.0 3.3 23.3 Delcenseri e Ceftazidime, Amika, Metro 10 0 25 9.1 25 Schwarz Ofloxacin, Metro 10 61.5 53.8 0 23 Nordback Imipenem/cila statin Not state d 8.0 42.4 8.0 15.1 Isenman Cipro, metro 14 12.0 8.9 5.1 7.1 Prophylactic antibiotics in AP
  • 53. Antibiotics in acute pancreatitis Routine use of prophylactic - not recommended Prophylactic antibiotic in necrotizing pancreatitis - not recommended Antibiotics should be given for an extra-pancreatic infection Infected necrosis should be considered in patients with pancreatic or extrapancreatic necrosis who deteriorate or fail to improve after 7 – 10 days of hospitalization. â–ș In these patients, either (i) initial CT-guided fine-needle aspiration (FNA) for Gram stain and culture to guide use of appropriate antibiotics or â–șEmpiric use of antibiotics after obtaining necessary cultures for infectious agents, without CT FNA, should be given ACG Guideline . Am J Gastroenterology 2013
  • 54. In patients with infected necrosis, antibiotics known to penetrate pancreatic necrosis, such as carbapenems, quinolones, and metronidazole, may be useful in delaying or sometimes totally avoiding intervention, thus decreasing morbidity and mortality Duration of antibiotics : ?? Routine administration of antifungal agents along with prophylactic or therapeutic antibiotics is not recommended Antibiotics in acute pancreatitis ACG Guideline . Am J Gastroenterology 2013
  • 55. Prophylactic antibiotics in AP Mild pancreatitis : Not recommended SAP: The prophylactic administration of antibiotics may improve the prognosis, if carried out in the early phases of pancreatitis (within 72 h of onset). (2B) Prophylactic antifungals are not recommended. (1C) Japanese Guideline. J Hepatobiliary Pancreat Sci (2015) 22:405–432
  • 56. Antibiotics Efficacy factor Imipenem 0.98% Ofloxacin 0.87% Ciprofloxacin 0.86% Ceftriaxone 0.79% Cefotaxime 0.78% Tobramycin 0.22% Netilmycin 0.21% Efficacy factor of antibiotics in SAP Trop GE 1998
  • 57. Issue 9 – Nutrition in acute pancreatitis Feeding in acute pancreatitis â–șWhich is the preferred route – enteral or parenteral? â–șWhen to start feeding”? â–șMild to moderate pancreatitis â–șSevere acute pancreatitis â–șWhich is preferred feeding formula – elemental/polymeric/Immune feeding? â–șWhich is the preferred enteral feeding route – nasogastric or nasoduodenal or nasojejunal?
  • 58. Nutrition in acute pancreatitis In mild AP, oral feedings can be started once there is no nausea and vomiting, and abdominal pain â–șlow-fat solid diet appears as safe as a clear liquid diet In severe AP, enteral nutrition is recommended to prevent infectious complications. Parenteral nutrition â–șenteral route is not available, not tolerated, or not meeting caloric requirements Nasogastric delivery and nasojejunal delivery of enteral feeding appear comparable in efficacy and safety
  • 59. Nutrition in acute pancreatitis Petrov M et al. ISRN Inflammation 2013 Reduced risk of infective complications and possibly reduced mortality with enteral feeding in severe acute pancreatitis
  • 60. Nutrition in acute pancreatitis Petrov M et al. ISRN Inflammation 2013 Most of the patients with SAP are able to tolerate enteral feeding and nutritional goal is achieved in most patients
  • 61. Enteral feeding formula Elemental â–șComprising amino acids or oligopeptides, maltodextrins, and medium—chain and long-chain triglycerides; Polymeric â–șComprising nonhydrolyzed proteins, maltodextrins, and oligofructosaccharides, as well as long-chain triglycerides; Immune-enhancing â–șComprising substrates that have been hypothesised to modulate the activity of the immune system, for example, immunonutrition (glutamine, arginine, and omega-3 fatty acids), probiotics, fibre-enriched formulation.
