Acute Pancreatitis Managementdoccdn.simplesite.com/d/a8/e9/287104482457151912... · Member of...
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Acute Pancreatitis Management
Imam Sofii, MD
Staff of General Surgery, Sardjito General Hospital/
Gadjah Mada University Yogyakarta Indonesia
Member of Indonesian College of Surgeon
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Leppaniemi A, Tolonen M, Tarasconi A, et al. WSES Guideline for the Management of severe acute pancreatitis. 2019
• Atlanta (1998) and Revise Atlanta Classification (RAC, 2012).
• British Society of Gastroenterology.
• American Collage of Gastroenterology.
• International Association of Pancreas.
• World Congress of Gastroenterology.
Guidelines
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Definition
• Acute pancreatitis is an inflammatory
condition of the pancreas, clinically
characterized by acute abdominal pain and
elevated levels of pancreatic enzymes in the
blood
• Auto digestion of pancreatic substance by
inappropriately activated pancreatic enzymes
( especially trypsinogen )
Leppaniemi A, Tolonen M, Tarasconi A, et al. WSES Guideline for the Management of severe acute pancreatitis. 2019
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Leppaniemi A, Tolonen M, Tarasconi A, et al. WSES Guideline for the Management of severe acute pancreatitis. 2019
• Clinical sign and symptom.
• Mild to severe (critical).
• Laboratory support.
• Organ failure impact (transient/persistent, single/multiple)
• Imaging support.
• Local complication pattern.
• Acute peripancreatic fluid collections
• Pancreatic pseudo cyst
• Acute necrotic collections
• Walled-off pancreatic necrosis
Diagnosis of acute pancreatitis
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Acute Pancreatitis ( 2 of the following )
• Abdominal pain ( acute onset of a persistent, severe, epigastric pain often
radiating to the back )
• Serum lipase activity ( or amylase ) at least 3 times greater than the upper.
• Characteristics findings of acute pancreatitis on computed tomography or
magnetic resonance imaging
Mild acute pancreatitis
• No organ failure, local or systemic complications
Key Term Diagnosis
Leppaniemi A, Tolonen M, Tarasconi A, et al. WSES Guideline for the Management of severe acute pancreatitis. 2019
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Moderately severe acute pancreatitis
• Organ failure that resolves within 48 hour and or
• Local or systemic complications without persistent organ failure
Severe acute pancreatitis
• Persistent organ failure >48 hours
Interstitial edematous acute pancreatitis
• Acute inflammation of the pancreatic parenchyma and peripancreatic tissues,
but without recognizable necrosis
Leppaniemi A, Tolonen M, Tarasconi A, et al. WSES Guideline for the Management of severe acute pancreatitis. 2019
Key Term Diagnosis
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Necrotizing acute pancreatitis • Inflammation associated with pancreatic parenchymal necrosis and/or peri-
pancreatic necrosis
Organ failure and systemic complications of acute pancreatitis
• Respiration : PaO2/FiO2 ≤ 300
• Cardiovascular : systolic blood pressure <90 mmHg ( off inotropic support) not
fluid responsive, or pH <7.3
• Renal serum creatinine ≥ 170 µmol/L Leppaniemi A, Tolonen M, Tarasconi A, et al. WSES Guideline for the Management of severe acute pancreatitis. 2019
Key Term Diagnosis
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Local complications of acute pancreatitis
• Acute peripancreatic fluid collections
• Pancreatic pseudo cyst
• Acute necrotic collections
• Walled-off pancreatic necrosis
Shah AP, Mourad MM, Bramhall SR. Acute Pancreatitis: Current Perspectives on Diagnosis and Management. 2018
Key Term Diagnosis
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• Serum lipase has a slightly higher sensitivity for detection of acute
pancreatitis than serum amylase because elevation occur earlier and last
longer.
