A very simple description of basics of acute pancreatitis with pnemonics to remember different scores

1. Acute Pancreatitis
Department of Critical Care Medicine
King Saud Medical City
Riyadh, Saudi Arabia
Muhammad Asim Rana
MBBS, MRCP, SF-CCM, EDIC, FCCP

2. 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 patients
with acute pancreatitis and the optimum mode of delivery.
Identify and manage local and systemic complications of acute pancreatitis
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3. 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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4. GALLSTONES
ETHANOL
TRAUMA
STEROIDS
MUMPS/VIRUSES
AUTOIMMUNE(PAN)
SCORPIONVENOM/Toxins
HYPERLIPIDEMIA
ERCP
DRUGS
G E T S M A S H E D
Causes of Acute Pancreatitis

5. Diagnosis of acute pancreatitis
Symptoms Signs
Grey Turner’s signCullen’s Sign

6. Laboratory Investigations
S/AmylaseS/LipaseUrine amylaseOther Enzymes
Non enzymatic pancreatic
secretory products
PAP TAP CAPAP
Markers of immune activation
& nonspecific markers
IL-6, IL-8, IL-10
TNF
PMN Elastase
CRP

7. Radiological Investigations
Plain X-Ray Ultrasound
CT Scan MRI
Pancreatitis without pain is particularly misleading. Lack of a major symptom is
usually attributed to a postoperative situation where analgesics/sedatives are in use.
Diagnostic pitfalls
Diabetic comasevere hypothermia remote organ failuresSevere GI bleeding

8. Pancreatic swelling
Lack of enhancement
Peri-pancreatic fluid
collection
Diagnostic Imaging

9. How to recognize the at risk patient
System Manifestations Significance
General
CVS
Pulmonary
Renal
Neurological
Abdominal
Age > 60
BMI > 30 Kg/m2
Risk of local & systemic
complications
↓ BP, ↑HR,↑ Lactate
Tachypnea,Cyanosis
↓ OUT PUT
↑ Creatinine
Confusion
Agitation
Tense abdomen
ReboundTenderness
Risk of local & systemic
complications
Impending remote organ
failure
Impending remote organ
failure
Impending remote organ
failure
Extent of peritoneal
involvement

10. Definition of severe pancreatitis
 Acute pancreatitis + organ failure and/or
 Acute pancreatitis + local complications
 Three or more Ranson Criteria OR
 APACHE II > 8

11. Early assessment of severity
Ranson’s criteria
ON Admission After 48 hours
G A L A W
Glucose > 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

12. 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%)

13. Grading based upon findings on unenhanced CT
Grade Findings Score
A Normal pancreas - normal size, sharply defined, smooth
contour, homogeneous enhancement, retroperitoneal
peripancreatic fat without enhancement
0
B Focal or diffuse enlargement of the pancreas, contour may
show irregularity, enhancement may be inhomogeneous but
there is on peripancreatic inflammation
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C Peripancreatic inflammation with intrinsic
pancreatic abnormalities
2
D Intrapancreatic or extrapancreatic fluid collections 3
E Two or more large collections of gas in the
pancreas or retroperitoneum
4

14. Necrosis, percent SCORE
0 0
Less than 33% 2
33-50% 4
More than 50% 6
Necrosis score based upon contrast enhancedCT

15. 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 of
pancreatic necrosis.
Labs adjunct to clinical judgment and the APACHE II .
A CRP level of >150 mg/L at 48 hours is preferred

16. 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

17. Management of Severe Acute Pancreatitis
General Intensive Care
SpecificTreatment Modalities
Surgery or No Surgery
Feeding the patient
Managing the Complications

