Acute pancreatitis - Review article on diagnosis and management - 2016

1. ACUTE PANCREATITIS
REVIEW ARTICLE- THE NEW ENGLAND JOURNAL OF MEDICINE, Nov. 17, 2016
-DR.SPANDANA KANAPARTHI

2. CAUSES
• Gall Stones are the most common cause
• Alcohol – the second most common
• Alcohol associated pancreatitis –4-5 drinks/day for >5yrs
• Overall lifetime risk in heavy drinkers – 2-5%
• Type of alcohol ingested does not affect risk
• Binge drinking(in the absence of long term heavy drinking) does not
precipitate
• Drug induced pancreatitis – ACEI, Valproic acid,
Azathioprine, 6-Mercatopurine, Didanosine
• Genetic mutations – Cationic trypsinogen, SPINK-1,
CFTR, Chymotrypsin C, Calcium sensing Receptor and
Claudin – 2

3. CAUSE
APPR
OX.
FREQ
DIAGNOSTIC CLUES COMMENTS
Gall Stones 40%
Gallbladder stones or sludge, abnormal
liver enzymes levels
EUS can reveal very small
GB/duct stones
Alcohol 30%
Acute flares superimposed on
underlying chronic pancreatitis
Diagnosis rests on history,
obtained with CAGE
questionnaire
Hypertriglyce
ridemia
2-5% Fasting triglycerides > 1000mg/dl
Drugs <5% Other evidence of drug allergy(rash) Idiosyncratic, usually mild
Autoimmune <1%
Type – 1 : Obstructive jaundice,
elevated IgG4 levels
systemic ds. affecting the
pancreas, salivary glands and
kidneys
Type – 2 : Present as acute pancreatitis,
in younger patients, no IgG4 elevation Only the pancreas is affected

4. CAUSE
APPROX.
FREQ
(%)
DIAGNOSTIC CLUES COMMENTS
Genetic
causes
Not
Known
Recurrent acute and chronic
pancreatitis
ERCP 5-10 Among pts undergoing ERCP –
5-10%
Symptoms reduced with rectal
NSAIDs or temporary placement of a
stent in the pancreatic duct
Trauma <1% Blunt or penetrating trauma,
particularly in midbody of
pancreas as it crosses spine
Infection <1% Viruses: CMV, mumps, EBV
Parasites: Ascariasis,
Clonorchis
Surgical
Complication
5-10 Among patients undergoing
Cardiopulmonary bypass
Due to pancreatic ischemia
Pancreatitis may be severe
Obstruction Rare Celiac disease and Crohn’s ds
Pancreas divisum and Sphinc
of Oddi dysfunction
On rare occasions, malignant
pancreatic duct or ampullary
obstruction is seen
Asso.
conditions
Comm
on
Diabetes, Morbid obesity and
smoking

5. DIAGNOSIS AND CLASSIFICATION
• Accurate diagnosis – atleast 2 of the following
three diagnostic features
1. Abdominal pain consistent with acute
pancreatitis
2. Serum lipase or amylase levels – 3 times the
upper limit
3. Findings of acute pancreatitis on cross-
sectional imaging(CT/MRI)

6. CLASSIFICATION SYSTEMS

7. • Systemic complications include:
• Failure of an organ system(respiratory, Cardiovasc., or
renal)
• Exacerbation of a pre-existing disorder(COPD, heart
failure or chr. liver ds.)
• Local complications include:
• Peripancreatic fluid collections
• Pseudocysts
• Pancreatic or peripancreatic necrosis (sterile/infected)
• Persistent organ failure(Severe Acute Pancreatitis) -
30% mortality
• Critical Pancreatitis – associated with the highest
mortality

8. PREDICTION OF SEVERITY
• Clinical factors – increase risk of
complications or death:
1. Age > 60 years of age
2. Comorbid illnesses(cancer, heart failure, and
chronic kidney and liver disease),
3. H/o chronic alcohol consumption
4. Obesity (body mass index 30 kg/m2
5. Long term, heavy alcohol use

9. Laboratory measures
• Measure of intravascular volume depletion:
• Elevated hematocrit
• Elevated BUN and creatinine
• Markers of inflammation:
• C-reactive protein
• IL- 6, 8, 10
• Degree of elevation of amylase or lipase level – no
prognostic value
• CT study – Early CT study underestimates the severity
of the disease

10. Scoring systems
• APACHE-II,
• APACHE-O(combined with scoring for obesity),
• the Glasgow scoring system,
• HAPS,
• PANC 3,
• the Japanese Severity Score,
• Pancreatitis Outcome Prediction and
• BISAP score