  • 62. Nutrition in Acute pancreatitis Enteral nutrition – â–șCurtails of acute inflammation of the pancreas â–șReduces septic complications Nasojejunal tube feeding improves outcomes in SAP Safety and efficacy of nasogastric tube feeding in SAP Early NG feeding may have benefits even in mild-to- moderate acute pancreatitis Optimal enteral feeding formulations – more information is required Petrov M et al. ISRN Inflammation 2013
  • 63. Put on IV antibiotics – Piperacillin+ Tazobactum for 14 days Nasojejunal tube placed – feeding attempted â–șDistension of abdomen â–șSOB Feeding had to be stopped temporarily O2 supplementation CXR was unremarkable IAP was measured Index case: Course
  • 64. Issue 10 : IAP monitoring in acute pancreatitis Role of intra-abdominal pressure monitoring in acute pancreatitis? â–șHow to define abdominal compartment syndrome? â–șHow to monitor for abdominal compartment syndrome? â–șHow to treat abdominal compartment syndrome?
  • 65. Abdominal compartment syndrome IAH – IAP> 12 mmHg ACS – IAP> 20 mmHg Causes â–șInflammatory fluid collection, inflammatory mass â–șParalytic ileus and distension of bowel â–șAscites Consequences â–șReduced renal and abd perfusion â–șIschemic bowel complication â–șRespiratory impairment Remedial measure â–șDecompression of stomach & bowel â–șAscitic tap/ placement of drains â–șMechanical ventilation with muscle relaxants â–șRestrict fluid if possible Mentula P et al. World Journal of Emergency Surgery 2014, 9:15
  • 66. NJ feeding could be established after 5 days NJ feeding was given for two weeks Oral feeding in third week – gradually built up â–șFullness and bloating – post meals â–șNo vomiting Palpable lump abdomen, No fever , No vomiting Labs: normal RFT, LFT, Mild leucocytosis Discharged in 5th week Index case: Course
  • 67. Re-evaluation during 7 – 8 th week â–șMild abdominal pain/discomfort, post prandial bloating â–șNo fever â–șTolerating oral diet, low fat â–șExamination: large upper abdominal lump, mild tenderness Index case: Course
  • 68.
  • 69.
  • 70. Issue 11 : Management of Non-Infected Necrosis Pancreatic necrosis without infection â–șWhat are factors which determine the outcome? â–șWhat should be the preferred approach in management?
  • 71. Management of local complication of AP Japanese Guideline 2015
  • 72. Sterile pancreatic necrosis Debridement for sterile necrosis is recommended if â–șAssociated with gastric outlet obstruction â–șBile duct obstruction Asymptomatic pancreatic and / or extrapancreatic necrosis does not mandate intervention regardless of size, location, and extension.
  • 73. 10th week of illness â–șGradual increase in upper abdominal pain over 3-4 days â–șFever – High grade â–șVomitng off and on â–șShortness of breath â–șExamination Palpable upper abominal lump, tender Reduced breath sound at lung bases â–șLabs RFT, LFT – N HMG – Hb 10.5 gm, TLC – 24000, DLC – N88%, L 12 PCT – 3.9 Index case: Course
  • 74.
  • 75.
  • 76. Issues 12: Infected Pancreatic Necrosis Pancreatic necrosis - With evidence of infection â–șShould all patients be referred for surgery? â–șWhat are the factors which determine the outcome? â–șHow to select the cases for non-surgical management? â–șWhat is the optimum timing for surgery?
  • 77. Issue Infections in acute pancreatits â–șWhat are the common sites of infection in patients with acute pancreatitis? â–șWhat are the risk factors for infected pancreatic necrosis? â–șTiming of pancreatic infection â–șMethods of diagnosis â–șOrganisms â–șWhat are the common organisms? â–șWhat is the source of these organisms â–șHow common are the anaerobes? â–șHow common is fungal infection ?
