Acute Pancreatitis Management updates from PSG

Acute pancreatitis is one of the common GI emergency.

1. Acute Pancreatitis DR NAZISH BUTT MBBS, FCPS , MACG ASSOCIATE PROFESSOR HEAD OF GASTROENTEROLOGY DEPARTMENT JINNAH POST GRADUATE MEDICAL CENTRE , WARD 25. 1

2. POINTERS DEFINITION PATHOGENESIS GLOBAL INCIDENCE CAUSES SEVERITY ASSESMENT SCORING POINTS IMAGING MODALITIES MANAGEMENT September 19, 2023 2

3. ACUTE PANCREATITIS 3

4. Pathogenesis September 19, 2023 4

5. Pathogenesis September 19, 2023 5

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7. Acute pancreatitis global incidence map:  Global Incidence of Acute Pancreatitis Is Increasing Over Time: A Systematic Review and Meta-Analysis Published:September 24, 2021DOI: https://doi.org/10.1053/j.gastro.2021.09.043 7

8. The worldwide incidence of Acute Pancreatitis (AP) is 34 per 100,000 people, and on rapid rise worldwide. The overall mortality rate is estimated to be approximately 20 %. MS Petrov , D Yadav . Global epidemiology and holistic prevention of pancreatitis. Nat Rev Gastro enterol Hepatol 2019; 16:175-84. 8

9. Diagnostic criteria for AP Besselink M., van Santvoort H., Freeman M., Gardner T., Mayerle J., Vege S.S., Werner J., Banks P., McKay C., Fernandez-del Castillo C., et al. IAP/APA evidence-based guidelines for the management of acute pancreatitis.  Pancreatology .  2013;13:E1–E15 9

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11. Should be done in all patients within 48 hours To risk stratify patients as per severity scores Early transfer to ICU if needed To monitor ongoing severity To prevent complications and mortality 11

12. S everity A. Leppäniemi , M. Tolonen , A. Tarasconi et al., “2019 WSES guidelines for the management of severe acute pancreatitis,”  World Journal of Emergency Surgery : WJES , vol. 14, no. 1, p. 27, 2019 12

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14. Ranson’s Score 14

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16. CTSI SCORE 17 It has maximum of 10 points It’s the sum of B althazar grade points and pancreatic necrosis grade points

17. Defining severity of AP in terms of different scores September 19, 2023 18

18. Initial imaging –USG The main role of ultrasound is:  to identify  gallstones  as a possible cause diagnosis of vascular complications, e.g. thrombosis identify areas of necrosis that appear as hypoechoic regions assessment of clinically similar etiologies of an acute abdomen September 19, 2023 19

19. USG abdomen-Normal anatomy September 19, 2023 20

20. Ultrasound findings Radiopedia   Mohammadtaghi Niknejad ◉ on 22 Jun 2023 21

21. CT scan pancreatic protocol Purpose Best-done ≥2-3days after symptom onset S taging and severity assessment S earch for etiology ( choledocholithiasis ,  autoimmune pancreatitis ,  groove pancreatitis  etc.) D etection of complications in early and late phases including extrapancreatic complications   Radiopedia Mohammadtaghi Niknejad ◉ on 22 Jun 2023 22

22.   CT Pancreas - Triphasic contrast study Early arterial phase: 10-15 seconds post contrast arteriogram – celiac artery, SMA Delayed arterial phase: 35-45 seconds post contrast pancreatic parenchymal phase, to detect necrosis/ mass/ hemorrhage . Venous phase: 60-70secs post contrast contrast is predominantly in Portal vein, HV and IVC, delineated liver parenchyma and associated vascular involvement. Radiodpedia   Mohammadtaghi Niknejad ◉ on 22 Jun 2023 23

23. CT abdomen with contrast   Radiopedia Mohammadtaghi Niknejad ◉ on 22 Jun 2023 24

24.   Radiopedia Mohammadtaghi Niknejad ◉ on 22 Jun 2023 25

25. Acute Pancreatitis: Revised Atlanta Classification and the Role of Cross-Sectional Imaging https://doi.org/10.2214/AJR.14.14056 26

