ACUTE PANCREATITIS management journal club .pptx

Acute pancreatitis

1. ACUTE PANCREATITIS Presenter – Mohammad Juned Ansari Moderator – Prof Sadaf Ali

2. Introduction Acute pancreatitis is one of the most common causes of hospitalisation from gastrointestinal diseases. Global incidence ranging from 5-30 cases per 100,000 population per year.

3. Alcohol is still the dominant disease in Western countries I n Eastern countries, especially Asia, the most common cause is biliary disease (49-54%) D rug reactions, pancreatic and cystic malignancies, and hypertriglyceridemia are other causes.

4. Grading and Severity

5. Score more than 2 of any organs indicate organ failure Revised Atlanta recommend Modified Marshall scoring system as the main tool in determining organ failure

6. Diagnosis E pigastric pain, followed by nausea and vomiting. R ebound tenderness, abdominal distention, Cullen’s sign, Grey Turner’s sign I ncrement of amylase or lipase more than 3 times upper limit of the normal range Pancreatic gland necrosis completely appears in 4 days after the onset of SAP. Before that time, CE-CT scan cannot precisely detect pancreatic necrosis

7. Management Fluid resuscitation Fluid loss d/t - excessive vomiting, reduced oral intake, third space extravasation , respiratory losses, and Diaphoresis Ringer Lactate is the preferred choice in resuscitation

8. NS vs RL

9. Hematocrit < 44%-47% is a risk factor for developing necrosis in the pancreas Aggarwal A, Manrai M, Kochhar R. Fluid resuscitation in acute pancreatitis. World J Gastroenterol . 2014; 20(48):18092-103. https://doi.org/10.3748/wjg.v20.i48.18092 PMid:25561779 PMCid:PMC4277949 If fluid resuscitation had been done, BUN was not decreased, then the patient would have increased risk of pancreas necrosis Wu BU, Hwang JQ, Gardner TH, Repas K, Delee R, Yu S, Smith B, Banks PA, Conwell DL. Lactated Ringer's solution reduces systemic inflammation compared with saline in patients with acute pancreatitis. 2011; 9(8):710-17 B eside BUN and hematocrit , the physician recommended to monitor urine output (> 0.5 ml/kg/hour)

10. WATERFALL trial included 249 patients from India, Italy, Mexico, and Spain The patients were randomized in a 1:1 ratio to receive either aggressive fluid resuscitation or moderate fluid resuscitation Aggressive resuscitation - bolus of lactated Ringer’s solution (LR) at a dose of 20 mL /kg of body weight administered over a period of 2 hours, followed by infusion at a rate of 3 mL / kg per hour

11. Moderate fluid resuscitation - 10 mL /kg bolus if the patient was also diagnosed with hypovolemia , f/b LR at a dose of 1.5 mL /kg per hour. trial’s primary efficacy outcome was the development of moderately severe or severe acute pancreatitis during hospitalistation .

12. 17% of the patients receiving moderate fluid resuscitation progressed to moderately severe and severe pancreatitis, compared to roughly 22% in the aggressive resuscitation arm Patients receiving the aggressive fluid treatment had a fluid overload of roughly 20%, versus roughly 6% in the moderate resuscitation arm.

13. Nutrition Enteral nutrition was recommended for severe acute pancreatitis over parenteral nutrition. Enteral nutrition was suggested to be given as early as 48 hours of admission Shah AP, Mourad MM, Bramhall SR. Acute pancreatitis: current perspectives on diagnosis and management. Dovepress . 2018; 11:77-85 Early enteral nutrition could reduce mortality, multiple organ failure and infection in comparison with late enteral nutrition and parenteral nutrition Li Y, Yu T, Chen G, et al. Enteral nutrition within 48 hours of admission improves clinical outcomes if acute pancreatitis by reducing complications: a meta -analysis. Plos One . 2013

14. Contraindications of EN prolonged paralytic ileus Abdominal Compartment Syndrome mesenteric ischemia enteric fistulae

15. Enteral vs TP Nutrition

16. NJ vs NG Feeding

17. Antibiotics Antibiotic as prophylaxis does not decrease mortality and secondary infection significantly. given as prophylaxis when infection marker, such as procalcitonin , IL-6, is detected. recommended antibiotics in treating severe acute pancreatitis that covers gram-positive (Clostridium) and gram-negative (E. coli, Klebsiella , Pseudomonas, Proteus) as well as anaerobes such as imipenem , meropenem , ciprofloxacin, clindamycin and metronidazole

18. S uggest that procalcitonin -guided care can reduce antibiotic use without increasing infection or harm in patients with acute pancreatitis

19. Analgesics P ain management needs to be given in the first 24 hours to maintain the patient’s quality of life WHO analgesic ladder Step 1 : NSAID, Step 2 : low potent opioid ± NSAID Step 3 : High potent opioid ± NSAID Step 4 : interventional treatment ± high potent opioid ± NSAID

20. Opioids had been reported in the past study as a trigger of spasm of the sphincter of Oddi . In a recent Cochrane review on five RCTs showed no difference between opioids and other analgesic options regarding the risk of complications or clinically serious adverse events Basurto Ona X, Rigau Comas D, Urrutia G - Opioids for acute pancreatitis pain. Cochrane Database Syst Rev. 2013. 7:CD009179 meta-analysis that was made by Stigliano et al. concluded there was no credible evidence to avoid the use of morphine in managing pain in acute pancreatitis Stigliano S, Sternby H, Madaria E, Capurso G, Petrov MS. Early management of acute pancreatitis: A review of best evidence. Digestive and Liver Disease. 2017; 49:585-94.