  • 78. Risk of pancreatic infection Risk depends upon â–șSeverity of pancreatitis Ranson’s score < 3 : 5.3% Ranson’s score > 5 : 58% â–șExtent of necrosis <30% : 5-10% 30 – 50% : 10-20% > 50% : 30 – 70% â–șBacterial colonization of gut Br J Surgery 1999
  • 79. Surgical necrosectomy Medical series Guided FNA First week 11.1% 22.2% Second week 17.7% 33.3% Third week 22.2% 22.2% Fourth week 48% 22.2% Timing of pancreatic infection Gastroenterology 1986, 1987
  • 80. Bacteriology of pancreatic infection Organism Frequenc y E coli 35% K pneumoniae 24% Enterococcus 24% Staphylococcus 14% Pseudomonas 11% Proteus 8% Aerobic streptococci 7% Enterobacter 7% Bacteroides 6% Compiled data No of series : 45 Total patients > 1100 Am Surgeon 2000
  • 81. Fungal infection in pancreatic necrosis Risk factors â–șBroad spectrum antibiotics â–șAbdominal surgery â–șMale sex, Age > 40 years â–șCentral venous access , Hypotension at admission â–șHigh APACHE II score â–șRenal failure , TPN, Respiratory failure at admission â–șMechanical ventilation â–șERCP/ Pancreatic stenting â–șDiabetes mellitus â–șPercutaneous drainage â–șDuration of hospital stay > 4 weeks Kochhar R, JGH 2013
  • 82. Fungal infection in pancreatic necrosis
  • 83. Impact of pancreatic infection Increased mortality Increased morbidity â–șIncreased risk of renal failure â–șIncreased risk of GI bleed â–șIncreased risk of respiratory failure â–șIncreased cardiovascular complication Longer hospital stay Increased probability of surgery Increased cost of therapy
  • 84. Infected necrosis Sterile necrosis Cardiovascular complication 31.0% 7.3% Pulmonary insufficiency 40.0% 14.3% Renal insufficiency 42.2% 21.7% Sepsis/SIRS 35.6% 8.7% G I bleeding 17.8% 5.8% Gastroenterology 1996 Impact of pancreatic infection
  • 85. Infection in pancreatic necrosis When to suspect â–șTiming : second or third week â–șClinical feature Recurrence of pain abdomen Worsening of organ system function Increasing temperature Increasing TLC New onset ileus Am Surgeon 2000
  • 86. Methods of diagnosis â–șPlain X-Ray â–șUltrasonography, CT â–șBlood culture â–șGallium scan â–șIn111 labelled leucocyte scan â–șUSG/CT guided FNA â–șPET CT Infection in pancreatic necrosis Gut 2005, Gastroenterology2004
  • 87. Methods of diagnosis â–șPlain X-Ray â–șUltrasonography, CT â–șBlood culture â–șGallium scan â–șIn111 labelled leucocyte scan â–șUSG/CT guided FNA â–șPET CT Infection in pancreatic necrosis Gut 2005, Gastroenterology2004
  • 88. USG/CT guided FNA Needle should not pass through a bowel Each suspected area should be sampled, multiple passes may be required Multiple sessions may be required Samples for gram’s stain, aerobic & anaerobic bacterial culture, fungal smear & culture Rapid inoculation, use of transport medium
  • 89. USG/ CT guided FNA Complications : rare Results : High PPV, high NPV â–șTotal patients : 60 â–șTotal aspirations : 92 Grams stain + : 41 Culture + : 42 â–șFinal diagnosis Infected : 42 Uninfected : 50 Gastroenterology 1997
  • 90. Infected pancreatic necrosis Antibiotics alone can lead to resolution of infection and, in select patients, avoid surgery altogether â–ș16/28 pts improved with antibiotics Unstable patients with infected necrosis needs consideration for urgent debridement â–șa course of antibiotics before intervention to allow the inflammatory reaction to become better organized â–șIf pt fails to improve : Necrosectomy Endoscopic/radiologic/video-assisted retroperitoneal/ laparoscopic approach/ combination
  • 91. Cochrane review â–șThe minimally invasive step-up approach resulted in fewer adverse events, serious adverse events, less organ failure, and lower costs compared to open necrosectomy. No evidence to suggest that early open necrosectomy is superior or inferior to peritoneal lavage or delayed open necrosectomy Endoscopic minimally invasive step-up approach resulted in fewer adverse events than the video-assisted minimally invasive step-up approach but increased the number of procedures required for treatment Infected pancreatic necrosis
