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

A detailed case studies of patients having acute pancreatitis

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

  1. 1. Acute Pancreatitis S K Sinha Professor Department of Gastroenterology PGIMER, Chandigarh
  2. 2. Index Case 24May 2016 40 yrs old male, alcohol abuser presented with ►Pain abdomen for 3 hours Upper abd, non-colicky, severe, radiating to back Associated vomiting, multiple time bilious Associated abd distension + ►Past, Family History : Not significant ►Personal History: 80-100 gms of alcohol/day for 15-16 yrs
  3. 3. GPE – Pulse 122 , BP 140/82 mmHg, RR 24/min Abdomen ►Liver 3 cm, soft to firm ►Spleen not palpable ►Diffuse tenderness & guarding in whole abdomen ►Bowel sound sluggish Chest: reduced breath sound at bases CVS, CNS – NS Possibilities: Index Case
  4. 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. 5. Issue 1 What is the practically acceptable criteria for diagnosis of acute pancreatitis?
  6. 6. Acute pancreatitis: Diagnosis At least two of the following ►Abdominal pain consistent with the disease ►Serum amylase and / or lipase greater than three times the upper limit of normal ►Characteristic findings from abdominal imaging CECT and / or MRI should be reserved for ►Patients in whom the diagnosis is unclear ►Who fail to improve clinically within the first 48 – 72 h after hospital admission ►To evaluate complications ACG Guideline. Am J Gastroenterol 2013; 108:1400–1415
  7. 7. Issue 2 Which enzyme assay is preferable : amylase or lipase or combination of two? ►Relative accuracy ►False negative and false positive
  8. 8. Pattern of rise ►Rises within a few hours, may return to normal within 5 days ►Sensitivity in AP – approx 80% Acute pancreatitis with no rise in amylase ►Hypertriglyceridemia ►Alcohol related AP ►Acute on chronic pancreatitis High amylase but no pancreatitis ►Macroamylasemia ►Renal failure ►diseases of the salivary glands ►Extrapancreatic abdominal conditions with inflammation ►Gynaecological diseases Serum amylase estimation: Pitfalls
  9. 9. Amylase vs Lipase Barbieri JS. Journal of Hospital Medicine 2016;11 :366-68
  10. 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. 11. Index case Repeat Lipase at 24 hours : 480 IU Diagnosis of Acute pancreatitis was made Treatment ►IV fluid ►Analgesia
  12. 12. Issue 3 Fluid for initial resuscitation/therapy of acute pancreatitis? ►Does initial aggressive fluid resuscitation matter? ►Which the preferred or currently recommended crystalloid fluid in initial management of acute of pancreatitis? ►How to monitor fluid resuscitation? Non-invasively – clinical/lab parameter Invasively How frequently the fluid therapy should be monitored?
  13. 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. 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. 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. 16. Issue 4 Which narcotic analgesic should be used in acute pancreatitis?