21. Somatostatin and octreotide I nhibitors of exocrine pancreatic secretion and further prevent the release and activation of enzymes. W Uhl et al . revealed that octreotide had no benefit in the treatment of acute pancreatitis. Paran et al. showed that in their study, complication rate was lower in treatment group than in control group (sepsis [24% vs 76%, p < 0.0002], ARDS [28% vs 56%, p = 0.04]).

22. Surgical management Treatment options for infected necrotizing pancreatitis Percutaneous retroperitoneal or transperitoneal drainage. Endoscopic transmural or transpapillary drainage. Minimally invasive retroperitoneal necrosectomy . Video-assisted retroperitoneal debridement. Endoscopic therapy necrosectomy . Laparoscopic or open necrosectomy . Laparoscopic or open cystgastrostomy or cystojejunostomy

23. PANTER trial term ‘step-up’ was coined with this trial It randomized 88 patients to either an open necrosectomy or a step-up approach , defined as either a percutaneous drain or an endoscopic transgastric drainage followed by minimally invasive retroperitoneal necrosectomy if necessary.

24. major complications such as new-onset organ failure, perforation, fistula or bleeding occurred in 12% of patients in the step-up group compared with 40% in the open group (p=0.002). less organ failure, diabetes, and incisional hernia in the step-up group

25. PENGUIN trial comparing specifically endoscopic transgastric drainage versus surgical necrosectomy randomized 20 patients and evaluated the inflammatory response as well as secondary endpoints inclusive of major complications or death. Patients in both groups underwent video-assisted retroperitoneal necrosectomy , if necessary

26. initiating with a transgastric endoscopic necrosectomy had reduced risk of major complications or death (20% vs. 80%; risk difference 0.60; 95% CI 0.16 to 0.80; p=0.03).

27. TENSION trial This study randomized 98 patients with infected pancreatic necrosis to receive initial management with either endoscopic drainage or percutaneous drainage, with escalation as necessary. The results of this study found the study groups to be comparable in primary outcomes of major complications or death (43% vs. 45%, relative risk 0.97, 95% CI 0.62 to 1.51; p=0.88).

28. Differences between the groups were noted in the secondary endpoints of new-onset cardiovascular failure and persistent cardiovascular failure in the percutaneous group (relative risk 0.21, 95% CI 0.09 to 1.07; p=0.045 and relative risk 0.23, 95% CI 0.05 to 1.03; p=0.32) P ancreatic fistula was lower in the endoscopy group (5% vs. 32%, relative risk 0.15, 95% CI 0.04 to 0.62; p=0.0011) as well as a shorter hospital stay by 16 days on average (53 days (SD 47) vs. 69 days (SD 38), p=0.014)

29. MISER trial compares endoscopic step-up approach to minimally invasive surgery (defined as a laparoscopic necrosectomy or video-assisted retroperitoneal debridement). primary endpoints of death or major complications. primary endpoints occurred in 11.8% of the endoscopic group and 40.6% of the surgical group rate of death was comparable between groups

30. 28.1% rate of pancreatic fistula in the surgical group compared with none in the endoscopic group (p=0.001). endoscopic group showed lower rates of systemic inflammatory response syndrome (SIRS), early resolution of pre-existing SIRS, and fewer patients with new-onset SIRS

31. POINTER trial C ompared immediate drainage within 24 hours after randomization once infected necrosis was diagnosed with drainage that was postponed until the stage of walled-off necrosis was reached.

32. Mortality was 13% in the immediate-drainage group and 10% in the postponed-drainage group. mean number of interventions (catheter drainage and necrosectomy ) was 4.4 in the immediate-drainage group and 2.6 in the postponed-drainage group In the postponed-drainage group, 19 patients (39%) were treated conservatively with antibiotics and did not require drainage

33. This trial did not show the superiority of immediate drainage over postponed drainage with regard to complications in patients with infected necrotizing pancreatitis

34. ExTENSION Trial long-term follow-up study reevaluated all clinical data on 83 patients (of the originally 98 included patients) from the TENSION trial who were still alive after the initial 6-month follow-up.

35. The primary end point, similar to the TENSION trial, was a composite of death and major complications Secondary end points included pancreaticocutaneous fistula, reinterventions , pancreatic insufficiency, and quality of life

36. After a mean followup period of 7 years, the primary end point occurred in 27 patients (53%) in the endoscopy group and in 27 patients (57%) in the surgery group. Fewer pancreaticocutaneous fistulas were identified in the endoscopy group (8% vs 34%; RR, 0.23; 95% CI, 0.08–0.83). Pancreatic insufficiency and quality of life did not differ between groups.

37. At long-term follow-up, the endoscopic step-up approach was not superior to the surgical step-up approach in reducing death or major complications in patients with infected necrotizing pancreatitis. P atients assigned to the endoscopic approach developed overall fewer pancreaticocutaneous fistulas and needed fewer re interventions.

38. Thank You