  • 92. Treatment of Infected pancreatic necrosis Before demarcation of necrosis develops (< 4 weeks), it is almost impossible to remove all necrotic tissue without causing hemorrhage. Early surgical debridement â–șHigh risk of hemorrhage â–șIncreased organ dysfunction and death. Necrosectomy within the first two weeks - 75% mortality Necrosectomy after 6-8 weeks – Mortality 5% Multiple organ dysfunction increases mortality
  • 93. Because high mortality is associated with early surgery , it is recommended that surgery for infected necrosis should be postponed as late as possible, preferable later than four week from disease onset â–șRole of percutaneous drain – single or multiple â–șMinimally invasive surgery/ endoscopic procedure Infected pancreatic necrosis
  • 94. Infected pancreatic necrosis Supportive care for organ failure Nutrition Antibiotics : as per sensitivity and local data Drainage and necrosectomy â–șOpen surgical â–șLaparoscopic â–șRadiological â–șEndoscopic
  • 95. USG guided aspiration â–șPus culture – E coli sensitive to Imipenem, Meropenem and Colistin Was started on Meropenem PCD was places – upgraded to 16 F Percutaneous endoscopic necrosectomy – 2 sessions Patient became afebrile after first session ERCP – Disrupted MPD, stented Index case: Course
  • 96. Necrosectomy for infected necrosis Best surgical method not defined â–șNo direct comparison available Open surgical necrosectomy is the gold standard and standard of care Percutaneous and endoscopic necrosectomy are emerging modalities Local expertise and quality of ICU care matters
  • 98. Endoscopic drainage/necrosectomy Baron & Kozarek. Clin Gastro Hepatol 2012
  • 99. Endoscopic necrosectomy Baron & Kozarek. Clin Gastro Hepatol 2012
  • 100. Issue 13 ERCP in acute biliary pancreatitis â–șWhat are the indications for ERCP in acute biliary pancreatitis? Urgent indications Semi-elective indications â–șDoes timing of ERCP matter? â–șWhat is the preferred ERCP intervention – stent or NBD or sphincterotomy or CBD clearance? â–șPatient taken up for ERCP but no stone on cholangiogram – what to do next?
  • 101. Diagnosis of Biliary Pancreatitis
  • 102. ERCP in acute biliary pancreatitis Indications â–șSuspected bile-duct stones as the cause of pancreatitis established clinically, and one of the following: Cholangitis (fever, jaundice, sepsis) Persistent biliary obstruction (conjugated bilirubin level >5 mg/dl Clinical deterioration (worsening pain, increasing white-cell count, worsening vital signs) Stone detected in the common bile duct on imaging ACG Guideline. Am J Gastroenterology 2013
  • 103. Contraindications â–șAbsolute Unstable medical condition precluding safe administration of moderate sedation or general anesthesia Decision by competent patient not to provide consent for the procedure Endoscopist with inadequate training in ERCP â–șRelative (may be overcome) Anatomical condition (gastroduodenal disease or surgical alteration) that would impede endoscopic access to the major papilla; Clinically significant or uncorrectable coagulopathy ERCP in acute biliary pancreatitis ACG Guideline. Am J Gastroenterology 2013
  • 104. UK guideline 2005 â–șEarly ERCP (within 72 hours after admission to the hospital) in all patients with predicted or actual severe biliary pancreatitis AGA 2007 â–șUrgent ERCP (within 24 hours after admission) if cholangitis â–șEarly ERCP (within 72 hours after admission) if suspicion of persistent bile-duct stones ACG 2013 â–șPatients with AP and concurrent acute cholangitis should undergo ERCP within 24 h of admission â–șERCP is not needed early in most patients with gallstone pancreatitis who lack laboratory or clinical evidence of ongoing biliary obstruction ERCP in acute biliary pancreatitis
  • 105. ERCP in acute pancreatitis Sphincterotomy and CBD clearance â–șEvidence of CBD stone, biliary obstruction : at any time during course â–șSuspicion or evidence of cholangitis : at any time during course â–șPersistent biliary obstruction â–ș? Any case of biliary pancreatitis taken up for ERCP
  • 106. ERCP in acute pancreatitis “While laparoscopic cholecystectomy is the gold standard to avoid recurrence in patients with gall stone related pancreatitis, ERCP and sphincterotomy are accepted alternatives in patients who are unfit for surgery” Gut 2005
  • 107. Issue 14 Timing of cholecystectomy after an episode of acute biliary pancreatitis? â–ș What is the risk of recurrence over time?
