Webinar at YMCH Medicine dept BY Dr Nikhil Nadkarni

1. MD ,DM (PGI ,Chandigarh)
Advanced fellowship Gastroenterology (Mayo Clinic ,USA)
Associate Director
Department of Gastroenterology & Hepatology
Max Superspecialty Hospital
Mohali,Punjab
India

2. ACUTE PANCREATITIS
FIRST 72 HOURS

3. Learning Objective

4. Diagnosis of acute pancreatitis
Two of the following
1)Abdominal pain consistent with acute pancreatitis
2)Serum lipase/amylase activity ≥3 times ULN
3)Characteristic findings on CECT (less commonly MRI
or USG)
Negative USG does not rule out pancreatitis

5. Examination
• P : > 100 /min
• BP : < 90 mm Hg
• RR : Tachypnea
• Tender in the epigastrium and periumbilicus

6. Mild
Severe

7. Investigations ?
• CBC : Hematocrit ; TLC
• LFT : Raised OT/PT Bilirubin
• Calcium : HypoCa Hyper
• Triglycerides : > 500
• RFT : Renal dysfunction
• ABG : pO2; Lactates; Hb
• Amylase and lipase
Only Diagnostic : Though not specific
No prognostication value
No need to follow up with these enzymes
Gall stone ?
Severity Hyperpara

8. AXR
Always look for free air !!

9. USG abdomen
• Gall stones
• CBD
• IHBRD
• Pancreas : obscured by bowel gas

10. CT scan
• Contrast enhanced
• Not required in all cases
• Usually after 72 hours
• At admission only when dilemma in diagnosis
• More useful to rule out other causes

11. Natural course: Summary
Acute
Pancreatitis
Mild Disease (80%)
Week 1………….Week 2…….…..Week 3…………Week4…………
Severe Disease (20%) 1st Phase 2nd Phase
• SIRS
• 40% develop organ
failure
• 30% mortality
• Susceptible to
Infections (2-4
weeks)
• 30% infected necrosis
• 12-39%
mortality

12. Treatment Platter
• Intravenous fluids
• Nutrition
• Antibiotics
• Protease inhibitor : Ulinastatin
• ERCP
• Surgery

13. While investigating…
• 18 G cannula
• Fluid resuscitation

14. IV Fluids
• Ringer Lactate
• Normal Saline
• Dextrose
• Plasmalyte
• Haemaccel

15. Route
• Intravenous
• Enteral

16. Rate of infusion
• 250 ml per hour (5-10 ml /kg/hour)
• Urine output of at least 0.5 mL/kg
• Adjustments :patient’s age, weight, physical
exam, and comorbid conditions
• Aim: decrease in hematocrit or BUN

17. PGI study
• Nasojejunal tube
• 20 ml/kg bolus
• 3 ml/kg/hour
• ORS

18. Management of pain
• Paracetamol
• Nsaids like Diclofenac
• Opiates : Tramadol, Fentanyl, Morphine

19. Nutrition
• Mild pancreatitis
• Once pain free
• Usually D2-D3
• Liquids fb Solids
• Low fat

20. • Severe Pancreatitis
• Most intolerant to oral feeds because of ileus
• Nasogastric v/s Nasojejunal
• Semielemental v/s Polymeric
• Immunomodulators; Immunonutrition

21. Antibiotics
• No role in mild pancreatitis
• In severe or predicted severe : Controversial
• Drug of choice : Carbapenems
• Start antibiotics if fever persists beyond first
week

22. Need to know the etiology
• TG : Heparin ; Glucose-Insulin
• Calcium : Hydration; Steroids
• Gall stones : ERCP
• Drug : Stoppage

23. Role of Ulinastatin
• Intravenous infusion
• 200,000 IU ulinastatin over one hour every 12
hours for 5 days
• In severe pancreatitis reduces new onset
organ dysfunction
• Decreases mortality

24. Role of ERCP
• In Gall stone pancreatitis
• Preferably first 72 hours
• In predicted severe pancreatitis
• Cholangitis

25. Early Complications Requiring Surgery
• Abdominal compartment syndrome (ACS)
• Bowel ischemia

26. IAH/ACS: Definition
• Intra-abdominal hypertension (IAH):
– Intra-abdominal pressure ≥12mmHg
• Abdominal compartment syndrome(ACS):
– Intra-abdominal pressure >20mmHg
– Signs of new organ failure (eg, respiratory,
circulatory, renal)

28. ACS: Treatment
• Immediate measures
– Nasogastric decompression, fluid restriction, and
diuretics
• No rapid clinical improvement, intervention
required
– Percutaneous catheter decompression
– Surgical decompression laparotomy
• In cases where laparotomy is necessary,
advised not to perform necrosectomy

29. • P : Perfusion
• A : Analgesia
• N : Nutrition
• C : Clinical assessment
• R : Radiology
• E : Endoscopic intervention
• A : Antibiotics
• S : Surgery
Take home message !!