its a presentation about diagnosis and management of acute pancreatitis.

1. ACUTE SEVERE PANCREATITIS – MANAGEMENT IN 1ST & 2ND WEEK
Presenter : DR M CHAITHANYA
Moderator: DR JAHANGEER

2. Outline
• Definition
• Risk factors
• Severity assessment
• Initial resuscitation
– IV Fluids
– Analgesia
• Role of early ERCP
• Nutrition
• Role Of Antibiotics
• POTENTIAL AREAS OF RESEARCH

3. • Definition of acute pancreatitis
• Classification of acute pancreatitis
• Defines Severity
• Definition - Local complications

4. SEVERITY – Revised ATLANTA Classification
EARLY
(< = 1 WEEK)
LATE (> 1WEEK)
MILD MODERATE SEVERE
EDEMATOUS NECROTISING
TEMPORAL
SEVERITY
MORPHOLOGY
SEVERITY DEFINITION
MILD
No Organ Failure Or
NO Local Complications
MODERATELY SEVERE TRANSIENT ORGAN FAILURE (<48 HRS) /
LOCAL COMPLICATIONS
SEVERE PERSISTENT ORGAN FAILURE (>48 HRS)
(SINGLE OR MULTIPLE)
Banks PA, et al Classification of acute pancreatitis—2012: revision of the Atlanta
classification and definitions by international consensusGut 2013;62:102-111.

5. ORGAN FAILURE – Modified Marshall Scoring System
A score >= 2 defines organ failure in any
organ system
Need ICU admission
Supportive management only

6. CLINICAL SCENARIO
• A obese young female, presented to ER with acute epigastric pain radiating to back
since few hours, a/w intermittent vomiting
– Vitals : BP: 90/60 MM HG; PR: 120/MIN; RR 24/MIN; SPO2 : 96%
– S/E : epigastric tenderness+, BS – sluggish, no signs of peritonitis, Murphy Sign –ve
– AXR : normal
– Amylase / Lipase – significantly elevated

7. Resolution in few
days
POSSIBLE OUTCOMES
Organ failure within
first week
Resolution
DEATH
NECROSIS
Resolution
Infected necrosis/
sepsis
Resolution
Organ
failure
Resolution
DEATH
> 50% deaths occur in
2 weeks of onset of
acute pancreatitis

8. TRIAGE
MICU

9. Assessment of
Severe Acute
Pancreatitis

10. CLINICAL
• Weight
• Co-morbidities
• HR, RR & Temp
• UOP
• chest crepitations
• Rebound tenderness
LABORATORY
• TC/DC, HCT
• LFT
• BUN
• CREATNINE
• TG, Ca
• ABG
• USG

11. SEVERITY PREDICTION
SINGLE PARAMETER
• HCT
• BUN
• CREATNINE
• CRP
• CTSI
• PROCALCITONIN
SCORING SYSTEMS
• RANSON
• APACHE II
• SIRS
• HAPS
• BISAP ? IDEAL

12. Cho JH, et al. World Journal of Gastroenterology:
WJG. 2015 Feb 28;21(8):2387.
Mounzer R,. Gastroenterology. 2012 Jun;142(7):1476-82;.
• All scoring systems have comparable severity prediction but with moderate
sensitivity.
• On the flipside these are cumbersome to use in real life scenario.
• Simple tests like SIRS, HCT, BUN have comparable Prediction rates with other
scoring systems.
COMPARISON BETWEEN SCORING SYSTEMS

13. PERSISTENT ORGAN FAILURE PANCREATIC NECROSIS
 In pooled analysis, admission hematocrit ≥44% and rise in BUN at 24 h both
showed a three- to sixfold increase in risk of developing persistent organ failure
and pancreatic necrosis.
 The risk for persistent organ failure and pancreatic necrosis exceeds 50% when
both admission hematocrit ≥44% and rise in BUN at 24 h are combined.
Koutroumpakis E et al. American Journal of Gastroenterology. 2015 Dec 1;110(12):1707-16

