Approach to pancreatitis

1. Acute pancreatitis
Dr. Ronak Raheja

2. Etiology of acute pancreatitis
-we need to know the causes first
1.MECHANICAL AMPULLARY OBSTRUCTION-
Gallstones
Biliary sludge and microlithiasis
2.ALCOHOL
3.SMOKING- by itself.
4.HYPERTRIGLYCERIDEMIA- (>1000)
5.POST-ERCP
6.HYPERCALCEMIA
7.GENETIC MUTATIONS-(CFTR)
8.DRUGS
9.INFECTIONS AND TOXINS
10.TRAUMA
11.PANCREAS DIVISUM
12.VASCULAR DISEASE
13.PREGNANCY
14.IDIOPATHIC

3. INFECTIOUS CAUSES
INFECTIONS AND TOXINS — Pancreatitis has been associated with
the following infections, although the frequency with which these
infections lead to pancreatitis is unknown .
●Viruses – Mumps, coxsackievirus, hepatitis B, cytomegalovirus,
varicella-zoster, herpes simplex, HIV
●Bacteria – Mycoplasma, Legionella, Leptospira, Salmonella
●Fungi – Aspergillus
●Parasites – Toxoplasma, Cryptosporidium, Ascaris
Drugs are shown in the next table .

5. Diagnosis step by step from American College of
Gastroenterology Guidelines
Step 1 - Two of the three following criteria:
(i) abdominal pain consistent with the disease
(ii) serum amylase and / or lipase greater than three times the upper limit of
normal, and / or
(iii) characteristic findings from abdominal imaging (strong recommendation,
moderate quality of evidence).
Step 2 - Transabdominal ultrasound should be performed in all patients with
AP (strong recommendation, low quality of evidence).
Step 3 - In the absence of gallstones and / or history of significant history of
alcohol use, a serum triglyceride should be obtained and considered the
etiology if > 1,000 mg / dl. (conditional recommendation, moderate quality
of evidence).
Step 4 -consider Drugs / rare idopathic causes / infectious causes

6. Step 5 -Contrast-enhanced computed tomographic (CECT) and / or magnetic
resonance imaging (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 (strong recommendation, low quality of evidence).
STEP 6 - Endoscopic investigation of an hidden etiology in patients with AP should
be limited, as the risks and benefits of investigation in these patients are unclear
(conditional recommendation, low quality of evidence).
Step 7) In a patient > 40 years old with red flags , a pancreatic tumor should be
considered as a possible cause of AP (conditional recommendation, low quality of
evidence).
Step 8) Patients with idiopathic AP (IAP) should be referred to centers of expertise
(conditional recommendation, low quality of evidence).
Step 9 ) Genetic testing may be considered in young patients ( < 30 years old) if no
cause is evident and a family history of pancreatic disease is present (conditional
recommendation, low quality of evidence).
Step 10 ) We do not routinely perform sphincter of Oddi manometry, but consider it
only when the etiology is not identified on EUS in patients with recurrent attacks.

7. CLINICAL PRESENTATION
The majority of patients with acute pancreatitis have acute onset of
severe upper abdominal pain,nausea and vomiting
Patients with severe acute pancreatitis may have fever, tachypnea,
tachycardia, hypoxemia, and hypotension.
Approximately 85 percent of patients with acute pancreatitis have
acute interstitial edematous pancreatitis characterized by an
enlargement of the pancreas due to inflammatory edema.
Approximately 15 percent of patients have necrotizing pancreatitis
with necrosis of the pancreatic parenchyma, the peripancreatic
tissue, or both

8. CLASSIFICATION — Acute pancreatitis is divided into the following:
●Mild acute pancreatitis, which is characterized by the absence
of organ failure and local or systemic complications
●Moderately severe acute pancreatitis, which is characterized by
transient organ failure (resolves within 48 hours) and/or local or
systemic complications without persistent organ failure (>48 hours)
●Severe acute pancreatitis, which is characterized by persistent
organ failure that may involve one or multiple organs

9. Initial assessment and risk stratification
First - Assess for early fluid losses, organ failure.
Second - measurement of the APACHE II score and Sirs score.
Third - measurement of amylase and lipase is not useful to predict disease
severity, prognosis, or for altering management.

