2. 22 years old male
Sudden onset of epigastric pain radiating to back
No significant past history
No drugs, no alcohol, no heavy meals
On examination:
In pain
Pulse 82/min, B.P.120/80
RR: 16/min, no cyanosis
Abdomen: Tenderness +, no guarding, No rigidity,
peristalses +
4. Diagnosis
Amylase and lipase are the cornerstone lab
parameters for the diagnosis.
"It is usually not necessary to measure
both amylase and lipase (3).
5. Diagnosis
Lipase may be preferable
It remains normal in some nonpancreatic
conditions that increase serum amylase including
macroamylasemia, parotitis, and some carcinomas.
Lipase is thought to be more sensitive and specific
and superior to amylase[3, 4, 5]
In one large study, there were no patients with
pancreatitis who had an elevated amylase with a
normal lipase [5].
7. Amylase and Lipase
Higher the numerical value more certain
is the diagnosis.
Although severe pancreatitis could also exist
without significant rise in these enzymes.
Numerical value of these enzymes have no
prognostic value and neither they
reflect severity
8. Diagnosis: Imaging
USG is cornerstone
CT
MR
EUS/ ERCP 100 acute pancreatitis….20% severe= 20
20% of severe become infected= 4
Infection usually sets in 2nd week or 3rd week
Surgeons would want to delay surgery till
about 4 weeks
Infected necrosis will always be clinically
manifest
So why CT scan in first week ????
10. Clinical features useful in
assessing severity
Toxic Look
Severe pain
Persistent tachycardia
Breathlessness and
Cyanosis
Sub-normal
temperature
Shock
Normal look
Mild pain
Normal Pulse rate
Normal Oxygen
saturation
Adequate urine output
Flat and soft and
movable abdomen
11. Bedside index of severity in acute
pancreatitis (BISAP) score
This calculator evaluates the following Clinical Criteria:
BUN >25 mg/dL (8.9 mmol/L)
Impairment of mental status with a Glasgow coma score
<15
SIRS (systemic inflammatory response syndrome)
Age >60 years old
Pleural effusion
Each determinant is given one point
The MedCalc 3000 module Bedside index of severity in acute pancreatitis (BISAP) score is available in MedCalc 3000 Complete Edition.
SIRS is defined as 2 or more of the following variables;
Fever of more than 38°C (100.4°F) or less than 36°C (96.8°F)
Heart rate of more than 90 beats per minute
Respiratory rate of more than 20 breaths per minute or arterial carbon dioxide tension (PaCO2) of less than 32mm Hg
Abnormal white blood cell count (>12,000/µL or < 4,000/µL or >10% immature [band] forms)
13. Comparison of BISAP, Ranson's, APACHE-II, and CTSI scores in
predicting organ failure, complications, and mortality in acute
pancreatitis.
Papachristou GI, Muddana V, Yadav D, O'Connell M, Sanders MK, Slivka A, Whitcomb DC. Am J Gastroenterol. 2010
Feb;105(2):435-41; quiz 442. doi: 10.1038/ajg.2009.622. Epub 2009 Oct 27
CONCLUSIONS:
BISAP score is an accurate means for risk stratification
in patients with AP.
Its components are clinically relevant and easy to
obtain.
The prognostic accuracy of BISAP is similar to those of
the other scoring systems.
14. Determinants of revised Atlanta
classification
Local
Pancreatic or peripancreatic fluid collection
Sterile
Infected
Necrosis
Sterile
Infected
Pseudocyst and walled-off necrosis (sterile or infected).
Organ failure
16. Revised Atlanta......
Acute pancreatitis identified two phases of the disease:
early and late.
Severity is classified as mild, moderate or severe.
Mild:
the most common form,
has no organ failure, local or systemic complications and
usually resolves in the first week.
Moderate:
Presence of transient organ failure, local complications or
exacerbation of co-morbid disease.
Severe:
Persistent organ failure >48 h.
Local complications are peripancreatic fluid collections, pancreatic
and peripancreatic necrosis (sterile or infected),
17. The presence of one determinant can modify the effect
of another such that the presence of both infected
(peri)pancreatic necrosis and persistent organ failure
have a greater effect on severity than either
determinant alone.
The derivation of a classification based on the above
principles results in 4 categories of severity-mild,
moderate, severe, and critical.
18. Acute Pancreatitis: Management
Issue
Fluid replacement
Vigorous hydration to optimize outcomes has been increasingly
recognized.