14.  N = 252
 SIRS on day 1 predicts severity
(85%)
 Absence of SIRS on day 1 has high
NPV (98-100%)
Singh VK, et al.Clinical Gastroenterology and Hepatology. 2009 Nov 1;7(11):1247-51

15. Simple, Reproducible, Accessible, Inexpensive Parameters
HCT, BUN, SIRS SCORE
Parameters With Possible Benefit But Complicated And Non Superior
RANSON, APACHE, BISAP
SUMMARY OF PREDICTORS

16. Day 1 Day 5
GUIDELINES SAY NO TO CT BEFORE 72 HRS OF ONSET OF
PANCREATITIS
ROLE OF CROSS SECTIONAL IMAGING

17. INDICATIONS OF CECT
Bollen TL. Pancreapedia: The Exocrine Pancreas Knowledge Base.
2016 Oct 31.

18. THINGS TO LOOK IN A CECT
Focal Inflammation NECROSIS PPFC

19. Vascular Infected

20. Modified CTSI
SCORE >= 8
 SAP

21. Case contd
• Patient in SIRS
• TLC elevated
• LFT: TB 4.1, ALT - 260
• USG: bulky pancreas with peri pancreatic edema +, fluid collection +, GS+
• ADMITTED TO MEDICAL ICU

22. INITIAL MANAGEMENT OF PANCREATITIS

23. ANALGESIA
• Uncontrolled pain  negative effect on micro vascularization  may lead to necrosis.
• Choice of analgesic: Opioids v/s NSAIDS Not much of data
• NSAIDS
– GI bleed
– Renal failure
• OPIODS
– Respiratory failure
– Ileus

24. Mahapatra SJ, Am J Gastroenterol. 2019 May;114(5):813-821.

25. • Route of analgesia: Intravenous v/s Epidural
– No RCT’s
– Retrospective study showed epidural analgesia reduced mortality in ICU patients with SAP.

26. IV FLUIDS
 WHY
 HOW MUCH
 TYPE OF FLUID
 MONITOR

28. N=266
MEDIAN FLUID SEQUESTRATION in
first 48 hrs  3.2 L(1.5-5 L)
Young age, alcohol, SIRS, glucose
de-Madaria E, Banks PA et al. Clin Gastroenterol Hepatol. 2014 Jun;12(6):997-1002.
FLUID SEQUESTRATION IN ACUTE PANCREATITIS

29. Aggressive versus Non Aggressive fluid
• Aggressive fluid resuscitation 
– Hemoconcentration >24 hrs necrosis  SIRS, OF and
mortality.
• Flip side may increase organ failure, intra-abdominal
hypertension, ICU care and mortality
• CAUTION should be in elderly, cardio-pulmonary disease , renal
failure and IAH.
Haydock MD,. Ann Surg. 2013 Feb;257(2):182-8.

30. • N= 88
• Group-I (N=45)  1.5 ml / hr x 24 hrs
• Group II (N=43)  20 ml/kg bolus+ 3 ml/kg/ hr for 24 hrs
• Both groups received 30 ml/kg over next 24 hrs
• CONCLUSION  No Differences in SIRS, Necrosis, OF, Hospital Stay
Cuéllar-Monterrubio et al. Pancreas. 2020 Apr 1;49(4):579-83.

31. RINGER’S LACTATE PREFERRED OVER NORMAL SALINE
Siregar GA, Siregar GP. Management of Severe Acute Pancreatitis. Open Access Maced J
Med Sci. 2019 Aug 30;7(19):3319-3323

32. MONITORING
• CLINICAL TARGETS
– UOP – 0.5-1 ml/ min
– MAP – 70 mm hg
– HCT – 40 – 42%
– BUN – Reduction
• Radiological monitoring with IVC diameter (~ 1.5 cm) and look for volume overload
signs (B lines)

33. RECOMMENDATION
• Crystalloids preferably ringer lactate initiated at the earliest.
• 200-250ml/hr or 5-10 ml/kg/hr continued for 24 hrs. (on an average 3-4 L/day within 48 hrs)
• Should be titrated by clinical targets.
• Caution should be taken to prevent volume overload and other adverse effects a/w aggressive
management.

