Acute pancreatitis investigations and treatment

prepared this as a part of my seminar.hope u guys like it

1. INVESTIGATIONS AND TREATMENT OF ACUTE PANCREATITIS MODERATOR – Dr.Basavaraj CHAIR PERSON – Dr.Rajanna Presented by Dr.Anuraj

2. LAB tests Diagnosis of AP- clinical findings+ elevation of pancreatic enzyme levels in the plasma threefold or higher elevation of amylase and lipase levels confirms the diagnosis. INVESTIGATIONS

3. SERUM AMYLASE Normal value 23-85U/L IF >4 times normal levels (>450 U/L) Normal levels do not exclude AP esp. if patient present 48 hrs later Less sensitivity and specificity

4. SERUM LIPASE Normal value 0-160 U/L If elevated (>400 U/L) likely indicate pancreatic damage or pancreatitis rises 4 to 8 hours from the onset of symptoms and normalizes within 7 to 14 days after treatment

5. CBC: neutrophil leucocytosis Electrolyte abnormalities include hypokaemia , hypocalcemia Elevated LDH in biliary disease Glycosuria ( 10% of cases) Blood sugar: hyperglycaemia in severe cases Serum phosphate LFTs RFTs CRP Routine

6. To RULE OUT other conditions, such as perforated ulcer disease. Nonspecific findings - cutoff colon sign gaseous distension seen in proximal colon associated with with narrowing of the splenic flexure - Widening of the duodenal C loop caused by severe pancreatic head edema - complications of lung such as pleural effusion, pulmonary edema and interstitial inflammation. X ray

7. to find an enlarged pancreas, a pseudocyst , ascites , biliary stone, dilated common bile duct and other pancreatic mass The usefulness of ultrasound to diagnose pancreatitis is limited by intra-abdominal fat and increased intestinal gas as a result of the ileus . However USG should be ordered because of high sensitivity in diagnosing gallstones Ultrasound

8. Contrast enhanced CT If the patient has….. Signs of severe acute pancreatitis No signs of clinical improvement after several days Diagnostic dilemma Infection suspected T > 101 o F Positive blood cultures What are you looking for? Necrosis : Lack of enhancement with contrast Fluid Collections Alternate diagnosis Acute Pancreatitis When Do I Order A CT?

9. Pancreas Pancreatic enlargement Decreased density due to edema Intrapancreatic fluid collections Blurring of gland margins due to inflammation Peripancreatic Fluid collections and stranding densities Thickening of retroperitoneal fat Acute Pancreatitis CT Findings * It may take up to 72h for inflammatory changes to become apparent on CT *

10. Acute Pancreatitis CT Findings Tail Indistinct Intraperitoneal fluid PANC LIVER

11. Acute Pancreatitis CT Findings Severe Pancreatitis Peripancreatic edema and inflammation Unenhancing Necrosis PANC LIVER GB

12. Acute Pancreatitis Normal Pancreas

13. CTSI, 0-3, mortality 3%, morbidity 8%; CTSI, 4-6, mortality 6%, morbidity 35%; CTSI, 7-10, mortality 17%, morbidity 92%.

14. useful to evaluate the extent of necrosis, inflammation , and presence of free fluid . Cost and availability limits its applicability Not indicated in the acute setting of AP unexplained or recurrent pancreatitis - the biliary and pancreatic duct anatomy.To rule out pancreas divisum , intraductal papillary mucinous neoplasm ( IPMN ), small tumor in the pancreatic duct. MRI - MRCP

15. Assessment of severity of disease RANSON’S CRITERIA MODIFIED GLASGOW CRITERIA ATLANTA classification Acute Physiology and Chronic Health Evaluation (APACHE II) MANAGEMENT

16. For non-gallstone pancreatitis , the parameters are: At admission: Age in years > 55 years White blood cell count > 16000 cells/mm 3 Blood glucose> 10 mmol /L (> 200 mg/ dL ) Serum AST > 250 IU/L Serum LDH > 350 IU/L Within 48 hours: Serum calcium < 2.0 mmol /L (< 8.0 mg/ dL ) Hematocrit fall > 10% Oxygen (hypoxemia PaO 2 < 60 mmHg) BUN increased by 1.8 or more mmol /L (5 or more mg/ dL ) after IV fluid hydration Base deficit (negative base excess) > 4 mEq /L Sequestration of fluids > 6 L RANSON’S CRITERIA