The ACG guidelines stress, “Patients with evidence of significant
third-space losses require aggressive fluid resuscitation.”
Many patients sequester substantial amounts of fluid into the
retroperitoneal space, producing very high fluid requirements.
Intravascular volume depletion may lead to tachycardia,
hypotension, renal failure, hemoconcentration, and generalized
circulatory collapse.
More than 6 L of fluid sequestration within the first 48 hours is
considered a marker of increased severity, according to the Ranson
criteria
19. Acute Pancreatitis:
Issues:
Antibiotics
Time frame:
Severe pancreatitis can be observed in 15–20 % of all cases.
The first two weeks after onset of symptoms are characterized
by the systemic inflammatory response syndrome
(SIRS).
Pancreatic necrosis develops within the first 4 days after the
onset of symptoms to its full extent,
Infection of pancreatic necrosis develops most
frequently in the 2nd and 3rd week
20. Authors' conclusions:
No benefit of antibiotics in preventing infection of
pancreatic necrosis or mortality was found, except for
when imipenem (a beta‐lactam) was considered on its
own, where a significantly decrease in pancreatic
infection was found.
None of the studies included in this review were
adequately powered. Further better designed studies
are needed if the use of antibiotic prophylaxis is to be
recommended
22. Background facts..
Nutritional management during acute pancreatitis has
• the purpose to avoid a negative influence on the outcome and to
preserve the morphofunctional integrity of the gut,
• preventing bacterial translocation.
• Preventing SIRS
• When the course of the disease is longer and the severity is
higher, an early artificial nutritional support is advisable.
• Caloric needs thought to be useful are 25-30 kcal/kg/d;
• 40-60% of nutrient mixture should consist of carbohydrates and
20-30% of lipids. Proteins should be approximately 1.0-1.5 g/kg/d
McClave SA, Chang WK, Dhaliwal R, Heyland DK. Nutrition support in acute pancreatitis: a
systematic review of the literature. JPEN J Parenter Enteral Nutr. 2006 Mar-Apr;30(2):143-56.
24. Authors' conclusions:
In patients with acute pancreatitis, enteral nutrition
significantly reduced mortality, multiple organ failure,
systemic infections, and the need for operative
interventions compared to those who received TPN.
In addition, there was a trend towards a reduction in
length of hospital stay.
These data suggest that EN should be considered the
standard of care for patients with acute pancreatitis
requiring nutritional support.
25. Nutrition Support in Acute Pancreatitis: A Systematic
Review of the Literature
Stephen A. McClave, Wei-Kuo Chang, Rupinder Dhaliwal, Daren K. Heyland,
JPEN J Parenter Enteral Nutr MARCH-APRIL 2006 vol. 30 no. 2 143-156 doi: 10.1177/0148607106030002143
Patients with acute severe pancreatitis should begin EN
early because such therapy modulates the stress response,
promotes more rapid resolution of the disease process, and
results in better outcome.
In this sense, EN is the preferred route and has eclipsed PN
as the new “gold standard” of nutrition therapy. When PN
is used, it should be initiated after 5 days.
Individual variability allows for a wide range of tolerance to
EN, even in severe pancreatitis
27. Emergency ERCP in AP
In persistent and severe biliary pancreatitis, when an
obstructing gallstone lodged at the ampulla of Vater
28. Any role of early Surgery?
Except in the unusual situation of fulminating acute
pancreatitis with organ failure and a rapidly progressive
downhill course soon after admission to the hospital, most
patients should not undergo operation during the first
week of their illness.
When clinical deterioration is rapid and surgery is
undertaken during the first week, these patients have a
high mortality rate.
The outcome is better when surgery is postponed at least
until the second week or later, when the margins of the
pancreatic necrosis have become better defined, and the
acute inflammation has subsided somewhat.
29. Acute Pancreatitis
Issue: Surgery:
Background facts
More than 80% of deaths amongst patients with acute
pancreatitis are caused by infected necrosis
Aggressive surgical treatment required in such cases
Patients with infected necrosis require emergent
surgery.
30. Common Organisms
Enteric Gram Negative organisms like E.coli
Gram positive organisms
Anaerobes
Fungal Infection is a late event usually following
prolonged antibiotic therapy
Daziel D J. Doolas A. “Pancreatic abscess and pancreatic necrosis: current concepts and controversies.” Problems in
General Surgery, vol 7 (3) pp 415-27. 1990
31. Diagnosis of infected necrosis
Most reliably by CT or ultrasound-guided fine needle
aspiration (FNA) with Gram staining and culture of
the aspirate. The material should be sent for bacterial
and fungal culture.
