Management of acute pancreatitis - American College of Gastroenterology Guideline 2013

1. MANAGEMENT OF ACUTE
PANCREATITIS
American College Of Gastroenterology guideline 2013
Dr Subhasish Deb
Dept. of General Medicine
Burdwan Medical College And Hospital
Dr. Subhasish Deb, BMCH

2. Dr. Subhasish Deb, BMCH

3. DIAGNOSIS
1. Presence of 2 of the 3 criteria:
(i) abdominal pain consistent with the disease,
(ii) serum amylase &/or lipase greater than 3 times the
UNL
(iii) characteristic findings from abdominal imaging
2. CECT and / or MRI of the pancreas should be
reserved for patients in whom the diagnosis is
unclear or who fail to improve clinically within
the first 48 – 72 h after hospital admission
Dr. Subhasish Deb, BMCH

4. AMYLASE VS LIPASE
• Limitations in sensitivity, specificity and positive and
negative predictive value of serum amylase (serum lipase
is preferred).
AMYLASE
a) rises within a few hours after the onset of symptoms
b) returns to normal values within 3 – 5 days (however, it
may remain within the normal range on admission in as
many as one-fifth of patients)
c) Serum amylase concentrations may be normal in
alcohol-induced AP and hypertriglyceridemia
Dr. Subhasish Deb, BMCH

5. d) Serum amylase concentrations might be high in
the absence of AP in macroamylasaemia (a
syndrome characterized by the formation of
large molecular complexes between amylase
and abnormal immunoglobulins)
e) May be high in patients with decreased GFR, in
diseases of the salivary glands, and in
extrapancreatic abdominal diseases associated
with inflammation, including acute appendicitis,
cholecystitis, intestinal obstruction or ischemia,
peptic ulcer, and gynecological diseases.
Dr. Subhasish Deb, BMCH

6. ETIOLOGY
1. Transabdominal ultrasound should be performed in all patients
with acute pancreatitis
2. In the absence of gallstones and / or significant h/o alcohol use, a
serum triglyceride should be obtained and considered the etiology
if > 1,000 mg / dl
3. In a patient older than 40 years, a pancreatic tumor should be
considered as a possible cause of acute pancreatitis
4. Endoscopic investigation in patients with acute idiopathic
pancreatitis should be limited, as the risks and benefits of
investigation in these patients are unclear
5. Patients with idiopathic pancreatitis should be referred to
centers of expertise
6. Genetic testing may be considered in young patients ( < 30 years)
if no cause is evident and a family history of pancreatic disease is
present
Dr. Subhasish Deb, BMCH

7. • M/c/c – Gall stones followed by alcohol
Dr. Subhasish Deb, BMCH

8. Alcohol and AP
The diagnosis should not be entertained unless a
person has a history of over 5 years of heavy
alcohol consumption
 “ Heavy ” alcohol consumption is generally
considered to be > 50 g per day, but is often
much higher
Clinically evident AP occurs in < 5 % of heavy
drinkers; thus, there are likely other factors that
sensitize individuals to the effects of alcohol, such
as genetic factors and tobacco use.
Dr. Subhasish Deb, BMCH

9. Idiopathic AP
• IAP is defined as pancreatitis with no etiology
established after
1. initial laboratory (including lipid and calcium
level) and
2. imaging tests (transabdominal ultrasound
and CT in the appropriate patient)
Dr. Subhasish Deb, BMCH

10. INITIAL ASSESSMENT AND RISK
STRATIFICATION
• Hemodynamic status should be assessed
immediately upon presentation and resuscitative
measures begun as needed
• Risk assessment should be performed to stratify
patients into higher- and lower-risk categories to
assist triage, such as admission to an intensive
care setting
• Patients with organ failure should be admitted to
an intensive care unit or intermediary care setting
whenever possible
Dr. Subhasish Deb, BMCH

11. Dr. Subhasish Deb, BMCH

12. Organ Failure
• Initially defined as:
1. shock (systolic blood pressure < 90 mm Hg)
2. pulmonary insufficiency (PaO2< 60 mm Hg)
3. renal failure (creatinine > 2 mg / dl after
rehydration)
4. and / or gastro intestinal bleeding ( > 500 ml of blood
loss / 24 h)
Organ failure is now defined as a score ≥2 for one of
the three scoring systems (cardiovascular,
respiratory, and renal) using the modified Marshall
scoring system.
Dr. Subhasish Deb, BMCH

13. Local Complications
1. acute fluid collection,
2. pancreatic necrosis,
3. pseudocyst and
4. pancreatic abscess.
Dr. Subhasish Deb, BMCH

14. Pancreatic necrosis
• Def: diffuse or focal areas of non viable pancreatic
parenchyma > 3 cm in size or > 30% of the pancreas.
• Pancreatic necrosis can be:
i. sterile or
ii. infected
• Patients with sterile necrosis can suffer from organ
failure and appear as ill clinically as those patients with
infected necrosis.
• In the absence of pancreatic necrosis, in mild disease
the edematous pancreas is defined as interstitial
pancreatitis.
Dr. Subhasish Deb, BMCH