• Sensitivity serum lipase vs serum amylase:
• day 1 : 100% vs 95%
• day 2-3 : 85 vs 68%
• Biliary stone and alcohol overuse are the causes of acute pancreatitis in
70-80% of cases.
Diagnosis of acute pancreatitis
Leppaniemi A, Tolonen M, Tarasconi A, et al. WSES Guideline for the Management of severe acute pancreatitis. 2019
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• USG has sensitivity and specificity > 95% in detection of gallstones.
• MRCP is useful in identifying CBD stones and delineating pancreatic
and biliary tract anatomy.
• Sensitivity and specificity of MRCP to diagnose biliary obstruction
were 95% and 97%. To detection biliary stones, sensitivity was 92%.
• CT is useful to distinguish between interstitial acute pancreatitis and necrotizing
acute pancreatitis, and to rule out local complication. However, these distinctions
typically occur more than 3-4 days from onset of symptoms (limited use on
admission).
Diagnosis of acute pancreatitis
Shah AP, Mourad MM, Bramhall SR. Acute Pancreatitis: Current Perspectives on Diagnosis and Management. 2018
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Diagnosis of local complication and acute pancreatitis
Local complication that can be recognized on abdominal CT scan:
• Peripancreatic fluid collections, gastrointestinal and biliary complications
(e.q.obstruction)
• Solid organ involvement (e.q. splenic infarct)
• Vascular complications (e.q.pseudoaneurysms, splenic vein thrombosis)
• Pancreatic ascites.
Leppaniemi A, Tolonen M, Tarasconi A, et al. WSES Guideline for the Management of severe acute pancreatitis. 2019
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Leppaniemi A, Tolonen M, Tarasconi A, et al. WSES Guideline for the Management of severe acute pancreatitis. 2019
Diagnosis of local complication and acute pancreatitis
FNA has been established as an accurate, safe & reliable technique for identification of :
• Infected acute peripancreatic fluid collection (APFCS)
• Pancreatic pseudocysts
• ANCS (Acute necrotic collections)
• WOPN (Walled-off pancreatic necrosis)
FNA should not be performed in the absence of a clinically or radiologically suspected infection
• Small necrosis.
• Associated infection into a previously sterile.
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Leppaniemi A, Tolonen M, Tarasconi A, et al. WSES Guideline for the Management of severe acute pancreatitis. 2019
• Laboratory (CRP, Hematocrit, BGA, etc)
• Ranson score
• APACHE II
• BISAP
• SOFA
• Modified Marshal score.
• …
Assessment of severity
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Level serum CRP above 14 286 nmol/L (150 mg/dL) at
48 hours help discriminate severe
from mild disease.
At 48 hours, serum CRP level above 14 286 nmol/dL (150 mg/dL)
have sensitivity, specificity, positive predictive value and negative
predictive value of 80%, 76%, 67%, and 8%, respectively, for severe
acute pancreatitis.
Level serum CRP > 17 143 nmol/dL (180 mg/dL) with in first
72 hours have been correlated with the
presence of necrosis (sensitivity and specificity both > 80
APACHE II scores at admission and during 72
hours < 8 (mortality < 4%).
APACHE II score within first 24 hours
had positive predictive value of 43% and negative predictive
value of 86% for severe acute pancreatitis.
APACHE II score ≧ 8 (mortality 11-18%).
If APACHE II score decreases within the first 48 hours strongly
predicts mild acute pancreatitis, if increases within the first 48 hours
strongly predict severe acute pancreatitis.
Assessment of severity
Shah AP, Mourad MM, Bramhall SR. Acute Pancreatitis: Current Perspectives on Diagnosis and Management. 2018
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Ranson score was found to be poor predictor of severity in a meta-analysis of 110 studies
A diagnosis of severe acute pancreatitis should also made if a patient exhibits signs of persistent
organ failure for more than 48 hours despite adequate iv fluid resuscitation (Revision Atlanta
Classification).
Transient organ failure (resolving in 48 h) : mortality was 1%.