10. Indications for monitored or intensive care
1)All Patients with severe acute pancreatitis.
2)Patients with acute pancreatitis Presenting with -
Pulse <40 or >150 beats/minute
•Systolic arterial pressure <80 mmHg or mean arterial pressure <60
mmHg or diastolic arterial pressure >120 mmHg
•Respiratory rate >35 breaths/minute
•Serum sodium <110 mmol/L or >170 mmol/L
•Serum potassium <2.0 mmol/L or >7.0 mmol/L
•PaO2 <50 mmHg •pH <7.1 or >7.7 •Serum glucose >800 mg/dL
•Serum calcium >15 mg/dL •Anuria •Coma ( by glasgow scale)

11. If admitted to wards then when should we shift to ICU
APACHE II score >8 in the first 24 hours of admission
●Persistent (>48 hours) SIRS
●Elevated hematocrit (>44 percent), blood urea nitrogen (BUN) (>20
mg/dL), or creatinine (>1.8 mg/dL)
●Age >60 years
●Underlying cardiac or pulmonary disease, obesity

12. INITIAL MANAGEMENT
● Fluid replacement
● Pain control
● Monitoring
● Nutrition
○ - Oral
○ - Non-oral enteral
○ - Parenteral
● Antibiotics
● Other

13. MANAGEMENT OF COMPLICATIONS
● Local complications
○ - Acute peripancreatic fluid collection
○ - Pancreatic pseudocyst
○ - Acute necrotic collection and walled-off necrosis
● Peripancreatic vascular complications
○ - Splanchnic venous thrombosis
○ - Pseudoaneurysm
● Abdominal compartment syndrome
● Systemic complications

14. MANAGEMENT OF UNDERLYING PREDISPOSING CONDITIONS
● Gallstone pancreatitis
○ - Endoscopic retrograde cholangiopancreatography
○ - Cholecystectomy
● Biliary sludge
● Hypertriglyceridemia
● Hypercalcemia

15. ● Fluid replacement
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 comorbidities exist. Early aggressive
intravenous hydration is most beneficial the first 12 – 24 h, and may
have little benefit beyond (strong recommendation, moderate quality
of evidence).
1. In rare patients with acute pancreatitis due to hypercalcemia,
lactated Ringer's is contraindicated because it contains 3 mEq/L
calcium.
1. The rate of fluid resuscitation should be adjusted based on clinical
assessment, hematocrit and blood urea nitrogen (BUN) values
1. Monitoring the BUN may be particularly important, as both the BUN at
the time of admission and the change in BUN during the first 24 hours
of hospitalization predict mortality

16. ● Fluid replacement
5. It is important to note that a low urine output may reflect the
development of acute tubular necrosis rather than persistent volume
depletion.
5. Persistent hemoconcentration at 24 hours has been associated with
development of necrotizing pancreatitis, The goal of aggressive
hydration should be to decrease the blood urea nitrogen (strong
recommendation, moderate quality of evidence).
5. It is important to limit fluid resuscitation mainly to the first 24 to 48
hours after 48 hours may not be advisable as overly-vigorous fluid
resuscitation is associated with an increased need for intubation and
increased risk of abdominal compartment syndrome.

17. ● Pain control
● Opioids are safe and effective at providing pain control in patients
with acute pancreatitis
● Hydromorphone or fentanyl (intravenous) may be used for pain
relief in acute pancreatitis.
● Fentanyl is being increasingly used due to its better safety profile,
especially in renal impairment.
● Meperidine has been favored over morphine for analgesia as
morphine caused an increase in sphincter of Oddi pressure

18. ● Monitoring
● Vital signs -Abg needed if spo2 is below 90 .Hypoxia may be due
to splinting, atelectasis, pleural effusions, opening of
intrapulmonary shunts, or acute respiratory distress syndrome
(ARDS)
● Urine output should be measured hourly should be above 50 ml
per hour atleast
● Electrolytes should be monitored- especially calcium
● Serum glucose levels should be monitored hourly in patients with
severe pancreatitis and hyperglycemia.
● Patients in the intensive care unit should be monitored for potential
abdominal compartment syndrome with serial measures of urinary
bladder pressures

19. ● Nutrition
● In mild AP, oral feedings can be started immediately if there is no
nausea and vomiting, and abdominal pain has resolved (conditional
recommendation, moderate quality of evidence).
● In mild AP, initiation of feeding with a low-fat solid diet appears as
safe as a clear liquid diet (conditional recommendations, moderate
quality of evidence).
● 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 (strong recommendation, high quality of evidence).
● Nasogastric delivery and nasojejunal delivery of enteral feeding
appear comparable in efficacy and safety (strong recommendation,
moderate quality of evidence).

20. ● Antibiotics
1. Antibiotics should be given for an extrapancreatic infection, such as
cholangitis, catheter-acquired infections, bacteremia, urinary tract
infections, pneumonia (strong recommendation, high quality of
evidence).If we suspect we can give antibiotics until blood culture
reports come back .
1. Routine use of prophylactic antibiotics in patients with severe acute
pancreatitis is not recommended (strong recommendation, moderate
quality of evidence).
1. The use of antibiotics in patients with sterile necrosis to prevent the
development of infected necrosis is not recommended (strong
recommendation, moderate quality of evidence).