26. Complications S. Tenner, J. Baillie, J. DeWitt, and S. S. Vege , “American College of Gastroenterology guideline: management of acute pancreatitis,”  The American Journal of Gastroenterology , vol. 108, no. 9, pp. 1400–1415, 2013 . M. Yokoe , T. Takada, T. Mayumi et al., “Japanese guidelines for the management of acute pancreatitis: Japanese Guidelines 2015,”  Journal of Hepato -Biliary-Pancreatic Sciences , vol. 22, no. 6, pp. 405–432, 2015. 27

27. Basic management principles The American College of Gastroenterology suggests aggressive early hydration, such as 250–500 ml/hour, especially for the first 24 hours. The preferable method to determine the volume status and to adjust the fluid administration after the first 24 hours is by central venous pressure (CVP) measurement. Ringer’s lactate solution is considered superior to normal saline. S. Tenner, J. Baillie, J. DeWitt, and S. S. Vege , “American College of Gastroenterology guideline: management of acute pancreatitis,”  The American Journal of Gastroenterology , vol. 108, no. 9, pp. 1400–1415, 2013. 28

28. Role of Antibiotics Recent scientific data have proven that prophylactic antibiotics do not decrease mortality and morbidity rates and therefore are no longer recommended for all AP cases. Infected necrosis should be suspected in patients with pancreatic or extrapancreatic necrosis who show no signs of improvement after 7–10 days of hospitalization. S. Tenner, J. Baillie, J. DeWitt, and S. S. Vege , “American College of Gastroenterology guideline: management of acute pancreatitis,”  The American Journal of Gastroenterology , vol. 108, no. 9, pp. 1400–1415, 2013. 29

29. Role of Antibiotics The most common Gram-negative bacterial species are  Pseudomonas aeruginosa ,  Escherichia coli ,  Klebsiella pneumoniae , and  Acinetobacter baumannii , The most common Gram-positive bacterial species are  Staphylococcus epidermidis and   Staphylococcus aureus . Antibiotics known to penetrate pancreatic necrosis should be given, such as third- or fourth-generation cephalosporins , carbapenems , quinolones, and metronidazole CT-guided FNA of collection for strain and Gram culture remains the diagnostic tool September 19, 2023 S. Tenner, J. Baillie, J. DeWitt, and S. S. Vege , “American College of Gastroenterology guideline: management of acute pancreatitis,”  The American Journal of Gastroenterology , vol. 108, no. 9, pp. 1400–1415, 2013. 30

30. Feeding E arly enteral feeding lowers the rates of infective complications, MOF, SIRS, and overall mortality, as well as intra-abdominal hypertension  .  Current evidence-based data recommend initiation within the first 24 to 48 hours Low-fat , solid diet When oral feeding is not feasible, either nasogastric or nasojejunal delivery could be used with the same safety and efficacy  . September 19, 2023 S. Tenner, J. Baillie, J. DeWitt, and S. S. Vege , “American College of Gastroenterology guideline: management of acute pancreatitis,”  The American Journal of Gastroenterology , vol. 108, no. 9, pp. 1400–1415, 2013. 31

31. Pain management P atient-controlled analgesia should be integrated with every possible strategy, including intravenous, epidural, and multimodal approaches   The parenteral analgesics used for pain control in AP can be divided into three groups: opioid analgesics, local anaesthetics , and nonsteroidal anti-inflammatory drugs (NSAIDs ). Parenteral opioids that are frequently used include buprenorphine, pethidine , morphine, and fentanyl September 19, 2023 S. Tenner, J. Baillie, J. DeWitt, and S. S. Vege , “American College of Gastroenterology guideline: management of acute pancreatitis,”  The American Journal of Gastroenterology , vol. 108, no. 9, pp. 1400–1415, 2013. 32

32. Management S. Tenner, J. Baillie, J. DeWitt, and S. S. Vege , “American College of Gastroenterology guideline: management of acute pancreatitis,”  The American Journal of Gastroenterology , vol. 108, no. 9, pp. 1400–1415, 2013. 33

33. Addressing complications September 19, 2023 S. Tenner, J. Baillie, J. DeWitt, and S. S. Vege , “American College of Gastroenterology guideline: management of acute pancreatitis,”  The American Journal of Gastroenterology , vol. 108, no. 9, pp. 1400–1415, 2013. 34

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35. THANKYOU September 19, 2023 36