Transient organ failure + local complication :
mortality was 29%
Persistent organ failure (lasting >48 h) :
mortality was 35%
Persistent organ failure + local complication :
mortality was 77%
Assessment of severity
Leppaniemi A, Tolonen M, Tarasconi A, et al. WSES Guideline for the Management of severe acute pancreatitis. 2019
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Leppaniemi A, Tolonen M, Tarasconi A, et al. WSES Guideline for the Management of severe acute pancreatitis. 2019
Management
Risk Factors Assessment
Monitoring Response to Initial Therapy
Clinical Risk Classification
Acute Pancreatitis Approach I G E T S M A S H E D
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Leppaniemi A, Tolonen M, Tarasconi A, et al. WSES Guideline for the Management of severe acute pancreatitis. 2019
• Mild to Moderate.
• No doubt.
• Severe.
• Organ failure or infectious local
complication.
• Critical.
• Organ failure and infectious local
complication
Clinical risk classification Monitoring initial treatment
• Global monitoring assessment.
• GCS, VS, UO
• Organ monitoring assessment.
• Organ function
• Cell monitoring assessment.
• Lactate, BE
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Leppaniemi A, Tolonen M, Tarasconi A, et al. WSES Guideline for the Management of severe acute pancreatitis. 2019
• Fluid resuscitation.
• Lose in third space.
• Intravascular pressure.
• Intraabdominal pressure (IAP).
• Pain.
• Nutrition support.
• Fasting.
• Oral/enteral feeding
• Parenteral.
Management
• Metabolic complication.
• Antibiotic rules.
• Monitoring and assessment.
• ERCP role.
• Early vs delay ERCP (cholecystectomy)
• One vs two stage.
• Surgery rule.
• Minimally invasive.
• Open surgery (stage laparotomy)
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Leppaniemi A, Tolonen M, Tarasconi A, et al. WSES Guideline for the Management of severe acute pancreatitis. 2019
• Fluid resuscitation.
• Lose in third space.
• Intravascular pressure.
• Intraabdominal pressure (IAP).
• Pain.
• Nutrition support.
• Fasting.
• Oral/enteral feeding
• Parenteral.
Management
• Metabolic complication.
• Antibiotic rules.
• Monitoring and assessment.
• ERCP role.
• Early vs delay ERCP (cholecystectomy)
• One vs two stage.
• Surgery rule.
• Minimally invasive.
• Open surgery (stage laparotomy)
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Supportive care
• Resuscitation with RL. After 24 hours of resuscitation there was an 84% reduction in
the incidence of SIRS and significant reduction in CRP from 9905 nmol/L (104 mg/dL to
5143 nmol/L (54 mg/dL) over normal saline.
• Necrotizing acute pancreatitis developed in all patients who received inadequate fluid
replacement as measured by a rise in hematocrit at 24 hours.
• Pain control is an important part of the supportive management of patients with
pancreatitis. Multi modal analgesic regimen is recommended, including narcotics,
NSAID and acetaminophen.
Management
Leppaniemi A, Tolonen M, Tarasconi A, et al. WSES Guideline for the Management of severe acute pancreatitis. 2019
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Nutrition
• Current recommendation from 32 RCTs is to commence oral feeding
• Serial RCT shown that early oral/enteral feeding in patients with acute pancreatitis is
not associated adverse effect and may be associated with substantial decreases in
pain, opiod usage and food intolerance.
• Current recommendation from 32 RCTs is to commence oral feeding
at time of admission if tolerated or within the first 24 hours.
• Oral feeding on admission for mild acute pancreatitis significant decrease in LOS
from 6 to 4 days compared with holding oral food and fluid (Eckerwall et al).
Management
Leppaniemi A, Tolonen M, Tarasconi A, et al. WSES Guideline for the Management of severe acute pancreatitis. 2019
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Nutrition
• Low fat diet was shown to be preferable to clear fluids on admission for mild acute
pancreatitis owing to higher caloric intake with no associated adverse effects.