18. General intensive care
Supportive therapy of vital organs
Cardiovascular system
Nowadays infection of
pancreatic necrosis
accounts for 50-80% of the
deaths
Splanchnic ischaemia is a 2nd
local hit:
Retroperitoneal necrosis, gut
barrier dysfunction, and
Secondary pancreatic infection
may ensue
Local splanchnic perfusion may be
worsened by abdominal
compartment syndrome-
increased pressure due to intra
abdominal oedema, fluid
sequestration and excessive fluid
resuscitation.
Respiratory system Prevention/correction of hypoxia.
Early physiotherapy and adequate analgesia (perhaps using epidural
analgesia) to ensure free airways and to prevent atelectasis, prevent
pulmonary aspiration by nasogastric decompression.
CPAP/ BIPAP/ Invasive MechanicalVentilation
Renal system Prevent and/or minimize renal injury by
rapid correction of hypovolaemia
If acute renal failure develops, start renal replacement therapy
without delay to ensure optimal fluid and metabolic control and
to enable nutritional support without haemodynamic instability.
CVVHD is preferred.
Gastrointestinal system
Beware of intra-abdominal
hypertension and assess the patient
for this complication regularly.
If abdominal compartment syndrome occurs, consider decompression either
surgically or in cases of colonic distension with a wide bore tube inserted via
the 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 diluted
local anaesthetic solution
(bupivacaine) and opiates)Miscellaneous
Octreotide
Somatostatin
Protease Inhibitors
(Aprotinin & Gabexate Mesilate)
Anti inflammatory Rx
Stress Ulcer Prophylaxis
DVT Prophylaxis

19. 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.

20. Indications for surgery
Controversial indicationsUndisputed indications
Infected pancreatic necrosis when
percutaneous/other techniques not indicated
Severe retroperitoneal haemorrhage
Acute abdomen – peritonitis
Biliary obstruction in case of failure of
Endoscopic Sphincterotomy
Abdominal compartment syndrome where
percutaneous/other drainage techniques not
successful.
Controversial indications
Extensive (>50%) sterile pancreatic necrosis
Early ‘routine’ debridement of necrosis
irrespective of its bacteriological status in
order to prevent remote organ dysfunction
and pancreatic infection
Persisting multiple organ failure despite intensive care therapy
Early and repeated removal of necrotic tissue combined
with 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 as
indications for surgery.
NOTE

21. Feeding the pt of SAP
Nutritional therapy: How, what and when?
Route of nutrient delivery:
Enteral versus parenteral
The more distally that
nutrients are infused in
the gut, the less they
stimulate pancreatic
secretion
The enteral route is safe
in acute pancreatitis, so
whenever possible,
use it!
In order to maximise clinical benefit, enteral
feeding should be initiated as soon as possible
after admission in all attacks predicted to be
severe.
Patients in whom enteral access cannot be
achieved or in whom clear-cut contraindications
(intestinal rupture, obstruction, or necrosis),
intolerance, or exacerbation of the disease
occurs should be considered for partial or total
parenteral nutrition (TPN).

22. Some Important Aspects of Feeding
Composition of the diet
Prescription and timing of nutrient administration
Issue of Functional Ileus
Oral refeeding
Complications of nutritional therapy

23. Resuscitation
Severity Index
Severe Disease Mild Disease
Conservative RxCT Scan
Balthazar > 7
Balthazar < 7
Management of Severe Acute Pancreatitis

24. Balthazar > 7
Aggressive Hydration/Antibiotics/ Entral feeding/TPN
No Improvement Improvement
Continue Same Rx
CT Guided Aspiration Deterioration

25. CT Guided Aspiration
Infected Sterile
Supportive Rx
Appropriate Antibiotics
Attempt to wait for 3-4
weeks from onset
NO IMPROVEMENT ?

26. NO IMPROVEMENT ?
Organized Collection Diffuse Collection
Percutaneous/ Endoscopic/
Laparoscopic drainage
Minimal access or Surgical
Debridement

27. Approach to Treat NECROSIS
Fine Needle Aspiration
SterileInfected
Aggressive
ICU Rx
Improvement
No Improvement
Endoscopic Expertise Available
YESNO
Necrosectomy
Percutaneous
Drainage

28. Necrosectomy
Necrosis EndoscopicallyAccessible
(posterior gastric or medial
duodenal wall)
Necrosis in peripancreatic,
retrodudenal, perinephric
Endoscopic Necrosectomy Laparoscopic Necrosectomy
No Improvement
Surgical Drainage
Adjuvant Percutaneous Drainage

29. I think its enough