  17. 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. 18. Effect of narcotics on Sphincter of Oddi pressure Staritz M et al. Gut, 1986, 27, 567-569
  19. 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. 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 ►S/Electrolytes, RFT – N ►LFT – Bil – N, Mild rise of transaminases ►Hb 12.9 gms TLC -13500 DLC – N 70 L 26 Index case: Course
  21. 21. Issue 5 How do we define severity of acute pancreatitis? ►Mild/moderate/severe
  22. 22. Revised Atlanta Definitions 2012 Interstitial oedematous pancreatitis ►Acute inflammation of the pancreatic parenchyma and peripancreatic tissues, but without recognisable tissue necrosis ►CECT criteria Pancreatic parenchyma enhancement by intravenous contrast agent No findings of peripancreatic necrosis Necrotizing pancreatitis ►Inflammation associated with pancreatic parenchymal necrosis and/or peripancreatic necrosis ►CECT criteria Lack of pancreatic parenchymal enhancement by intravenous contrast agent and/or Presence of findings of peripancreatic necrosis
  23. 23. Mild acute pancreatitis ►No organ failure ►No local or systemic complications Moderately severe acute pancreatitis ►Organ failure that resolves within 48 h ►Transient organ failure and/or ►Local or systemic complications without persistent organ failure Severe acute pancreatitis ►Persistent organ failure (>48 h) Single organ failure Multiple organ failure Severity of acute pancreatitis
  24. 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. 25. Organ failure in acute pancreatitis Shock ►(systolic blood pressure < 90 mm Hg), Pulmonary insufficiency ► (PaO 2 < 60 mm Hg), Renal failure ►creatinine > 2 mg / dl after rehydration Gastro intestinal bleeding ► > 500 ml of blood loss/ 24 h Bradley EL et al. Arch Surg 1993 ; 128 : 586 –
  26. 26. Local complications of AP
  27. 27. APFC (acute peripancreatic fluid collection)
  28. 28. Pancreatic pseudocyst
  29. 29. Acute necrotic collection
  30. 30. Acute necrotic collection
  31. 31. Infected pancreatic necrosis
  32. 32. WON (walled-off necrosis)
  33. 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. 34. Ranson’s Criteria for acute pancreatitis
  35. 35. Glasgow criteria for acute pancreatitis
  36. 36. APACHE II scoring system for acute pancreatitis
  37. 37. Japanese society severity score Variables ►BE level < -3 mEq/L or shock ►PaO2 < 60 mm Hg (room air) or respiratory failure ►Blood urea nitrogen level > 40 mg/dL or creatinine level > 2 mg/dL ►Lactate dehydrogenase level > 2 folds of upper normal limit ►Platelet count < 105/mm3 ►Calcium level < 7.5 mg/dL ►C-reactive protein level > 15 mg/dL ►Systemic inflammatory response syndrome score > 3 ►Age > 70 years old Pancreas 2014, 43:487-89
  38. 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: ►Temperature of <36℃ or >38℃ ►Respiratory rate >20 breaths/min or PaCO2<32 mmHg ►Pulse>90 beats/min ►WBC<4×109 or >12×109/L or >10% immature bands Age>60 yr Pleural effusion detected on imaging
  39. 39. Clinical findings predicting a severe course Patient characteristics ► Age > 55 years, Obesity (BMI > 30 kg / m2 ) ► Altered mental status Comorbid disease The systemic infl ammatory response syndrome (SIRS) ►Presence 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 ► BUN > 20 mg/dl, Rising BUN, HCT > 44 %, Rising HCT, Elevated creatinine Radiology findings ► Pleural effusions, Pulmonary infiltrates, Multiple or extensive extrapancreatic collections ACG Guideline 2013. Am J Gastroenterol 2013
  40. 40. Comparison of different scores Park JY. Hepatobiliary Pancreat Dis Int 2013
  41. 41. Issue 7 – Imaging in AP CECT of abdomen in acute pancreatitis ►What are the findings which should especially be taken into consideration? ►What is accuracy of CT scan? ►Should all patients be subjected to CT scan examination? ►When should CT scan be done? ►What is the ideal timing? ►Does accuracy depend on timing and technique? ►What are the risks involved with CT scan examination? ►What are the modalities to reduce the risk?
  42. 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 ►MRCP can detect CBD stones upto 3 mm Timing of CT scan ►For assessment of severity and local complications: after 3-5 days ►When diagnosis in doubt: any time ACG Guideline. Am J Gastroenterol 2013; 108:1400–1415
  43. 43. CT severity index of acute pancreatitis Balthazar CT Score ►A -Normal ► B -Focal or diffuse enlargement of the pancreas, including irregularities of contour and inhomogeneous attenuation ► C - Pancreatic gland abnormalities in grade B plus per pancreatic inflammation ► D - Grade C plus a single fluid collection ► E - Grade C plus 2 or more fluid collections and/or the presence of gas in or adjacent to the pancreas Necrosis ►None – score 0 ►Less than 30% - score 2 ►30-50% - score 4 ►> 50% - score 6
  44. 44. Mortele KJ et al. AJR 2004;183:1261–1265 Modified CT Severity Index
  45. 45. CECT abdomen: CTSI – 8/10 MCTSI – 10/10 Patient having low grade fever - ? Start antibiotics Nutritional support???? Index case: Course
  46. 46. Issue 8 – Antibiotic prophylaxis in AP Antibiotics in acute panreatitis ►Should prophylactic antibiotics be given to all patients with acute pancreatitis? ►Should prophylactic antibiotics be given to all patients with severe acute pancreatitis? ►What are the commonly acceptable indications of emperical use of antibiotics? ►What the antibiotics preferred for prophylactic or emperical use? ►When to start and when to stop?