34. CASE cont… - DAY 2-4
Febrile (>101 C)
TLC – elevated
PAO2/FIO2  <300
S.Creatinine – 2.5 mg/dl
USG showed  small collection+
LFT  T.B - 1.8
ALT 150
Concerns:
 Organ Failure
 Biliary Obstruction – need for ERCP

35. BILIARY DRAINAGE
FEB/2013 - MAR/2017; ERCP N=117 & Conservative Group N=114
Conclusion
 Urgent ERCP with sphincterotomy did not reduce major complications or mortality, compared with
conservative treatment.
 In patients with predicted severe acute gallstone pancreatitis  ercp indicated only in patients with
cholangitis or persistent cholestasis.
Schepers NJ et al.The Lancet. 2020 Jul 18;396(10245):167-76.

36. “GUT ROUSING - BUT NOT RESTING”
Kanthasamy KA, Akshintala VS, Singh VK. Nutritional Management of Acute Pancreatitis.
Gastroenterology Clinics. 2021 Mar 1;50(1):141-50.
 Nutritional support plays a key role in mitigating the sequelae of the SIRS response
with specific attention to hypoperfusion of the gut barrier mediated by inflammatory and
microcirculatory damage.
 Promote the integrity of the damaged gut barrier by preventing luminal mucosal
atrophy  reducing gut permeability and translocation of gut microbiota that
potentiates AP-associated SIRS, multiorgan failure, and infection
Akshintala VS, Talukdar R. et al Clinical Gastroenterology and Hepatology. 2019 Jan 1;17(2):290-5.

37. EARLY FEEDING V/S ON DEMAND (DELAYED)
• systematic review of 11 randomized control trials (RCTs)1
– compared the role of early feeding (within 48 hours of admission) with delayed feeding across all severities
of AP
– no difference in outcomes including mortality, rates of multiorgan failure, and complications related to
pancreatic necrosis.
• The PYTHON trial, a multicenter RCT from the Netherlands,2
– patients with predicted SAP, found no differences in major infection and death or pancreatic necrosis or
need for intensive care unit level care
1) Vege SS, American Gastroenterological Association Institute Technical Review.
Gastroenterology 2018;154(4):1103–39.
2) Bakker OJ,. N Engl J Med 2014;371(21):1983–93.

38. ENTERAL V/S PARENTERAL
EN compared with PN across all severities of pancreatitis, two-fold
reduction in the rate of multiorgan failure and nearly a four-fold reduction in
infected peripancreatic necrosis with the use of EN
Siregar GA, Siregar GP. Management of Severe Acute Pancreatitis.
Open Access Maced J Med Sci. 2019 Aug 30;7(19):3319-3323

39. NASOGASTRIC (NG) V/S NASOJEJUNAL (NJ)
 The distal delivery of EN via NJT offers a theoretic reduction in aspiration risk and
middistal jejunal nutrition shown to minimize pancreatic stimulation.
 However, RCTs and metaanalyses shown feeding in SAP have no difference in
mortality, infectious complications, or LOS.
 no difference tracheal aspiration, exacerbation of pain, or energy balance between
the two routes
 Patient tolerance better with NJT
Siregar GA, Siregar GP. Management of Severe Acute Pancreatitis.
Open Access Maced J Med Sci. 2019 Aug 30;7(19):3319-3323

40. TYPE OF FEED
• Oligomeric  small peptides + MCFA + simple carbs; costly
• Polymeric  full proteins + lipids + complex carbs; COST effective
• Immunonutrition  immunomodulatory supplements
• Two meta-analyses comparing oligomeric with polymeric formulations found
– no difference in terms of feeding intolerance, mortality, or LOS between the two formulations.
Petrov MS et al. Br J Surg 2009; 96:1243–52.

