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Acute Pancreatitis

Department of Critical Care Medicine

King Saud Medical City

Riyadh, Saudi Arabia

Muhammad Asim RanaMBBS, MRCP, SF-CCM, EDIC, FCCP


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Learning Objectives

Diagnose acute pancreatitis and determine the severity, etiological factors and

complications. Recognize the patient at risk.

Manage severe acute pancreatitis with appropriate use of supportive therapy for

organ function, antibiotics and surgery.

Feed the patient with acute pancreatitis. Determine nutritional needs of patientswith acute pancreatitis and the optimum mode of delivery.

Identify and manage local and systemic complications of acute pancreatitis

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INTRODUCTION

1. Reported incidence ranges from 21 to 900 cases per million, per year.

2. Overall mortality rate ranges from 2 to 10% but reaches 10 to 40% in ANP.

3. Those > 60 years are at the highest risk of death as consequence of co morbidity.

The male/female ratio ranges from 1/1.2 - 1/1.5. Females for biliary pancreatitis &

males for acute pancreatitis secondary to alcohol abuse.

Epidemiology of acute pancreatitis

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GALLSTONES

ETHAN

OL

TRAUMA

STERO

IDS

MUMPS/VIRUSES

AUTOIMMU

NE(PAN)

SCORPIONVEN

OM/Toxins

HYPERLIPIDEMIA

ERCP

DRUG

S

G E T S M

A S

H E D

Causes of Acute Pancreatitis


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Diagnosis of acute pancreatitis

Symptoms Signs

Grey Turners sign

Cullens Sign


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Radiological Investigations

Plain X-Ray Ultrasound

CT Scan MRI

Pancreatitis without pain is particularly misleading. Lack of a major symptom isusually attributed to a postoperative situation where analgesics/sedatives are in use.

Diagnostic pitfalls

Diabetic comasevere hypothermia remote organ failuresSevere GI bleeding


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Pancreatic swelling

Lack of enhancement

Peri-pancreatic fluid

collection

Diagnostic Imaging


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How to recognize the at risk patient

SystemManifestations Significance

General

CVSPulmonary

RenalNeurological

Abdominal

Age > 60BMI > 30 Kg/m2

Risk of local & systemiccomplications

BP, HR,Lactate

Tachypnea, Cyanosis

OUT PUTCreatinine

ConfusionAgitation

Tense abdomenRebound Tenderness

Risk of local & systemic

complicationsImpending remote organ

failure

Impending remote organ

failureImpending remote organ

failure

Extent of peritonealinvolvement


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Definition of severe pancreatitis

Acute pancreatitis + organ failure and/or

Acute pancreatitis + local complications

Three or more Ranson Criteria OR

APACHE II > 8


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Early assessment of severity

Ransonscriteria

ON Admission After 48 hours

G A L A WGlucose > 200 mg%

Age > 55 yrs

LDH > 350

AST > 250

WBCs > 16000

C H O B B SCalcium < 8.0

Haematocrit by > 10%

PaO2 < 60

Base Excess > 4

BUN > 5 mg%

Sequestered fluid > 6 liters


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Glasgow (Imrie) scoring system

P A N C R E A S

PaO2 < 8kPa

Age > 55yrs

Neutrophils (WBCs)> 15x 109 / L

Calcium < 8mg% (2mmol)

Renal Urea > 16 mmol/L (45 mg/dL)

Enzymes LDH > 600 iU/L, AST > 200iU/L

Albumin < 32 G /L

Sugar (Blood Glucose)> 10 mmol /L (180mg%)


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Grading based upon findings on unenhanced CT

Grade Findings Score

A Normal pancreas - normal size, sharply defined, smoothcontour, homogeneous enhancement, retroperitonealperipancreatic fat without enhancement

0

B Focal or diffuse enlargement of the pancreas, contour mayshow irregularity, enhancement may be inhomogeneous butthere is on peripancreatic inflammation 1

C Peripancreatic inflammation with intrinsicpancreatic abnormalities

2

DIntrapancreatic or extrapancreatic fluid collections 3

ETwo or more large collections of gas in the

pancreas or retroperitoneum 4


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Necrosis, percent SCORE

00

Less than 33% 2

33-50% 4

More than 50% 6

Necrosis score based upon contrast enhanced CT


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AGA Guidelines for CT Scan

Patients in whom the diagnosis is in doubt.

Patients with Ranson >3 or APACHE II 8

In patients with predicted severe disease

and those with evidence of organ failure during the

initial 72 hours, rapid-bolus CT should be performed

after 72 hours of illness to assess the degree ofpancreatic necrosis.

Labs adjunct to clinical judgment and the APACHE II .

A CRP level of >150 mg/L at 48 hours is preferred


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Other Severity Indices

The APACHE II score

Systemic inflammatory response syndrome score

Bedside index of severity in acute pancreatitis (BISAP) score

Harmless acute pancreatitis score

Organ failure-based scores


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Management of Severe Acute Pancreatitis

General Intensive Care

Specific Treatment Modalities

Surgery or No Surgery

Feeding the patient

Managing the Complications


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General intensive care

Supportive therapy of vital organs

Cardiovascular systemNowadays infection of

pancreatic necrosisaccounts for 50-80% of the

deaths

Splanchnic ischaemia is a 2ndlocal hit:Retroperitoneal necrosis, gut

barrier dysfunction, andSecondary pancreatic infectionmay ensue

Local splanchnic perfusion may beworsened by abdominalcompartment syndrome-increased pressure due to intra

abdominal oedema, fluidsequestration and excessive fluidresuscitation.