  47. 47. 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
  48. 48. Last 15 years ►Multiple trials ►Included mainly severe pancreatitis ►Many randomized trials, only one double blind randomized trial ►Variable results ►Antibiotics : Imipenem, Cephalosporins, Ciprofloxacin/Metronidazole Prophylactic antibiotics in SAP Gastroenterology 2004
  49. 49. 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
  50. 50. Prophylactic antibiotics in AP
  51. 51. 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. ► In these patients, either (i) initial CT-guided fine-needle aspiration (FNA) for Gram stain and culture to guide use of appropriate antibiotics or ►Empiric use of antibiotics after obtaining necessary cultures for infectious agents, without CT FNA, should be given ACG Guideline . Am J Gastroenterology 2013
  52. 52. 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
  53. 53. 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
  54. 54. 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
  55. 55. Issue 9 – Nutrition in acute pancreatitis Feeding in acute pancreatitis ►Which is the preferred route – enteral or parenteral? ►When to start feeding”? ►Mild to moderate pancreatitis ►Severe acute pancreatitis ►Which is preferred feeding formula – elemental/polymeric/Immune feeding? ►Which is the preferred enteral feeding route – nasogastric or nasoduodenal or nasojejunal?
  56. 56. Nutrition in acute pancreatitis In mild AP, oral feedings can be started once there is no nausea and vomiting, and abdominal pain ►low-fat solid diet appears as safe as a clear liquid diet In severe AP, enteral nutrition is recommended to prevent infectious complications. Parenteral nutrition ►enteral 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
  57. 57. 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
  58. 58. 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
  59. 59. Enteral feeding formula Elemental ►Comprising amino acids or oligopeptides, maltodextrins, and medium—chain and long-chain triglycerides; Polymeric ►Comprising nonhydrolyzed proteins, maltodextrins, and oligofructosaccharides, as well as long-chain triglycerides; Immune-enhancing ►Comprising 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.
  60. 60. Nutrition in Acute pancreatitis Enteral nutrition – ►Curtails of acute inflammation of the pancreas ►Reduces 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
  61. 61. Put on IV antibiotics – Piperacillin+ Tazobactum for 14 days Nasojejunal tube placed – feeding attempted ►Distension of abdomen ►SOB Feeding had to be stopped temporarily O2 supplementation CXR was unremarkable IAP was measured Index case: Course
  62. 62. Issue 10 : IAP monitoring in acute pancreatitis Role of intra-abdominal pressure monitoring in acute pancreatitis? ►How to define abdominal compartment syndrome? ►How to monitor for abdominal compartment syndrome? ►How to treat abdominal compartment syndrome?
  63. 63. Abdominal compartment syndrome IAH – IAP> 12 mmHg ACS – IAP> 20 mmHg Causes ►Inflammatory fluid collection, inflammatory mass ►Paralytic ileus and distension of bowel ►Ascites Consequences ►Reduced renal and abd perfusion ►Ischemic bowel complication ►Respiratory impairment Remedial measure ►Decompression of stomach & bowel ►Ascitic tap/ placement of drains ►Mechanical ventilation with muscle relaxants ►Restrict fluid if possible Mentula P et al. World Journal of Emergency Surgery 2014, 9:15
  64. 64. NJ feeding could be established after 5 days NJ feeding was given for two weeks Oral feeding in third week – gradually built up ►Fullness and bloating – post meals ►No vomiting Palpable lump abdomen, No fever , No vomiting Labs: normal RFT, LFT, Mild leucocytosis Discharged in 5th week Index case: Course
  65. 65. Re-evaluation during 7 – 8 th week ►Mild abdominal pain/discomfort, post prandial bloating ►No fever ►Tolerating oral diet, low fat ►Examination: large upper abdominal lump, mild tenderness Index case: Course
  66. 66. Issue 11 : Management of Non-Infected Necrosis Pancreatic necrosis without infection ►What are factors which determine the outcome? ►What should be the preferred approach in management?