• There is no evidence to suggest that a low fat diet is preferable to a regular diet.
• Meta-analysis 8 RCT (348 patients) EN vs TPN for acute pancreatitis showed reduced
mortality (RR 0.5), multiorgan failure (RR 0.55), systemic infection (RR 0.39), operative
intervention (RR 0.44), local septic complication (RR 0.74), complication (RR 0.74)
Management
Shah AP, Mourad MM, Bramhall SR. Acute Pancreatitis: Current Perspectives on Diagnosis and Management. 2018
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Prophylactic antibiotic
• 7 RCT (404 patients) comparing prophylactic antibiotic vs placebo in CT proven
necrotizing acute pancreatitis : no statistically significant reduction of mortality
with therapy (8.4% vs 14.4%), no significant reduction in infection rates of
pancreatic necrosis (19.7% vs 24.4 %). Non pancreatic infection rates (23.7% vs
36%), overall infection (37.5% vs 51.9%).
• Overuse of antibiotics is associated with the increase risk of antibiotic-associated
diarrhea and Clostridium difficile colitis
Management
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Most patients with sterile necrosis
• response to conservative medical management.
Patients with sterile necrosis, there have been several retrospective reports suggesting that :
• a delay in surgical necrosectomy and at times a total avoidance of surgery
results in less morbidity and mortality than early surgical debridement.
When sterile necrosis is debrided surgically
• a common sequel is the development of infected and the need for additional
surgery. Leppaniemi A, Tolonen M, Tarasconi A, et al. WSES Guideline for the Management of severe acute pancreatitis. 2019
Management of local complication acute pancreatitis
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Management of local complication acute pancreatitis
In RCT, that compared early to late surgery in small number of patients with sterile necrosis :
• there was a trend toward greater mortality among those operated within the
first 3 days after admission.
Antibiotics should be prescribed only in patients with infected necrosis
• confirmed by FNA or if there is gas within a collection visualized on CT scan.
Antimicrobial therapy should be tailored to FNA culture speciation and sensitiveties.
Leppaniemi A, Tolonen M, Tarasconi A, et al. WSES Guideline for the Management of severe acute pancreatitis. 2019
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Management of local complication and acute pancreatitis
The most commonly isolated bacteria from pancreatic necrosis :
• E.coli, Enterobacter cloacae, Enterococcus faecalis, Bacteriodes fragilis.
The mortality of patients with infected pancreatic necrosis is higher than 30%, and up to 80% of fatal outcomes in patients with acute pancreatitis
• due to septic complication resulting from pancreatic infection.
Leppaniemi A, Tolonen M, Tarasconi A, et al. WSES Guideline for the Management of severe acute pancreatitis. 2019
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Management of local complication and acute pancreatitis
Recommedation empiric antimicrobial therapy :
• Imipenem and ertapenem have both been shown to penetrate pancreatic
tissue and pancreatic fluid at levels exceeding the minimum inhibitory
concentration (MIC) for the most commonly seen bacteria after as little as a
single iv dose.
The other empiric antimicrobial therapy
• Moxifloxacin (dose > 400 mg).
Leppaniemi A, Tolonen M, Tarasconi A, et al. WSES Guideline for the Management of severe acute pancreatitis. 2019
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Management of local complication and acute pancreatitis
The NOM of infected pancreatic necrosis associated with MOF has a mortality
• Mortality is up to 100%. Surgical treatment of patients with infected pancreatic necrosis is associated with mortality
• as low as 10-30% in some specialized centres.
Patients with confirmed or suspected infected necrosis :
• Open necrosectomy
• Percutaneous drainage.
• Minimally invasive retroperitoneal necrosectomy. Surgical Infections. Volume 16, Number 1, 2015
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ERCP should be performed early (within 24-48 h) in patients with
acute gallstone pancreatitis
associated with bile duct obstruction or
cholangitis.
in unstable patients percutaneous
transhepatic gallbladder drainage if ERCP is not
feasible.
