Acute pancreatitis
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This document provides information on the diagnosis and management of acute pancreatitis in the first 72 hours. It summarizes that acute pancreatitis is diagnosed when a patient has abdominal pain consistent with pancreatitis along with serum lipase or amylase levels 3 times the upper limit of normal or characteristic findings on CT scan. Mild disease affects 80% of patients and severe disease 20%, with higher mortality risks. Treatment involves intravenous fluids, nutrition, antibiotics if needed, protease inhibitors, and potentially ERCP or surgery for gallstone pancreatitis or complications like abdominal compartment syndrome.
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Acute pancreatitis
- 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
- 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
- 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 !!