  67. 67. Management of local complication of AP Japanese Guideline 2015
  68. 68. Sterile pancreatic necrosis Debridement for sterile necrosis is recommended if ►Associated with gastric outlet obstruction ►Bile duct obstruction Asymptomatic pancreatic and / or extrapancreatic necrosis does not mandate intervention regardless of size, location, and extension.
  69. 69. 10th week of illness ►Gradual increase in upper abdominal pain over 3-4 days ►Fever – High grade ►Vomitng off and on ►Shortness of breath ►Examination Palpable upper abominal lump, tender Reduced breath sound at lung bases ►Labs RFT, LFT – N HMG – Hb 10.5 gm, TLC – 24000, DLC – N88%, L 12 PCT – 3.9 Index case: Course
  70. 70. Issues 12: Infected Pancreatic Necrosis Pancreatic necrosis - With evidence of infection ►Should all patients be referred for surgery? ►What are the factors which determine the outcome? ►How to select the cases for non-surgical management? ►What is the optimum timing for surgery?
  71. 71. Issue Infections in acute pancreatits ►What are the common sites of infection in patients with acute pancreatitis? ►What are the risk factors for infected pancreatic necrosis? ►Timing of pancreatic infection ►Methods of diagnosis ►Organisms ►What are the common organisms? ►What is the source of these organisms ►How common are the anaerobes? ►How common is fungal infection ?
  72. 72. Risk of pancreatic infection Risk depends upon ►Severity of pancreatitis Ranson’s score < 3 : 5.3% Ranson’s score > 5 : 58% ►Extent of necrosis <30% : 5-10% 30 – 50% : 10-20% > 50% : 30 – 70% ►Bacterial colonization of gut Br J Surgery 1999
  73. 73. 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
  74. 74. 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
  75. 75. Fungal infection in pancreatic necrosis Risk factors ►Broad spectrum antibiotics ►Abdominal surgery ►Male sex, Age > 40 years ►Central venous access , Hypotension at admission ►High APACHE II score ►Renal failure , TPN, Respiratory failure at admission ►Mechanical ventilation ►ERCP/ Pancreatic stenting ►Diabetes mellitus ►Percutaneous drainage ►Duration of hospital stay > 4 weeks Kochhar R, JGH 2013
  76. 76. Fungal infection in pancreatic necrosis
  77. 77. Impact of pancreatic infection Increased mortality Increased morbidity ►Increased risk of renal failure ►Increased risk of GI bleed ►Increased risk of respiratory failure ►Increased cardiovascular complication Longer hospital stay Increased probability of surgery Increased cost of therapy
  78. 78. 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
  79. 79. Infection in pancreatic necrosis When to suspect ►Timing : second or third week ►Clinical feature Recurrence of pain abdomen Worsening of organ system function Increasing temperature Increasing TLC New onset ileus Am Surgeon 2000
  80. 80. Methods of diagnosis ►Plain X-Ray ►Ultrasonography, CT ►Blood culture ►Gallium scan ►In111 labelled leucocyte scan ►USG/CT guided FNA ►PET CT Infection in pancreatic necrosis Gut 2005, Gastroenterology2004
  81. 81. Methods of diagnosis ►Plain X-Ray ►Ultrasonography, CT ►Blood culture ►Gallium scan ►In111 labelled leucocyte scan ►USG/CT guided FNA ►PET CT Infection in pancreatic necrosis Gut 2005, Gastroenterology2004
  82. 82. 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
  83. 83. USG/ CT guided FNA Complications : rare Results : High PPV, high NPV ►Total patients : 60 ►Total aspirations : 92 Grams stain + : 41 Culture + : 42 ►Final diagnosis Infected : 42 Uninfected : 50 Gastroenterology 1997