  • 108. Risk of delayed cholecystectomy Jee SL. Asian Journal of Surgery 2016
  • 109. Summary AP – disease with unpredictable severity Significant morbidity and mortality in severe disease Team approach is crucial in management Enteral nutrition is preferable to parenteral nutrition Radiological interventions may play a crucial role in stabilizing a critically ill patient Endoscopic interventions are indicated in a select group of patient Early surgery is associated with higher complication rate compared with late surgery Specific treatment should be instituted when applicable
  • 110.
  • 111. Open surgical necrosectomy Various techniques â–șOpen packing â–șPlanned re-laparotomies â–șClosed packing â–șClosed continuous lavage
  • 112. Author No. of patients Pts with infected necrosis Mortality Re- laparotomy Bradley 1993 71 100% 15% 1-5/pt Branum 1998 50 84% 12% 2-13/pt Bosscha 1998 28 100% 39% 17/pt Nieuwenh uijs 2003 38 47% Surgical necrosectomy : Open packing
  • 113. Author No. of patients Pts with infected necrosis Mortality Re- laparotomy Beger 1988 95 39% 8% 27% Farkas 1996 123 100% 7% Buchler 2000 29 93% 24% 22% Buchler 2001 42 93% 21% 17% Nieuwenh uijs 2003 21 33% Surg. necrosectomy : closed continuous lavage
  • 114. AP: Magnitude of problem Incidence : 4.9 – 73.4 cases per lac population Incidence is increasing Mortality: minimal decrease over years Severity of pancreatitis â–șMild : 70 -80% No local or systemic complication Usually no necrosis Recovery in 3 – 7 days â–șSevere : 20 -30 % Local or systemic complications Necrosis usual Infection : 20 – 70% Gut 2005, Am J Gastro 2013
  • 115. Course of acute pancreatitis Overall mortality: 5 – 10% Almost all mortality in severe cases Two phases of illness â–șEarly phase - within 7 days: largely unrelated to infection, mostly cytokine mediated SIRS Organ failure â–șLate phase – after 7 days, largely related to infection and consequences of organ failure Local complications Fluid collections, necrosis – sterile or infected Acute pseudocyst Walled off pancreatic necrosis Organ failure - persistent Tanner S et al. Am J Gastroenterol 2013
  • 116. Cochior D et al. Chirurgia (2013) 108: 631-642 Course of acute pancreatitis
  • 117. Initial assessment and risk stratification Hemodynamic status be assessed immediately upon presentation â–șAggressive hydration, defined as 250-500 ml per hour of isotonic crystalloid solution preferably Ringer Lactate Exceptions: Cardiovascular and renal comorbidity â–șHigher infusion rate in those with hypotension or tachycardia â–șAssess fluid requirement every 6 hours for 48 hours – aim to decrease BUN Risk assessment : â–șStratify patients into higher- and lower-risk categories to assist triage, such as admission to an intensive care setting Patients with organ failure: â–șadmitted to an ICU or HDU
  • 118. APFC (acute peripancreatic fluid collection) Peripancreatic fluid associated with interstitial oedematous pancreatitis with no associated peripancreatic necrosis. This term applies only to areas of peripancreatic fluid seen within the first 4 weeks after onset of interstitial oedematous pancreatitis and without the features of a pseudocyst. CECT criteria â–șOccurs in the setting of interstitial oedematous pancreatitis â–șHomogeneous collection with fluid density â–șConfined by normal peripancreatic fascial planes â–șNo definable wall encapsulating the collection â–șAdjacent to pancreas (no intrapancreatic extension)
