Acute Pancreatitisbykemal tuke mgt K.pptx

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1. Management Of Acute Pancreatitis And It’s Complications Presenter : Dr. Kemal T. ( GSR-3) Moderator : Dr. Dessalegn T . (Assistant professor of General Surgery)

2. Outline Objectives Introduction Etiology and pathophysiology of AP Diagnostic evaluation Management of AP Management of complications of AP Summary References 5/8/2024 2

3. Objectives To understand the common etiology and pathophysiology of Acute pancreatitis To know how to assess and categorize patients based on severity To have knowledge on treatment of AP and specific complications. 5/8/2024 3

4. Introduction Acute pancreatitis ( AP ) is an acute inflammatory disease of the pancreas resulting from a variety of insults It is the most common GI disease for which patients are acutely hospitalized . World wide incidence is 5 to 80 per 100,000 population . Most of AP present as mild disease ~ 80 %. AP affects males more often than females The overall clinical outcome has improved over recent decades. 5/8/2024 4

5. Etiology 5/8/2024 5

6. Pathophysiology of AP Acute Pancreatitis begins with the premature activation of digestive zymogens inside acinar cells. Trypsinogen  trypsin  acinar cell injury  AP with SIRS Protective mechanisms for auto-digestion of the pancreas by these enzymes : Synthesis of enzymes as inactive precursors Separation of the site of production & activation of the enzymes P resence of trypsin inhibitors in the pancreas 5/8/2024 6

7. Pathophysiology The pancreas secretes the digestive enzymes as proenzymes which are activated in the intestinal lumen. Acute pancreatitis may result when activation occurs in pancreatic duct system or acinar cells. The pancreas show edema and necrosis. Premature activation of trypsinogen into trypsin while it is still in pancreas, resulting in auto digestion of the pancreas. 5/8/2024 7

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10. Diagnostic evaluation Clinical, biochemical, and radiologic features need to be considered together to diagnose AP. History Acute & constant epigastric or RUQ pain that radiates to the back. Painless acute pancreatitis ??? Nausea and vomiting ~ 90% Hx of smoking, alcohol drinking or previous hx of GB disease 5/8/2024 10

11. Diagnostic evaluation…. P/E Fever, tachycardia, abdominal tenderness, distension & ileus are common . Jaundice Dyspnea , tachypnea and basilar rales may be present. Rarely;- Cullen’s sign , grey turner’s sign and tetany. 5/8/2024 11

12. Diagnostic evaluation…. Laboratory CBC, BG & RH ; (leukocytosis , hemoconcentration ) Amylase & Lipase; 3x above UNL is diagnostic. LFT & RFT Serum electrolyte Lipid profile and serum glucose CRP, PCT 5/8/2024 12

13. Diagnostic evaluation…. Imaging Abdominal and chest radiographs Abdominal U/S Abdominal Ultrasound Abdominal computed tomography MRI “Sentinel loop sign” “Colon cut-off sign” Pleural effusion Pulmonary edema 5/8/2024 13

14. Diagnostic evaluation…. Indications of abdominal CT scan;- When diagnosis is in doubt. To assess complications in patients with severe clinical pancreatitis. Patients who fail to improve after 72 hrs. of conservative medical therapy. New onset a cute clinical deterioration To guide percutaneous drains. To determine response to treatment & before discharge of patients with severe AP. 1 st episode in patients over 40 yrs and with out identifiable cause Limitations - radiation, use of contrast (renal failure, allergy). 5/8/2024 14

15. Diagnostic criteria Presence of 2 of the following:- Acute onset of persistent, severe, epigastric pain often radiating to the back Elevation in serum lipase or amylase to three times or greater than upper normal limit and Characteristic findings of acute pancreatitis on imaging 5/8/2024 15

16. Classification of severity Accurately classifying or staging AP severity is important for;- timely administration of appropriate care assessment of treatment modalities standardization of reporting The key determinants are;- Local and Systemic complications Two classification systems have recently been proposed The Revised Atlanta Classification (RAC) The Determinants Based Classification (DBC) 5/8/2024 16

17. Predicting severity Predicting is important for;- Making triage decisions Decisions about fluid therapy Whether an ERCP is indicated etc. The most widely used prognostic criteria’s are;- Ranson’s criteria APACHE II BISAP score Modified Glasgow criteria. 5/8/2024 17

18. Predicting Severity… Other mechanism used for assessing severity of AP are: S ingle prognostic markers (CRP, HCT, PCT, and BUN) H armless acute pancreatitis score CT severity index 5/8/2024 18

19. Phases of Acute Pancreatitis Traditionally, severe AP was described as running a biphasic course with two peaks of mortality : Early Phase Lasts about 1 to 2 wks. C haracterized by a SIRS Late Phase C ompensatory , anti-inflammatory response syndrome (CARS) Weeks to months 5/8/2024 19