  84. 84. Infected pancreatic necrosis Antibiotics alone can lead to resolution of infection and, in select patients, avoid surgery altogether ►16/28 pts improved with antibiotics Unstable patients with infected necrosis needs consideration for urgent debridement ►a course of antibiotics before intervention to allow the inflammatory reaction to become better organized ►If pt fails to improve : Necrosectomy Endoscopic/radiologic/video-assisted retroperitoneal/ laparoscopic approach/ combination
  85. 85. Cochrane review ►The 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
  86. 86. 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 ►High risk of hemorrhage ►Increased organ dysfunction and death. Necrosectomy within the first two weeks - 75% mortality Necrosectomy after 6-8 weeks – Mortality 5% Multiple organ dysfunction increases mortality
  87. 87. 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 ►Role of percutaneous drain – single or multiple ►Minimally invasive surgery/ endoscopic procedure Infected pancreatic necrosis
  88. 88. Infected pancreatic necrosis Supportive care for organ failure Nutrition Antibiotics : as per sensitivity and local data Drainage and necrosectomy ►Open surgical ►Laparoscopic ►Radiological ►Endoscopic
  89. 89. USG guided aspiration ►Pus 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
  90. 90. Necrosectomy for infected necrosis Best surgical method not defined ►No 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
  91. 91. Percutaneous drainage of necrosis/collection
  92. 92. Endoscopic drainage/necrosectomy Baron & Kozarek. Clin Gastro Hepatol 2012
  93. 93. Endoscopic necrosectomy Baron & Kozarek. Clin Gastro Hepatol 2012
  94. 94. Issue 13 ERCP in acute biliary pancreatitis ►What are the indications for ERCP in acute biliary pancreatitis? Urgent indications Semi-elective indications ►Does timing of ERCP matter? ►What is the preferred ERCP intervention – stent or NBD or sphincterotomy or CBD clearance? ►Patient taken up for ERCP but no stone on cholangiogram – what to do next?
  95. 95. Diagnosis of Biliary Pancreatitis
  96. 96. ERCP in acute biliary pancreatitis Indications ►Suspected 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
  97. 97. Contraindications ►Absolute 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 ►Relative (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
  98. 98. UK guideline 2005 ►Early ERCP (within 72 hours after admission to the hospital) in all patients with predicted or actual severe biliary pancreatitis AGA 2007 ►Urgent ERCP (within 24 hours after admission) if cholangitis ►Early ERCP (within 72 hours after admission) if suspicion of persistent bile-duct stones ACG 2013 ►Patients with AP and concurrent acute cholangitis should undergo ERCP within 24 h of admission ►ERCP 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
  99. 99. ERCP in acute pancreatitis Sphincterotomy and CBD clearance ►Evidence of CBD stone, biliary obstruction : at any time during course ►Suspicion or evidence of cholangitis : at any time during course ►Persistent biliary obstruction ►? Any case of biliary pancreatitis taken up for ERCP
  100. 100. 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
  101. 101. Issue 14 Timing of cholecystectomy after an episode of acute biliary pancreatitis? ► What is the risk of recurrence over time?