  • 119. Pancreatic pseudocyst An encapsulated collection of fluid with a well defined inflammatory wall usually outside the pancreas with minimal or no necrosis. This entity usually occurs more than 4 weeks after onset of interstitial oedematous pancreatitis to mature. CECT criteria â–șWell circumscribed, usually round or oval â–șHomogeneous fluid density â–șNo non-liquid component â–șWell defined wall; that is, completely encapsulated â–șMaturation usually requires >4 weeks after onset of acute pancreatitis; occurs after interstitial oedematous pancreatitis
  • 120. ANC (acute necrotic collection) A collection containing variable amounts of both fluid and necrosis associated with necrotising pancreatitis; the necrosis can involve the pancreatic parenchyma and/or the peripancreatic tissues CECT criteria â–șOccurs only in the setting of acute necrotizing pancreatitis â–șHeterogeneous and non-liquid density of varying degrees in different locations (some appear homogeneous early in their course) â–șNo definable wall encapsulating the collection â–șLocation—intrapancreatic and/or extrapancreatic
  • 121. WON (walled-off necrosis) A mature, encapsulated collection of pancreatic and/or peripancreatic necrosis that has developed a well defined inflammatory wall. WON usually occurs >4 weeks after onset of necrotising pancreatitis. CECT criteria â–șHeterogeneous with liquid and non-liquid density with varying degrees of loculations (some may appear homogeneous) â–șWell defined wall, that is, completely encapsulated â–șLocation—intrapancreatic and/or extrapancreatic â–șMaturation usually requires 4 weeks after onset of acute necrotising pancreatitis
  • 122. Etiology work up Initial work up: â–șAlcohol, Gall stones, Hypercalcemia, hypertriglyceridemia idiopathic acute pancreatitis, â–șEUS - to assess for occult microlithiasis, neoplasms and chronic pancreatitis. â–șIf EUS is negative, (secretin-stimulated) MRCP is advised For rare morphologic abnormalities - CT of the abdomen If etiology remains unidentified, especially after a second attack of idiopathic pancreatitis - genetic counseling (not necessarily genetic testing) ACG Guideline. Am J Gastroenterology 2013
  • 123. Abdominal compartment syndrome IAH – IAP> 12 mmHg ACS – IAP> 20 mmHg Causes â–șInflammatory fluid collection, inflammatory mass â–șParalytic ileus and distension of bowel â–șAscites Consequences â–șReduced renal and abd perfusion â–șIschemic bowel complication â–șRespiratory impairment Remedial measure â–șDecompression of stomach & bowel â–șAscitic tap/ placement of drains â–șMechanical ventilation with muscle relaxants â–șRestrict fluid if possible Mentula P et al. World Journal of Emergency Surgery 2014, 9:15
  • 124. Interventions in local complications
  • 125. Acute pancreatitis Antibiotics prophylaxis for prevention of infection in necroting pancreatitis
  • 126. EUS and acute pancreatitis Fusaroli P et al. World J Gastroenterol 2012; 18(32): 4243-4256
  • 127. Role of EUS in acute pancreatitis EUS may prevent ERCP in 71% of patients with AP and offers a complication-free alternative EUS seems superior to MRCP (51% vs 20%) in the evaluation of AP Cholelithiasis and biliary sludge (24%) are the most frequent EUS diagnoses, and pancreas divisum (8%) is the most frequent MRCP diagnosis EUS can diagnose underlying chronic pancreatitis Treatment of local complication – fluid collection, FNA, necrosectomy, pseudocyst drainage
  • 128. Hypertriglyceridemia induced acute pancreatitis Tsuang W et al. Am J Gastroenterol 2009
  • 129. Hypertriglyceridemia induced acute pancreatitis Tsuang W et al. Am J Gastroenterol 2009
  • 130. Management of Acute Pancreatitis Da Cost DW et al. BJS 2014;101:65-79
  • 131. Da Cost DW et al. BJS 2014;101:65-79 Management of Acute Pancreatitis