Some patients with infection have only a low grade
fever and a WBC <15,000. Thus, threshold must be low.
In a minority of patients, gas bubbles are evident on
the CT study in the area of the pancreas. If this is
found, FNA is unnecessary.
32. Surgical indications in acute
pancreatitis.
Haas B, Nathens AB. Curr Opin Crit Care. 2010 Apr;16(2):153-8. doi: 10.1097/MCC.0b013e328336ae88.)
Infected pancreatic necrosis remains the primary indication for
surgery in patients with acute pancreatitis.
Up to a quarter of patients with acute pancreatitis develop early
bacteremia and pneumonia, and assessment of patients for
surgery should include a thorough search for nonpancreatic
sources of infection.
Retroperitoneal, percutaneous and endoscopic approaches to
pancreatic debridement can be used with success in
appropriately selected critically ill patients.
All minimally invasive approaches to necrosectomy are evolving,
and there is currently insufficient evidence to advocate one
approach over another.
Management of patients with acute pancreatitis at high-volume
centers appears to be associated with a survival benefit.
33. Surgery in Acute Pancreatitis: Indications
other than Infected Necrosis.
1. When the patient's condition deteriorates, often with
the failure of one or more organ systems even in
sterile necrosis
2. To drain a pancreatic abscess, if percutaneous
drainage does not produce the desired result.
34. Cholecystectomy in Gall Stone
Pancreatitis
In mild gallstone-associated acute pancreatitis,
cholecystectomy should be performed as soon as the
patient has recovered and ideally during the same
hospital admission.
In severe gallstone-associated acute pancreatitis,
cholecystectomy should be delayed until there is
sufficient resolution of the inflammatory response and
clinical recovery.
35. Summary
Patients with sterile pancreatic necrosis should be managed
conservatively and only undergo intervention in selected cases.
Minimally invasive approach to necrosectomy is expected to
play a significant role in a selected group of patients
Surgical and other forms of interventional management should
favor an organ-preserving approach, which involves debridement
or necrosectomy combined with a postoperative management
concept that maximizes postoperative evacuation of
retroperitoneal debris and exudate.
Cholecystectomy should be performed to avoid recurrence of
gallstone-associated acute pancreatitis.
ES is alternative to cholecystectomy but there is a theoretical risk
of introducing infection into sterile pancreatic necrosis.
36. Other tests
61-80 % of patients show leukocytosis with
shift to the left.
54-82 % lymphopenia is noted.
Anemia
S. Bil, Urea, SGOT,LDH, Sugar, Calcium,
and ABG abnormal
Daily urine examination is helpful. In urine
the proteinuria, a microhematuria, and
casts may be seen.
38. Acute pancreatitis graded with CT and CT severity index
table
Grade CT finding Points Necrosis Severity index
Percentage Additional points A Normal pancreas 0 0 0 0
B Pancreatic enlargement 1 0 0 1 C Pancreatic
inflammation and/or peripancreatic fat 2 < 30 2 4 D Single
peripancreatic fluid collection 3 30-50 4 7 E Two or more
fluid collections and/or retroperitoneal air 4 > 50 6 10
World J Gastroenterol. 2009 June 28; 15(24): 2945–2959.
Published online 2009 June 28. doi: 10.3748/wjg.15.2945.
39. Ranson’s Criteria
At 48 hours
Calcium < 8.0 mg/dL)
Hematocrit fall > 10%
Oxygen (hypoxemia PO2 < 60 mmHg)
BUN increased by 5 or more mg/dL) after IV fluid
hydration
Base deficit (negative base excess) > 4 mEq/L
Sequestration of fluids > 6 L
40. APACHE II score
Hemorrhagic peritoneal fluid
Obesity
Indicators of organ failure
Hypotension (SBP <90 mm HG) or tachycardia >
130 beat/min
PO2 <60 mmHg
Oliguria (<50 mL/h) or increasing BUN and
creatinine
Calcium <8.0 mg/dL or
Albumin <3.2.g/dL)
41. APACHE II score
Apache score of ≥ 8 Organ failure Substantial
pancreatic necrosis (at least 30% glandular
necrosis according to contrast-enhanced CT)
Interpretation If the score ≥ 3, severe pancreatitis
likely. If the score < 3, severe pancreatitis is
unlikely, Or
Score 0 to 2 : 2% mortality Score 3 to 4 : 15%
mortality Score 5 to 6 : 40% mortality Score 7 to 8 :
100% mortality
43. Diagnosis
Computerized tomography (CT) scan.