11. • Scoring systems overestimate the severity of
disease
• Clinical evaluation – better
• Systemic Inflammatory Response
Syndrome(SIRS) : ≥ 2/4
• Temp< 360C or >380 C
• Pulse ≥ 90/min
• WBC <4000 or >12000/mm3
• Respiratory Rate > 20/min
• SIRS persisting for ≥ 48 hrs – poor prognosis

12. TO IDENTIFY PATIENTS AT RISK
• Demographic and clinical factors at admission:
1. Age> 60yrs
2. BMI > 30
3. Coexisting conditions
• Lab values at admission and during the next 24-
48 hrs:
1. Hct > 44%
2. BUN > 20mg/dl
3. S. Creat > 1.8mg/dl
• Presence of SIRS

13. INDICATIONS FOR INTENSIVE CARE
• Patients with signs of respiratory failure or
hypotension that fail to respond to initial
resuscitation
• Patients with multiorgan dysfunction
• Patients with persistent SIRS, increased levels
of BUN or creatinine, increased hematocrit, or
underlying cardiac or pulmonary illness

14. INDICATIONS FOR TRANSFER
• Patients who do not respond to initial
resuscitation, with persistent organ failure or
extensive local complications, should be
considered for transfer to a comprehensive
pancreatitis center with multidisciplinary
expertise that includes therapeutic endoscopy,
interventional radiology, and surgery.

15. MANAGEMENT OF ACUTE
PANCREATITIS

16. FLUID RESUSCITATION
• Aggressive fluid administration during first 24 hours –
reduces morbidity and mortality
• Administration of a crystalloid solution:
• 5-10ml/kg/hr about 2500-4000 ml within first 24hrs
• Patients undergoing volume resuscitation should have the
head of the bed elevated, undergo continuous pulse
oximetry, and receive supplemental oxygen
• Clinical cardiopulmonary monitoring for fluid status, hourly
measurement of urine output and monitoring of BUN and
Hct
• Excessive fluid administration – risk of abdominal
compartment syndrome, sepsis, need for intubation and
death

17. FEEDING
• Total Parenteral Nutrition – Expensive, riskier and
no more effective than enteral nutrition
• Mild acute pancreatitis – No need for complete
resolution of pain or normalisation of enzymes
before oral feeding is started
• Start on a low fat diet in the absence of severe
pain, nausea, vomiting and ileus.
• Artificial enteral feeding – if symptoms continue
to be severe or intolerant to oral feeds

18. • Nasojejunal feeding – best for minimising
pancreatic secretion
• Nasogastic or nasoduodenal feeding clinically
equivalent
• TPN – reserved for cases in which enteral
nutrition is not tolerated or nutritional goals
are not met
• Oral feeding – attempted with an interval of 3-
5 days before tube feeding is considered

19. ANTIBIOTICS AND ERCP
• Prophylaxis with antibiotic therapy - not recommended
for type of acute pancreatitis unless infection is suspected
or confirmed
• ERCP- indicated in pts with E/O cholangitis superimposed
on gallstone pancreatitis and in patients with documented
choledocholithiasis
• MRCP - identifying retained common bile duct stones - for
patients with suspected gallstone pancreatitis.
• MRI - helpful in distinguishing walled-off necrosis from a
pseudocyst
• Endoscopic ultrasonography is a highly sensitive test for
detecting cholelithiasis and choledocholithiasis - an
alternative to MRCP, which has limited accuracy for
detecting smaller gallstones or sludge.

20. TREATMENT OF FLUID COLLECTIONS AND NECROSIS
• Acute peripancreatic fluid collections – no therapy
• Symptomatic pseudocysts – use of endoscopic techniques
• Necrotising pancreatitis:
- Sterile : no treatment
- Infected(H/o fever, leukocytosis, increasing abd pain and air
bubbles in the necrotic cavity on CT scan): Broad spectrum
antibiotics
• Delay of invasive intervention for atleast 4 weeks for
walling off of the necrotic collection – makes debridement
easier and reduces the complications
• Unstable patients – Initial placement of a percutaneous
drain in the collection to reduce sepsis and allow the 4-
week delay

21. LONG TERM CONSEQUENCES
• Pancreatic exocrine and endocrine
dysfunction(20-30%)
• Chronic pancreatitis(33-50%)
• Risk factors for transition to recurrent attacks
and chronic pancreatitis:
- Severity of initial attack, degree of pancreatic
necrosis, cause of acute pancreatitis
- Heavy alcohol with smoking as cofactor
dramatically increases the risk

22. PREVENTION OF RELAPSE
• Cholecystectomy – prevents recurrent gall
stone pancreatitis(should be performed
during the initial hospital stay for mild
pancreatitis – reduce the risk of relapse)
• Abstinence markedly lowrs the risk of
recurrence
• Smoking cessation
• Tight control of hyperlipidemia

23. THANK YOU