41. Arutla M et al. Indian J Gastroenterol. 2019 Aug;38(4):338-347.

42. RECOMENDATION
Calorie intake:
25-30 kcal/kg/day
Protein intake
1.5-2gm/kg/day
Polymeric feeds
Kanthasamy KA, Akshintala VS, Singh VK. Nutritional Management of Acute Pancreatitis.
Gastroenterology Clinics. 2021 Mar 1;50(1):141-50.

43. CASE Contd – 2ND WEEK
• SIRS continuing with fever spikes and TLC
• Creatinine  resolving
• PAO2/ FIO2 <400 (requiring O2 supplementation)
• Patient still in ICU
• NJ feeding started
• USG showed PPFC (~7 x 10 cm)
Concerns
 Organ failure :
Continuing/resolving
 Adequate Nutrition
 1500-2000 kcal/day
 Role of antibiotics
 Infection
 Fluid collections

44. ROLE OF ANTIBIOTICS
• Prophylaxis
• Extra pancreatic infection
• Infected pancreatic collections

45. PROPHYLACTIC ANTIBIOTICS
• No role for prophylactic antibiotics
• Extensive usage in India (66%)*
• Concern
– Resistant infection
– Gram positive infection
– Fungal infections
* Talukdar R, et al. Antibiotic use in acute pancreatitis: an Indian multicenter observational study.
Indian J Gastroenterol. 2014 Sep;33(5):458-65.
Crockett, S. D. et al. American Gastroenterological Association Institute Guideline on Initial
Management of Acute Pancreatitis. Gastroenterology 154, 1096–1101 (2018).

46. Extra pancreatic infection
Talukdar R et al. Indian J Gastroenterol. 2014 Sep;33(5):458-65.

47. WHEN TO START ANTIBIOTICS - EMPERICALLY
• Persistence of SIRS / continues fever beyond 1 week / raising
TLC
• Initial improvement followed by clinical deterioration after
7-10 days of admission
• Extra luminal gas in the collection.
• Serum Procalcitonin / CT scan may guide
• Antibiotics with pancreatic tissue penetrance according to
local sensitivity can be started

48.  Carbapenems
 Quinolones + metronidazole
 3rd generation cephalosprorin/
piperacillin - tazobactum +
metronidazole
Uomo G. Antibiotic treatment in acute pancreatitis. Rocz Akad Med
Bialymst. 2005;50:116-21.

49. FLUID COLLECTIONS
• CT showing fluid collections with patient having persistent fever spikes / raising TLC.
CONCERN
 ? Infected collection
 need for antibiotics
 when to drain the collection
• Factors deciding the course
– Necrosis and size of the collection (> 30% necrosis / large collection likely to persist

50. • Guidelines
– Infected pancreatic necrosis early in the disease course (that is, <4 weeks from onset of disease)
 clinically unstable despite the administration of intravascular antibiotics, a percutaneous
drain placement for decompression is advised.
Arvanitakis, M. et al. : European Society of Gastrointestinal Endoscopy (ESGE) evidence-
based multidisciplinary guidelines. Endoscopy 50, 524–546 (2018).

51. POTENTIAL THERAPEUTIC TARGETS AND TARGET PATHWAYS IN ACUTE
PANCREATITIS

53. TAKE HOME MESSAGE
• Acute pancreatitis has a dynamic clinical course
• No ideal severity assessment tool, but simple tools like HCT,BUN and SIRS are good
predictors of SAP.
• Aggressive hydration and adequate analgesia – corner stone of initial Rx.
• Early initiation of Enteral Nutrition.
• Avoid blanket antibiotic cover.
• Requires meticulous clinical monitoring.

54. THANK YOU