20. Management of Acute Pancreatitis 5/8/2024 20

21. General considerations All patients w ith suspected acute pancreatitis should be admitted to hospital. The risk of mortality is proportional to degree of severity. The management of severe AP is multidisciplinary team approach The essential requirements for the management of acute pancreatitis are;- Accurate diagnosis, Appropriate triage, High-quality supportive care, and Monitoring for and treatment of complications 5/8/2024 21

22. Initial management Admission to an ICU setting is indicated Patients with severe AP Patients with AP and one or more of the following; - PR <40 or >150 bpm SBP <80 mmHg or MAP <60 mmHg RR >35 breaths/min Serum Na+ <110 or >170mmol/L Serum K+ <2.0 or >7.0 mmol/L Pao2 <50 mmHg pH <7.1 or >7.7 Serum glucose >800 mg/dL Serum Ca++ >15mg/dL Anuria Coma Transfer to a monitored/ICU may be considered in the following patients ; Persistent SIRS (>48 hrs.) Elevated HCT (>44%),BUN (>20mg/dL) or creatinine (>1.8mg/dL) Age >60 yrs. Underlying cardiac or pulmonary disease, obesity 5/8/2024 22

23. Initial management Fluid resuscitation T he most important intervention in the early management. It is not known w/c fluid, how aggressive, or what goal to use . The aim is to restore normal blood volume, normal BP, PR, and urine output. Lactated Ringer’s solution vs NS? R ate - 5 to 10 mL/kg/h Caution for those, where the risks of over-resuscitation are greater. 5/8/2024 23

24. Management… Pain Management Pain relieve is priority, little evidence on choice of analgesic. NSAID’s, Opoids Epidural analgesia ?? 5/8/2024 24 Nutritional support No more resting the pancreas Early oral or EN recommended Oral vs EN ? Enteral over parenteral

25. Management…. Antibiotics Prophylactic - Not supported by most of recent studies Therapeutic - For established infection, choice of antibiotics ? Cholecystectomy Mild gallstone AP -- at the same admission Severe gallstone pancreatitis -- delayed cholecystectomy ERCP Absolute indications of ERCP in Acute Pancreatitis patients : - Severe g allstone pancreatitis Cholangitis LFT not improving after 2 nd to 3 rd days Persistent Cholestasis (stone on imaging) 5/8/2024 25

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27. Complications of AP 5/8/2024 27

28. Local Complications 5/8/2024 28

29. Management of local complication Severity of the systemic course doesn’t always correlate with the presence or severity of the local complications Half of the deaths attributable to AP: O ccur within the first 7 days of admission T he majority in the first 3 days Patients with severe AP who survive the first phase of illness are at risk of developing secondary infection of pancreatic necrosis 5/8/2024 29

30. Acute Pancreatic Collection (Fluid/Necrosis) Usually start to develop in the first 48 to 72 hrs & occur in 30-50%. Imaging can be done to confirm the dx and follow serially Usually remain asymptomatic and resolves spontaneously Intervention - large collection or when infection is present USG/CT guided percutaneous drainage/debridement EUS guided Trans-gastric drainage/debridement 5/8/2024 30

31. Infected pancreatic necrosis Complicates 30-70% of acute necrotizing pancreatitis & commonly at 3 rd - 4 th wk , but may occur at anytime. Most data suggested that mortality of untreated IPN approach 100 %. Diagnosis: Suspected clinical features Imaging findings; i.e. air bubble on CT Confirmation;- cultures of aspirated(CT-guided FNA) ??? 5/8/2024 31

32. Management of I PN Management of AP is essentially conservative in the first 2 weeks Therapeutic interventions—radiological, endoscopic or surgical—are indicated to treat IPN. Unlike the practice in 1980s, currently, most of the centers practice a “step-up” approach. Open necrosectomy is reserved for the sub-group of patients in whom the preceding modalities fail or not feasible. 5/8/2024 32

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34. Infected pancreatic necrosis… mgt PANTER trial (2010) compares surgical “step-up” approach vs open surgical approach It showed that 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 Mortality rate was similar among both groups C oncept of step-up approach : D elay, D rain and D ebride. 5/8/2024 34

35. Infected pancreatic necrosis… mgt Timing of intervention Surgery should be undertaken:- As late as possible after the onset (preferably 3- 4 wks ). When the necrotic process has stopped extending When there is clear demarcation b/n viable & nonviable tissues. When infected necrotic tissue has become organized & “walled off’’ 5/8/2024 35

36. Cont … Surgery for necrosis in the first 2 weeks has high risk of morbidity and mortality Indications:- Bleeding Ischemia, hollow viscus perforation Abdominal compartment syndrome I nfection which failed with conservative Rx. 5/8/2024 36

37. Infected Pancreatic Necrosis…mgt. Approaches The choice of the approach is determined by: Clinical condition of patient Local experience & expertise Anatomic position /content of the collection/ Time from presentation /maturation of the wall of collection/ 5/8/2024 37

38. Management of IPN…. The most common current treatment options for local complications of AP are : 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 5/8/2024 38