21. Infected necrosis
1. Infected necrosis should be considered in patients with pancreatic or
extrapancreatic necrosis who deteriorate or fail to improve after 7 – 10
days of hospitalization.
2. In these patients, either (i) initial CT-guided fine needle aspiration
(FNA) for Gram stain and culture to guide use of appropriate
antibiotics or (ii) empiric use of antibiotics without CT FNA should be
given (strong recommendation, low quality of evidence).
3. 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
(conditional recommendation, low quality of evidence).
4. Routine administration of antifungal agents along with prophylactic
or therapeutic antibiotics is not recommended (conditional
recommendation, low quality of evidence).

22. MANAGEMENT OF UNDERLYING PREDISPOSING CONDITIONS
Gallstone pancreatitis-In patients with gallstone pancreatitis, most
stones pass into the duodenum. However, in a small proportion of
patients, obstructive stones in the biliary tract or ampulla of Vater
can cause persistent biliary and pancreatic duct obstruction leading
to acute pancreatitis and cholangitis.
Endoscopic retrograde cholangiopancreatography — Endoscopic
retrograde cholangiopancreatography (ERCP) should be performed
early in the course (within 24 hours of admission) for patients with
gallstone pancreatitis and cholangitis
Indications for EUS/MRCP prior to ERCP –
•Persistent elevation of liver tests and/or dilation of common bile
duct without overt cholangitis
•Pregnant patients
•Altered anatomy that would make an ERCP technically challenging

23. Endoscopic retrograde cholangiopancreatography
● indications for ERCP -Common bile duct obstruction (visible stone on
imaging)
● dilated common bile duct
● increasing liver tests without cholangitis.
● In the absence of common bile duct obstruction, ERCP is not
indicated for (mild or severe) gallstone pancreatitis without
cholangitis.
● If we are in doubt - then -repeat liver function tests or do mr
cholangiography or eus .
● In patients with gallstone pancreatitis and persistent obstruction
without cholangitis, although an ERCP may be needed, urgent ERCP is
controversial

24. Cholecystectomy
● Cholecystectomy should be performed after recovery in all patients
with gallstone pancreatitis including those who have undergone an
endoscopic sphincterotomy
● In patients who have had mild pancreatitis, cholecystectomy can
usually be performed safely within seven days after recovery and in
the same index hospitalization
● In patients who have had severe necrotizing pancreatitis,
cholecystectomy should be delayed until active inflammation
subsides and fluid collections resolve or stabilize
● Failure to perform a cholecystectomy is associated with a 25 to 30
percent risk of recurrent acute pancreatitis, cholecystitis, or
cholangitis within 6 to 18 weeks
● The risk of recurrent pancreatitis is highest in patients who have not
undergone a sphincterotomy.

25. Biliary sludge
● biliary sludge is commonly found in 20 to 40 percent of patients with
acute pancreatitis with no other obvious cause
● On ultrasound, sludge appears as a mobile, low-amplitude echo that
layers in the most dependent part of the gallbladder and is not
associated with shadowing.
● Cholecystectomy should be performed in patients who have had an
episode of pancreatitis and have biliary sludge
● A total of five patients needed to be treated to prevent one episode of
what was thought to be idiopathic acute pancreatitis.
● Biliary stones or sludge were detected during surgery in 59 percent of
patients with acute pancreatitis who underwent cholecystectomy.

26. local or systemic complications
Local complications of acute pancreatitis include
1)acute peripancreatic fluid collection,
2) pancreatic pseudocyst,
3)acute necrotic collection (ANC),
4)walled-off necrosis (WON) .
While acute peripancreatic fluid collections and acute necrotic collections
may develop less than four weeks after the onset of pancreatitis, pancreatic
pseudocyst and walled-off necrosis usually occur more than four weeks
after the onset of acute pancreatitis.

27. Infections
Both ANC and WON are initially sterile but may become infected.
● The occurrence of pancreatic infection is a leading cause of
morbidity and mortality in acute necrotizing pancreatitis.
● Infected necrosis should be suspected in patients with pancreatic
or extrapancreatic necrosis who deteriorate (clinical instability or
sepsis physiology, increasing white blood cell count, fevers) or fail
to improve after 7 to 10 days of hospitalization.
● In patients with suspected infected necrosis, we suggest empiric
antibiotics rather than CT-guided fine needle aspiration

28. What if conservative management fails ? Do we fail too ?
● In patients with infected necrosis who fail to respond to antibiotics
or who are clinically unstable, we recommend pancreatic
debridement rather than continued conservative management .
● Where possible we attempt to delay intervention until four weeks
after initial presentation to allow the infected necrosis to become
walled off.
● We perform necrosectomy with minimally invasive methods and
reserve open surgical debridement for patients who are clinically
unstable or if minimally invasive debridement is not possible or
fails.

29. Thank you