  • 132. Japanese Guideline 2015 Urinary trypsinogen-2 dipstick may be useful for minimally invasive method and rapid diagnosis of acute pancreatitis. The prophylactic administration of antibiotics in severe acute pancreatitis and necrotizing pancreatitis may improve the prognosis, if carried out in the early phases of pancreatitis (within 72 h of onset). (2B) Intravenous hyperalimentation is not recommended for mild cases. (1B) In severe cases, it is more significant as a measure to prevent infection rather than as a route of nutrition support. If initiated in the early phase, enteral nutrition can reduce
  • 133. In principle, it is recommended that enteral feeding tubes be inserted into the jejunum through the Treitz ligament. However, if a feeding tube cannot be inserted into the jejunum, nutrients can be infused into the duodenum or stomach instead. (2B) No life-saving effect has been observed from peritoneal lavage for acute pancreatitis The sequential measurement of IAP is recommended for cases with â–șexcessive fluid infusion, high severity, â–șrenal and respiratory complications, â–șfluid accumulation in multiple areas as observed by CT, Japanese Guideline 2015
  • 134. When there is persistent or recurrent IAP≧12mmHg, â–șgastrointestinal decompression, â–șintra-abdominal decompression, â–șimprovement of abdominal wall compliance, â–șappropriate fluid infusion and circulation management Surgical decompression should be considered only when internal treatment is not effective for patients with IAP>20mmHg and where the additional complication of organ failure is of concern Routine use of FNA is not required for diagnosis, and clinical signs and CT should be used for a comprehensive determination. Japanese Guideline 2015
  • 135. If possible, therapeutic intervention for infected pancreatic necrosis should be performed after 4 weeks of onset, when the necrosis has been sufficiently walled off, or in other words, during WON period for infected pancreatic necrosis, percutaneous (retroperitoneal) drainage or endoscopic transluminal drainage should be first given, and if no improvement is achieved, necrosectomy should then be performed Japanese Guideline 2015
  • 139. Author No. of patients Pts with infected necrosis Mortality Re- laparotomy Planned re- laparotomies Sarr 1991 23 75% 17% 2-5/pt Tsiotos 1998 72 79% 25% 1-7/pt Closed packing Fernandez 1998 64 56% 6% 17% Surgical necrosectomy
  • 140. Surgical method Author No. of pts Fistula (pancreatic/ enteric) Bleeding Open packing Bradley 1993 71 46 7% Branum 1998 50 88% (72%/16%) Bosscha 1998 28 25% 50% Planned re-lap Sarr 1991 23 26%/52% 26% Tsiotos 1998 72 19% 27% 18% Closed packing Fernandez 1998 64 53%/16% 3% Closed cont. lavage Farkas 1996 123 13%/1% 2% Buchler 2001 42 19% 5% Open necrosectomy : complications
  • 141. Author No . Infected (%) Mort ality Succes sful Sepsis Complic ation Percut aneous Geeinwiese r 1997 29 100 27% 69% 86% Fistula 7% Freeny 1998 34 100 12% 47% 74% None Echenique 1998 20 100 0% 20% Fistula 50% Gouzi 1999 32 81 15% 65% Fistula 52% Endos copic Baron 1996 11 27 0% 81% Bleeding 9%, Fistula 36% Percutaneous or endoscopic drainage
  • 142. Author No. Infected(%) Mortality Bleeding/ Fistula Fagniez 1989 40 97% 33% 45% / 45% Villazan 1991 18 100% 22% 6% /32% Van Vyve 1993 20 20% 25% Nakasaki 1999 8 100% 25% 13% / ? Retroperitoneal laparotomy
  • 143.
  • 144. Decontamination group (n=50) Control group (n=55) Mortality 22% 35% Infected necrosis 18% 38% Laparotomy 32% 46% Laparotomy/pt 0.9 3.1 Selective decontamination in SAP Ann Surgery 1995
  • 145. Probiotics in acute pancreatitis Four RCTs (n=428) were included in the review. Sample size ranged from 25 to 296 participants. The present study showed that enteral feeding with probiotics could not reduce rates of infected necrosis and mortality. Future studies were required Langenbeck's Archives of Surgery 2009; 394(1): 171-177