Respiratory system Prevention/correction of hypoxia.Early physiotherapy and adequate analgesia (perhaps using epiduralanalgesia) to ensure free airways and to prevent atelectasis, preventpulmonary aspiration by nasogastric decompression.

CPAP/ BIPAP/ Invasive Mechanical Ventilation

Renal system Prevent and/or minimize renal injury byrapid correction of hypovolaemia

If acute renal failure develops, start renal replacement therapywithout delay to ensure optimal fluid and metabolic control andto enable nutritional support without haemodynamic instability.CVVHD is preferred.

Gastrointestinal system

Beware of intra-abdominal

hypertension and assess the patientfor this complication regularly.

If abdominal compartment syndrome occurs, consider decompression eithersurgically or in cases of colonic distension with a wide bore tube inserted viathe rectum. Abdominal compartment syndrome should be suspected

whenever there is evidence of new or worsening organ dysfunction.

Pain relief

Conventional Analgesics (IV)Use of MORPHINE

Epidural Analgesia( mixture of dilutedlocal anaesthetic solution(bupivacaine) and opiates)Miscellaneous

Octreotide

SomatostatinProtease Inhibitors

(Aprotinin & Gabexate Mesilate)

Anti inflammatory Rx

Stress Ulcer Prophylaxis

DVT Prophylaxis


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Specific therapeutic modalities

Antibiotics

Systemic Antibiotics

Use antibiotics on demand for sepsis rather than

prophylactically!

Selective Decontamination of

the Digestive system (SDD)

Antibiotics are an adjuvant therapy in infected pancreatic necrosis.

Drainage is mandatory for most if not all pancreatic infections.


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Indications for surgery

Controversial indicationsUndisputed indications

Infected pancreatic necrosis when

percutaneous/other techniques not indicatedSevere retroperitoneal haemorrhage

Acute abdomen peritonitisBiliary obstruction in case of failure of

Endoscopic SphincterotomyAbdominal compartment syndrome wherepercutaneous/other drainage techniques notsuccessful.

Controversial indications

Extensive (>50%) sterile pancreatic necrosis

Early routine debridement of necrosis

irrespective of its bacteriological status in

order to prevent remote organ dysfunctionand pancreatic infection

Persisting multiple organ failure despite intensive care therapy

Early and repeated removal of necrotic tissue combinedwith continuous drainage/lavage have been advocated to

overcome systemic effects.

Neither the extent of sterile pancreatic necrosis, the

clinical severity of the disease or the duration of

intensive supportive therapy should be regarded asindications for surgery.

NOTE


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Feeding the pt of SAP

Nutritional therapy: How, what and when?

Route of nutrient delivery:Enteral versus parenteral

The more distally thatnutrients are infused inthe gut, the less they

stimulate pancreatic

secretion

The enteral route is safein acute pancreatitis, so

whenever possible,

use it!

In order to maximise clinical benefit, enteralfeeding should be initiated as soon as possibleafter admission in all attacks predicted to besevere.Patients in whom enteral access cannot beachieved or in whom clear-cut contraindications

(intestinal rupture, obstruction, or necrosis),intolerance, or exacerbation of the diseaseoccurs should be considered for partial or total

parenteral nutrition (TPN).


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Some Important Aspects of Feeding

Composition of the diet

Prescription and timing of nutrient administration

Issue of Functional Ileus

Oral refeedingComplications of nutritional therapy


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Resuscitation

Severity Index

Severe Disease Mild Disease

Conservative RxCT Scan

Balthazar > 7

Balthazar < 7

Management of Severe Acute Pancreatitis


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Balthazar > 7

Aggressive Hydration/ Antibiotics/ Entral feeding/ TPN

No Improvement Improvement

Continue Same Rx

CT Guided Aspiration Deterioration


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CT Guided Aspiration

Infected Sterile

Supportive Rx

Appropriate AntibioticsAttempt to wait for 3-4

weeks from onset

NO IMPROVEMENT ?


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NO IMPROVEMENT ?

Organized Collection Diffuse Collection

Percutaneous/ Endoscopic/Laparoscopic drainage

Minimal access or SurgicalDebridement


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Approach to Treat NECROSIS

Fine Needle Aspiration

SterileInfected

AggressiveICU Rx

Improvement

No Improvement

Endoscopic Expertise Available

YESNO

NecrosectomyPercutaneous

Drainage


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Necrosectomy

Necrosis Endoscopically Accessible(posterior gastric or medial

duodenal wall)

Necrosis in peripancreatic,retrodudenal, perinephric

Endoscopic Necrosectomy Laparoscopic Necrosectomy

No ImprovementSurgical Drainage

Adjuvant Percutaneous Drainage


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I think its enough

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