Cholecystectomy performed during the
index admission in patient who have mild
acute pancreatitis
patient who have severe acute pancreatitis ,
cholecystectomy delayed until clinical resolution.
If cholecystectomy is contraindicated in
patients because of medical comorbidities :
ERCP and sphincterectomy should be considered prior to
discharge in patient with acute gall stone pancreatitis.
Management of patient with acute gallstone pancreatitis
Surgical Infections. Volume 16, Number 1, 2015
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Case 1
• A 39 yo male with a history of gallstones 1 year ago, came to the emergency room
complaining of epigastric abdominal pain for the past 2 days.
• He describes the pain as constant and radiating to his back.
• He also complains of nausea and has vomited several times.
• His vital signs are BP 90/60 mm Hg, HR 110 x/mnt, resp. 24x/mnt, temp. 39°C.
• Physical exam reveals abdominal distension and diffuse tenderness to palpation,
worse over the epigastrium, but no guarding or rigidity.
• He is jaundiced and has no Grey-Turner or Cullen signs.
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Laboratory (on admission) • HB 11 gr%
• Ht 33%
• WBC count of 16,400 cells/cm3
• Serum glucose 230 mg/dL
• Lipase 8,200 U/L,
• amylase 5,800 U/L
• AST of 124 IU/L
• ALT of 119 IU/L).
• LDH 411 IU/L
• CRP 160 ml/dl.
• AFP 320 U/L
• Total billirubin 3,4 mg/dl, direct bill 2,2 mg/dl
• Creatinine 2,4 mg/dl, ureum 59 mg/dl.
• BGA: pH 7.31, PaO2 of 72 mm Hg, BE -6.
RAC
• Clinical sign and symptom.
• Laboratory result.
• CT scan, USG?, MRCP?
Risk factor classification.
Severity classification.
• ?
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A contrast-enhanced CT scan of the abdomen and pelvis:
• Stranding, inflammation, and edema within the peripancreatic
area and extending inferiorly along the paracolic until tail of the
pancreas.
• Necrosis and represents approximately 10% of the pancreatic
parenchyma.
• There was no free air.
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Treatment
• Initial assessment and resuscitation.
• Monitoring initial treatment 48 hours.
• Success
• Fail
• Nutrition?
• AB?
• Repeated Ct scan?
• Rule of ERCP?
• Rule of surgery?
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• A 39 yo male came to the
emergency room complaining of
abdominal pain after stab wound
accident 1 hour before.
• Primary survey: Airway, Breathing,
and Disability were clear but
Circulation not clear.
• Secundary survey: ‘klitih accident’
one hour before.
Case 2
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• USG: free fluid collection in the hepatorenal, splenorenal, and
perivesical spaces.
• Operation report:
• Laceration of pancreatic body grade II
• Rupture of the liver grade II
• Rupture of gastroduodenal artery
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• Postoperative:
o Drain seroushemorragic 100 cc a day and increase day by day.
• Second look for source and infection control.
o Deep SSI
o Fibrin and pancreatic juice (caseous).
o Open wound and VAC treatment.
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Conclusion
• Acute pancreatitis is an inflammatory condition of the pancreas, auto digestion of
pancreatic substance.
• Misdiagnosis may happen anywhere and anytime.
• The success factors of management are risk classification, specific stage of acute
pancreatitis, and monitoring initial assessment, that do comprehensive and
multidiscipline approach team.
• Surgical management is a challenge to necrotizing pancreatitis increase morbidity and
mortality.
o Appropriate in infectious local complication.
o Persistent systemic organ failure involvement.
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TERIMA KASIH
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Leppaniemi A, Tolonen M, Tarasconi A, et al. WSES Guideline for the Management of severe acute pancreatitis. 2019
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Leppaniemi A, Tolonen M, Tarasconi A, et al. WSES Guideline for the Management of severe acute pancreatitis. 2019