39. Management of IPN…. Percutaneous drainage/debridement lateral collections and those extending behind the colon Subsequent step-up escalation Endoscopic drainage/debridement Medial collections where a percutaneous route is compromised 5/8/2024 39

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41. Management of IPN…. Open Necrosectomy F or those patient not amenable to a minimally invasive approach Vertical midline/bilateral subcostal incision Pancreas is exposed by dividing gastrocolic ligament & entering lesser sac. If inflammatory changes obliterate lesser sac then via dividing transverse mesocolon . Blunt debridement of non-viable tissue & irrigated with several liters of N/S and removed by suction drain. 5/8/2024 41

42. Techniques of Open Necrosectomy 5/8/2024 42

43. Management of IPN …. cont Options of Open Necrosectomy Type of necrosectomy Comment Necrosectomy + closed drainage . Large-bore drains are placed & left postop at least 7 days until the effluent fluid becomes clear. Necrosectomy + closed packing Both gauze packing & drains are left at the time of surgery & gradually withdrawn postoperatively. Necrosectomy + continuous lavage High-volume of lavage of lesser sac is performed via drains placed at the time of surgery until effluent becomes clear Necrosectomy + open packing ( High morbidity & mortality rate ) Retroperitoneum is marsupialized, abdomen is left open, & necrosectomy w/t planned, staged relaparotomy. May be necessary if necrosectomy was done early. 5/8/2024 43

44. Post necrosectomy complications Residual retroperitoneal or intraperitoneal fluid collection Postoperative bleeding Early (<24 h ) – Bleeding is from colonic or peripancreatic artery Late (>24 h ) - D ue to pseudo - aneurysm common vessels are splenic, gastroduodenal, pancreaticoduodenal, and dorsal pancreatic arteries Pancreatic fistulas ( pancreatico -enteric or pancreatico-cutaneous) Exocrine and endocrine insufficiency, 25% & 30% respectively. Postoperative incisional hernias 5/8/2024 44

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46. Pseudocyst and Walled-Off Necrosis Pseudocyst fluid collection around the pancreas with minimal or no necrosis and has a well-defined wall incidence following acute pancreatitis - 5% to 15 %. Walled-off necrosis collections contain variable amount of necrosis. Diagnosis can be made on U/S, CT scan & MRI. 5/8/2024 46

47. Pathogenesis & classification of pseudocyst PATHOGENESIS Pancreatic duct disruption Pancreatic duct trauma Duct obstruction 5/8/2024 47

48. Pseudocyst and WON management Acute pseudocysts may resolve spontaneously in up to 50% of cases Asymptomatic pseudocysts can be managed expectantly and may resolve spontaneously or persist without complication . Pseudocyst without antecedent episode of AP requires investigation to determine the etiology Pseudocyst need to be differentiated from cystic neoplasm of pancreas before treatment 5/8/2024 48

49. Pseudocyst mgt … Indications of surgery Infection, either suspected radiologically or clinical picture Persistent abdominal pain. Mass effect i.e. GOO Duodenal obstruction Biliary obstruction 5/8/2024 49

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51. Pseudocyst and Walled-Off Necrosis Treatment Option Comments Percutaneous aspiration It is associated with high recurrence rates Percutaneous drainage High failure rate and external fistula especially those with duct abnormality Endoscopic cysto-gastro/duodenostomy For pts. in whom the pseudocyst/WON is adherent to the stomach/duodenum DEN for SWON Multiple stent & procedures are needed, often with mechanical debridement Open/lap cysto-gastro/duodenostomy Applicable if a portion of pseudo-cyst wall is adherent to the stomach/duodenum for anastomosis, delayed until wall maturation. Roux-en-Y cystojejunostomy Can be done if the pseudocyst wall is not adherent with the additional advantage of gravity drainage 5/8/2024 51

52. Open Surgical Treatment for Pseudocyst T he most effective and reliable means of treating a pseudocyst is internal drainage by an open surgical approach Recurrence rate is less than 5%, and mortality is less than 2 %. The pseudocyst can be drained into the stomach, the duodenum, or the jejunum. 5/8/2024 52

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56. Pancreatic Pseudocyst… COMPLICATIONS (10%) Infection Rupture Bleeding Mass effect 5/8/2024 56

57. Summary Acute pancreatitis is a challenging disease to manage with a myriad of etiologies. May progress to severe disease with sepsis, MOD and death Initial management is: relief of symptom s and preventing progression to severe disease Nonoperative management for most patients has become routine Minimally invasive options reduce the morbidity and mortality Open surgical debridement has a more limited role 5/8/2024 57

58. References Blumgart's Surgery of the Liver, Biliary and Pancreas 6 th ed. 2017 Schwartz's Principles of Surgery, 11 th ed. Maingot's Abdominal operations, 13 th ed. Shackelford's Surgery of the Alimentary Tract, Eighth Edition WSES guidelines Pub-med 5/8/2024 58

59. THANK YOU !!! 5/8/2024 59