17. For gallstone pancreatitis , the parameters are: At admission: Age in years > 70 years White blood cell count > 18000 cells/mm 3 Blood glucose > 12.2 mmol /L (> 220 mg/ dL ) Serum AST > 250 IU/L Serum LDH > 400 IU/L Within 48 hours: Serum calcium < 2.0 mmol /L (< 8.0 mg/ dL ) Hematocrit fall > 10% Oxygen (hypoxemia PaO 2 < 60 mmHg) BUN increased by 1.8 or more mmol /L (5 or more mg/ dL ) after IV fluid hydration Base deficit (negative base excess) > 5 mEq /L Sequestration of fluids > 4 L

18. Acute Pancreatitis MORTALITY † MORBIDITY * † Sn 73%, Sp 77% * > 7 d in ICU

19. GLASGOW’S

20. Management depends on SEVERITY MILD ACUTE PANCREATITIS Acute pancreatitis No dysfunction of organ or local complications Ranson’s score <3 or CT grading: A, B, C or CTSI <2 SEVERE ACUTE PANCREATITIS Acute pancreatitis Local complications or organ failure or Ranson’s score >3 or CT grading: D, E or CTSI >3. MANAGEMENT

21. Supportive care,fluid resuscitation and electrolyte balance NPO with i.v . fluids and electrolytes Analgesia Morphine Nutrition If unable to meet adequate protein and calorie needs within 5 days -> nasoenteric feeding Management of mild acute pancreatitis

22. Antibiotics Routine antibiotics not recommended General recommendations for use: Biliary pancreatitis with signs of cholangitis > 30% necrosis on CT scan OPERATIVE MANAGEMENT Early cholecystectomy once symptoms have subsided and cholestatic liver enzymes have returned to normal in GALLSTONE PANCREATITIS If cholestatic enzymes not returned to normal then suspect choledocholithiasis and do ERCP

23. Mainstay of management is Early diagnosis Aggressive resuscitation Staging by clinical scoring systems Radiologic imaging MANAGEMENT OF SEVERE ACUTE PANCREATITS

24. Admission to ICU Aggressive fluid resuscitation Analgesia Invasive monitoring of vitals,CVP,urine output,blood gases Nasogastric aspiration Frequent monitoring of lab investigations Antibiotics - imipenem Supportive therapy for organ failure ERCP if cholangitis

25. Timing of cholecystectomy Should be delayed until patient is stabilised,pseudocyst resolves or if it persists beyond 6 weeks then drained concomitantly at time of cholecystectomy

26. Infected necrosis Organisms on gram stain after aspirate Surgical drainage Trans-gastric drainage Try to delay necrosectomy 2-3wk for demarcation of necrosis Pancreatic abscess CT or EUS guided drainage Walled collection of pus Similar to management of pseudocyst Acute Pancreatitis Management of Pancreatic Complications

27. Open Endoscopic transluminal Once necrosectomy is completed,further necrotic tissue may form - Closed continuous lavage ( Beger ) -Closed drainage -Open packing -Closure and relaporotomy NECROSECTOMY

28. necrosectomy

29. Collection of pancreatic fluid enclosed by wall of granulation tissue Complicates 5-10% cases of AP Usually 4 weeks after attack The diagnosis is corroborated with by CT 25-50% resolve spontaneously Acute Pancreatitis Pseudocysts

30. Infection - 14% Rupture - 6.8% Hemorrhage - 6.5% Common bile duct obstruction - 6.3% GI obstruction - 2.6% Acute Pancreatitis Complications of Pseudocyst

31. Observation for asymptomatic patients spontaneous regression has been documented in up to 70% of cases Invasive therapies are indicated for symptomatic patients or when the differentiation between a cystic neoplasm and pseudocyst is not possible. PSEUDOCYST MANAGEMENT

32. Percutaneous endoscopic drainage Surgical drainage is indicated for patients with pancreatic pseudocysts that cannot be treated with endoscopic techniques and patients who fail endoscopic treatment - cystogastrostomy - cystoduodenostomy

33. Acute Pancreatitis Endoscopic Pseudocyst Management

34. Acute Pancreatitis Percutaneous Pseudocyst Drainage Open Cystgastrostomy

35. Acute Pancreatitis Laparoscopic Cyst Gastrostomy

36. Bailey and love’s Sabiston textbook of surgery Shackelford’s surgery of alimentary tract COURTESY

37. THANKYOU