15. INITIAL MANAGEMENT
1. Aggressive hydration, defined as 250-500 ml per hour of
isotonic crystalloid solution should be provided to all
patients, unless cardiovascular and / or renal co-morbidites
exist. Early aggressive intravenous hydration is most
beneficial the first 12 – 24 h, and may have little benefit
beyond.
2. In a patient with severe volume depletion, manifest as
hypotension and tachycardia, more rapid repletion (bolus)
may be needed .
3. Lactated Ringer’s solution may be the preferred isotonic
crystalloid replacement fluid.
4. Fluid requirements should be reassessed at frequent
intervals within 6 h of admission and for the next 24 – 48 h.
The goal of aggressive hydration should be to decrease the
blood urea nitrogen
Dr. Subhasish Deb, BMCH

16. Rationale for rapid hydration
• Despite dozens of randomized trials, no medication has been
shown to be effective in treating AP.
• The rationale for early aggressive hydration in AP arises from
observation of the frequent hypovolemia that occurs from
multiple factors:
i. including vomiting,
ii. reduced oral intake,
iii. third spacing of fluids,
iv. increased respiratory losses and
v. diaphoresis.
vi. In addition, researchers hypothesize that a combination of
microangiopathic effects and edema of the inflamed pancreas
decreases blood flow, leading to increased cellular death, necrosis,
and ongoing release of pancreatic enzymes activating numerous
cascades.
Dr. Subhasish Deb, BMCH

17. Why RL?
• benefits to using the more pH-balanced lactated
Ringer ’ s solution for fluid resuscitation
compared with normal saline. Low pH activates
the trypsinogen, makes the acinar cells more
susceptible to injury and increases the severity of
established AP in experimental studies. Although
both are isotonic crystalloid solutions, normal
saline given in large volumes may lead to the
development of a non-anion gap, hyperchloremic
metabolic acidosis.
Dr. Subhasish Deb, BMCH

18. ERCP IN AP
1. Patients with acute pancreatitis and concurrent acute
cholangitis should undergo ERCP within 24 h of admission.
2. ERCP is not needed in most patients with gallstone
pancreatitis who lack laboratory or clinical evidence of
ongoing biliary obstruction.
3. In the absence of cholangitis and / or jaundice, MRCP or
endoscopic ultrasound (EUS) rather than diagnostic ERCP
should be used to screen for choledocholithiasis if highly
suspected.
4. Pancreatic duct stents and / or postprocedure rectal
nonsteroidal anti-infl ammatory drug (NSAID)
suppositories should be utilized to prevent severe post-
ERCP pancreatitis in high-risk patients
Dr. Subhasish Deb, BMCH

19. ROLE OF ANITIOTICS IN AP
1. Antibiotics should be given for an extrapancreatic infection, such
as cholangitis, catheter-acquired infections, bacteremia, urinary
tract infections, pneumonia .
2. Routine use of prophylactic antibiotics in patients with severe
acute pancreatitis is not recommended .
3. The use of antibiotics in patients with sterile necrosis to prevent
the development of infected necrosis is not recommended .
4. 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 FNA for Gram stain and culture to guide use
of appropriate antibiotics or
– (ii) empiric use of antibiotics without CT FNA should be given.
Dr. Subhasish Deb, BMCH

20. 5. 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 .
6. Routine administration of antifungal agents
along with prophylactic or therapeutic
antibiotics is not recommended
Dr. Subhasish Deb, BMCH

21. NUTRITION IN AP
• In mild AP, oral feedings can be started immediately if
there is no nausea and vomiting, and abdominal pain
has resolved .
• In mild AP, initiation of feeding with a 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
should be avoided unless the 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.
Dr. Subhasish Deb, BMCH

22. • The need to place the pancreas at rest until complete
resolution of AP no longer seems imperative.
• Long held assumption that the inflamed pancreas
requires prolonged rest by fasting does not appear to
be supported by clinical and laboratory observations.
• TPN is associated with infections and other line related
complications. Enteral feeding maintains gut mucosal
barrier, prevents disruption and translocation of
bacteria that seed pancreatic necrosis.
Dr. Subhasish Deb, BMCH

23. ROLE OF SURGERY IN AP
• In patients with mild AP, found to have gallstones in the gallbladder,
a cholecystectomy should be performed before discharge to
prevent a recurrence of AP
• In a patient with necrotizing biliary AP, in order to prevent
infection, cholecystectomy is to be deferred until active
inflammation subsides and fluid collections resolve or stabilize .
• The presence of asymptomatic pseudocysts and pancreatic and / or
extrapancreatic necrosis do not warrant intervention, regardless of
size, location, and / or extension .
• In stable patients with infected necrosis, surgical, radiologic, and /
or endoscopic drainage should be delayed preferably for more than
4 weeks to allow liquefication of the contents and the development
of a fibrous wall around the necrosis .
• In symptomatic patients with infected necrosis, minimally invasive
methods of necrosectomy are preferred to open necrosectomy .
Dr. Subhasish Deb, BMCH

24. THANKYOU
Dr. Subhasish Deb, BMCH