  102. 102. Risk of delayed cholecystectomy Jee SL. Asian Journal of Surgery 2016
  103. 103. 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
  104. 104. Open surgical necrosectomy Various techniques ►Open packing ►Planned re-laparotomies ►Closed packing ►Closed continuous lavage
  105. 105. 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
  106. 106. 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
  107. 107. AP: Magnitude of problem Incidence : 4.9 – 73.4 cases per lac population Incidence is increasing Mortality: minimal decrease over years Severity of pancreatitis ►Mild : 70 -80% No local or systemic complication Usually no necrosis Recovery in 3 – 7 days ►Severe : 20 -30 % Local or systemic complications Necrosis usual Infection : 20 – 70% Gut 2005, Am J Gastro 2013
  108. 108. Course of acute pancreatitis Overall mortality: 5 – 10% Almost all mortality in severe cases Two phases of illness ►Early phase - within 7 days: largely unrelated to infection, mostly cytokine mediated SIRS Organ failure ►Late 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
  109. 109. Cochior D et al. Chirurgia (2013) 108: 631-642 Course of acute pancreatitis
  110. 110. Initial assessment and risk stratification Hemodynamic status be assessed immediately upon presentation ►Aggressive hydration, defined as 250-500 ml per hour of isotonic crystalloid solution preferably Ringer Lactate Exceptions: Cardiovascular and renal comorbidity ►Higher infusion rate in those with hypotension or tachycardia ►Assess fluid requirement every 6 hours for 48 hours – aim to decrease BUN Risk assessment : ►Stratify patients into higher- and lower-risk categories to assist triage, such as admission to an intensive care setting Patients with organ failure: ►admitted to an ICU or HDU
  111. 111. 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 ►Occurs in the setting of interstitial oedematous pancreatitis ►Homogeneous collection with fluid density ►Confined by normal peripancreatic fascial planes ►No definable wall encapsulating the collection ►Adjacent to pancreas (no intrapancreatic extension)
  112. 112. 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 ►Well circumscribed, usually round or oval ►Homogeneous fluid density ►No non-liquid component ►Well defined wall; that is, completely encapsulated ►Maturation usually requires >4 weeks after onset of acute pancreatitis; occurs after interstitial oedematous pancreatitis
  113. 113. 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 ►Occurs only in the setting of acute necrotizing pancreatitis ►Heterogeneous and non-liquid density of varying degrees in different locations (some appear homogeneous early in their course) ►No definable wall encapsulating the collection ►Location—intrapancreatic and/or extrapancreatic
  114. 114. 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 ►Heterogeneous with liquid and non-liquid density with varying degrees of loculations (some may appear homogeneous) ►Well defined wall, that is, completely encapsulated ►Location—intrapancreatic and/or extrapancreatic ►Maturation usually requires 4 weeks after onset of acute necrotising pancreatitis
  115. 115. Etiology work up Initial work up: ►Alcohol, Gall stones, Hypercalcemia, hypertriglyceridemia idiopathic acute pancreatitis, ►EUS - to assess for occult microlithiasis, neoplasms and chronic pancreatitis. ►If 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
  116. 116. Abdominal compartment syndrome IAH – IAP> 12 mmHg ACS – IAP> 20 mmHg Causes ►Inflammatory fluid collection, inflammatory mass ►Paralytic ileus and distension of bowel ►Ascites Consequences ►Reduced renal and abd perfusion ►Ischemic bowel complication ►Respiratory impairment Remedial measure ►Decompression of stomach & bowel ►Ascitic tap/ placement of drains ►Mechanical ventilation with muscle relaxants ►Restrict fluid if possible Mentula P et al. World Journal of Emergency Surgery 2014, 9:15
  117. 117. Interventions in local complications
  118. 118. Acute pancreatitis Antibiotics prophylaxis for prevention of infection in necroting pancreatitis
  119. 119. EUS and acute pancreatitis Fusaroli P et al. World J Gastroenterol 2012; 18(32): 4243-4256
  120. 120. 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
  121. 121. Hypertriglyceridemia induced acute pancreatitis Tsuang W et al. Am J Gastroenterol 2009
  122. 122. Hypertriglyceridemia induced acute pancreatitis Tsuang W et al. Am J Gastroenterol 2009
  123. 123. Management of Acute Pancreatitis Da Cost DW et al. BJS 2014;101:65-79
  124. 124. Da Cost DW et al. BJS 2014;101:65-79 Management of Acute Pancreatitis
  125. 125. 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
  126. 126. 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 ►excessive fluid infusion, high severity, ►renal and respiratory complications, ►fluid accumulation in multiple areas as observed by CT, Japanese Guideline 2015
  127. 127. When there is persistent or recurrent IAP≧12mmHg, ►gastrointestinal decompression, ►intra-abdominal decompression, ►improvement of abdominal wall compliance, ►appropriate 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
  128. 128. 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
  129. 129. Japanese Guideline 2015
  130. 130. Japanese Guideline 2015
  131. 131. Japanese Guideline 2015
  132. 132. 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
  133. 133. 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
  134. 134. 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
  135. 135. 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
  136. 136. 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
  137. 137. 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

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