Positive predictive value, negative predictive value,
sensitivity and specificity as good as USG
More useful for peripancreatic lesion and Necrosis.
44. Diagnosis
Endoscopic ultrasound (EUS):
Excellent Mode
Comparable or superior to both CT and USG
Additional advantage of accurately visualizing Lower
CBD.
Useful for outlining the treatment
45. Diagnosis
MRCP / MRI
Comparable to CT
Use of Gadolinium may increase sensitivity and
specificity
No “contrast” related renal problems
Additional advantage of visualizing Biliary tree
46. Diagnosis of Various Forms of
disease
The acute interstitial pancreatitis is characterized by
rapidity, a relative short duration of disease.
Clinical features usually disappear during 3-7, and
acute pathological changes by 10-14 days.
In most mild cases at an early stage, few of abnormal
signs of disease are observed.
Pain and vomiting are and quickly pass under the
influence of conservative treatment,
The systemic involvement is minimal and metabolic
abnormalities are very few.
50. In this CT scan there is evidence of multiple calcifications and stones in the
parenchyma and dilated pancreatic duct.
51.
52. ENDOSCOPIC ULTRASOUND (EUS): To diagnose
chronic pancreatitis requires the presence of at least
5 criteria of the followings:
53. Endoscopic treatment:
Papillary stenosis: In appropriately selected patients, a
pancreatic duct sphincterotomy will facilitate drainage,
reduce ductal pressures, and may help alleviate pain.
Pancreatic duct strictures: performing a pancreatic
sphincterotomy, dilating the stricture, and placing a stent.
Pancreatic duct stones: Requires a pancreatic duct
sphincterotomy and stricture dilation to enable their
extraction.
54. Surgical treatment:
I-Pancreatic duct drainage: In patients with a dilated
pancreatic duct, pancreaticojejunostomy is indicated.
II-Pancreatic resection: If the disease is limited to the
head of the pancreas, a Whipple operation
(pancreaticoduodenectomy) can produce good
results.
In patients with intractable pain and diffuse disease
with nondilated ducts, a subtotal or total
pancreatectomy can be offered.
55. III-Total pancreatectomy and islet autotransplantation:
In selected patients, the long-term morbidity caused
by diabetes following total pancreatectomy can be
avoided.
This involves harvesting the islets from the resected
pancreas and injecting them into the portal system,
which then lodges them in the liver.
56. IV- Drainage of pseudocyst:
The indications include rapid enlargement,
compression of surrounding structures (duodenal,
biliary obstruction or vascular occlusion), pain, or
signs of infection and abscess formation, suspected
malignancy, hemorrhage and intraperitoneal rupture.
57. SURGERY
Intractable pain
Complications related to adjacent organs
Endoscopically not permanently controlled
pancreatic pseudocysts in conjunction with
ductal pathology
Neither conservatively nor interventionally
tractable internal pancreatic fistula
Inability to exclude pancreatic cancer despite
broad diagnostic work-up
70. STEATORRHEA
Fat maldigestion is the principal clinical problem. It
has been estimated that 30,000 IU of lipase delivered
to the intestine with each meal should be sufficient
to eliminate steatorrhea.
This corresponds to approximately 10% of the normal
pancreatic output of lipase.
The goal of managing steatorrhea is to administer
30,000 IU of lipase in the prandial and postprandial
portions of each meal.
71. If non–enteric-coated preparations are chosen,
concomitant suppression of gastric acid with a
histamine-2 (H2) receptor antagonist or proton pump
inhibitor is necessary
There are several explanations for failure of enzyme
therapy for steatorrhea.
The most common is inadequate dose, generally due
to patient noncompliance with the number of pills
that must be taken.
72. DIABETES MELLITUS
Diabetes mellitus is an independent predictor of
mortality in patients with chronic pancreatitis.
Ketoacidosis is distinctly unusual.
Insulin is often needed and patients with chronic
pancreatitis tend to have lower insulin requirements
than patients with type 1 diabetes mellitus.
Overvigorous attempts at tight control of blood
glucose value are often associated with disastrous
complications of treatment-induced hypoglycemia.
