Acute pancreatitis

Acute Pancreatitis.
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What is pancreatitis? Signs and symptoms of acute pancreatitis?
Diagnosis of acute pancreatitis
management and treatment of pancreatitis.

1. Acute Pancreatitis
Mini Lecture
Farid Jalali
January 23, 2014

2. oEstablish the Diagnosis of Acute Pancreatitis
oEstablish the Etiology of Acute Pancreatitis
oInitial Management of Acute Pancreatitis
All recommendations are based on the latest ACG Management of
Acute Pancreatitis guidelines published in 2013.
Objectives

3. oDiagnosis of Acute Pancreatitis requires at least 2 of 3 from the following
criteria:
oAbdominal pain consistent with acute pancreatitis
oSerum amylase or lipase greater than 3 times the upper limit of normal
oCharacteristic findings on abdominal imaging
oCT w/ contrast or MRI should be reserved for patients in whom the diagnosis in
unclear or fail to improve within 48-72 hours.
A. Diagnosis

4. 47 year-old female with recent mild alcohol intake and no history of prior
gallstones or acute pancreatitis presents to ER with epigastric abdominal pain
radiating to the back. Lipase is 500 on admission.
oDiagnosis: Met the following 2 of 3 criteria (1) abdominal pain consistent
with acute pancreatitis (2) Lipase > 3 times upper limit of normal – therefore,
no CT or MR imaging required to establish diagnosis.
Case Vignette

5. oTransabdominal ultrasound should be performed in ALL patient with acute
pancreatitis to assess gallstones as etiology of acute pancreatitis.
oIn absence of gallstones or significant alcohol use, obtain serum triglycerides.
oIf serum triglycerides > 1,000 mg/dL, consider as etiology of acute
pancreatitis.
oIn patients > 40 years of age, consider pancreatic tumor in absence of other
causes.
oIn patients < 30 years of age and +FH of acute pancreatitis in absence of other
causes, consider genetic testing for hereditary pancreatitis.
B. Etiology

6. oEtiology: As all patients with acute pancreatitis are recommended to get
transabdominal ultrasound, a RUQ ultrasound was done which showed
cholelithiasis and CBD dilatation without choledocholithiasis. Likely etiology
was gallstone pancreatitis with or without a component of alcohol-induced
acute pancreatitis.
Case Vignette – cont.

7. oVarious methods exist to assess severity of acute pancreatitis.
oNext slide describes clinical findings associated with a severe course of acute
pancreatitis.
oBISAP score is a helpful tool in assessing severity and in-hospital mortality of
acute pancreatitis.
oBISAP, Ranson’s, APACHE-II and CTSI scores all have similar prognostic
accuracy.
C. Severity Assessment

8. Severity Scoring of Acute Pancreatitis
Bedside index of severity in acute pancreatitis (BISAP) score
Presence of organ failure and/or pancreatic necrosis defines Severe Acute
Pancreatitis.
Patients with high severity of initial presentation and/or presence of end-organ failure
(shock, AKI, altered mental status, respiratory failure, ARDS, etc) should be admitted to ICU.

9. oEarly AND Aggressive IV fluid hydration must be initiated.
oHow aggressive?
oIf severe hypovolemia present, bolus IV fluids initially
oThen keep maintenance rate of 250 – 500 mL/hr IV fluids
oWhat kind of IV fluids?
oIsotonic crystalloid (NS, LR)
oLR may be preferred (conditional recommendation)
oHow soon to start?
oEarly, early, early !!
oMost beneficial in the first 12-24 h
oWhat is my goal with IV fluid hydration?
oDecrease BUN (as checked q6h initially)
D. Initial Management

10. oManagement: NPO, IV fluid hydration at 250-500 cc/hr with monitoring BUN
q6h with goal of IVF hydration to decrease BUN in the first 12-24 hours.
Case Vignette – cont.

11. oDo NOT #1: Routine use of prophylactic antibiotics for severe acute
pancreatitis is NOT recommended.
oDo NOT #2: Use of antibiotics to prevent progression of sterile necrosis to
infected necrosis is NOT recommended.
oKeep in mind that patients with acute pancreatitis often and early have
fever but this does not necessarily mean infected necrosis exists.
E. Role of Antibiotics

12. oThink of infected necrosis if patient with pancreatic or extra-pancreatic
necrosis fails to improve after 7-10 days of hospitalization.
oIn case of infected necrosis, either FNA with gram-stain and culture to
narrow antibiotic regimen or empirically treat with antibacterial
antibiotics.
oRoutine antifungal therapy is not recommended unless specifically
indicated based on culture and/or gram-stain.
E. Role of Antibiotics

13. oAntibiotics role: Despite spiking one fever to 101 F, no clinical concern for
infected necrosis existed and patient improved clinically within 48 hours. No
antibiotics were therefore initiated.
Case Vignette – cont.

14. oNG versus NJ tube feeding are COMPARABLE in efficacy and safety.
oIn other words, do NOT delay enteral feeding because NJ tube is not
present.
oIV nutrition should be avoided unless enteral nutrition is not available, not
tolerated, or not meeting caloric requirements.
oEnteral feeding is not merely to meet caloric requirements; it also prevents
infectious complications.
oTiming of enteral feeding? Not mentioned in guidelines, but generally if
anticipate patient cannot have PO intake within 48 hours, start enteral
feeding with NG or NJ.
F. Feeding

15. oEnteral feeding: As patient was able to have PO intake within 48 hours,
neither NG nor NJ tube feeding was initiated.
Case Vignette – cont.

16. oMild acute pancreatitis with gallstones  Perform cholecystectomy before
discharge
oNecrotizing acute pancreatitis with gallstones  Delay cholecystectomy until
inflammation subsides
oAsymptomatic pseudocysts or sterile necrosis do NOT warrant intervention
(i.e drainage) regardless of size or location.
oDrainage of infected necrosis should be delayed for at least 4 weeks to allow
formation of walled-off necrosis.
G. Role of Surgery

17. oRole of Surgery: Given evidence of gallstones and mild acute pancreatitis,
cholecystectomy was performed before discharge to prevent recurrent
episodes of gallstones pancreatitis.
Case Vignette – cont.

18. oEarly and accurate diagnosis of acute pancreatitis is crucial.
oEarly treatment of acute pancreatitis with aggressive IV fluid hydration saves
lives and is most beneficial in the first 12-24 hours.
oRoutine prophylactic antibiotic use is not recommended for acute pancreatitis
unless presence of infected necrosis is established clinically or by FNA.
oMild acute pancreatitis due to gallstones warrants cholecystectomy before
discharge.
Summary

19. oScott Tenner MD, MPH, FACG, John Baillie MB, ChB, FRCP, FACG, John DeWitt MD, FACG and Santhi
Swaroop Vege MD, FACG. American College of Gastroenterology Guideline: Management of Acute Pancreatitis. Am
J Gastroenterol 2013; 108:1400–1415; doi:10.1038/ajg.2013.218; published online 30 July 2013.
References