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Acute Pancreatitis
Department of Critical Care Medicine
King Saud Medical City
Riyadh, Saudi Arabia
Muhammad Asim Rana
MBBS, MRCP, SF-CCM, EDIC, FCCP
Learning Objectives
Diagnose acute pancreatitis and determine the severity, etiological factors and
complications. Recognize the patient at risk.
Manage severe acute pancreatitis with appropriate use of supportive therapy for
organ function, antibiotics and surgery.
Feed the patient with acute pancreatitis. Determine nutritional needs of patients
with acute pancreatitis and the optimum mode of delivery.
Identify and manage local and systemic complications of acute pancreatitis
1
2
3
4
INTRODUCTION
1. Reported incidence ranges from 21 to 900 cases per million, per year.
2. Overall mortality rate ranges from 2 to 10% but reaches 10 to 40% in ANP.
3. Those > 60 years are at the highest risk of death as consequence of co morbidity.
The male/female ratio ranges from 1/1.2 - 1/1.5. Females for biliary pancreatitis &
males for acute pancreatitis secondary to alcohol abuse.
Epidemiology of acute pancreatitis
1
2
3
4
GALLSTONES
ETHANOL
TRAUMA
STEROIDS
MUMPS/VIRUSES
AUTOIMMUNE(PAN)
SCORPIONVENOM/Toxins
HYPERLIPIDEMIA
ERCP
DRUGS
G E T S M A S H E D
Causes of Acute Pancreatitis
Diagnosis of acute pancreatitis
Symptoms Signs
Grey Turner’s signCullen’s Sign
Laboratory Investigations
S/AmylaseS/LipaseUrine amylaseOther Enzymes
Non enzymatic pancreatic
secretory products
PAP TAP CAPAP
Markers of immune activation
& nonspecific markers
IL-6, IL-8, IL-10
TNF
PMN Elastase
CRP
Radiological Investigations
Plain X-Ray Ultrasound
CT Scan MRI
Pancreatitis without pain is particularly misleading. Lack of a major symptom is
usually attributed to a postoperative situation where analgesics/sedatives are in use.
Diagnostic pitfalls
Diabetic comasevere hypothermia remote organ failuresSevere GI bleeding
Pancreatic swelling
Lack of enhancement
Peri-pancreatic fluid
collection
Diagnostic Imaging
How to recognize the at risk patient
System Manifestations Significance
General
CVS
Pulmonary
Renal
Neurological
Abdominal
Age > 60
BMI > 30 Kg/m2
Risk of local & systemic
complications
↓ BP, ↑HR,↑ Lactate
Tachypnea,Cyanosis
↓ OUT PUT
↑ Creatinine
Confusion
Agitation
Tense abdomen
ReboundTenderness
Risk of local & systemic
complications
Impending remote organ
failure
Impending remote organ
failure
Impending remote organ
failure
Extent of peritoneal
involvement
Definition of severe pancreatitis
 Acute pancreatitis + organ failure and/or
 Acute pancreatitis + local complications
 Three or more Ranson Criteria OR
 APACHE II > 8
Early assessment of severity
Ranson’s criteria
ON Admission After 48 hours
G A L A W
Glucose > 200 mg%
Age > 55 yrs
LDH > 350
AST > 250
WBCs > 16000
C H O B B SCalcium < 8.0
Haematocrit ↓ by > 10%
PaO2 < 60
Base Excess > 4
BUN ↑ > 5 mg%
Sequestered fluid > 6 liters
Glasgow (Imrie) scoring system
P A N C R E A S
PaO2 < 8kPa
Age > 55yrs
Neutrophils (WBCs)> 15x 109 / L
Calcium < 8mg% (2mmol)
Renal – Urea > 16 mmol/L (45 mg/dL)
Enzymes LDH > 600 iU/L, AST > 200iU/L
Albumin < 32 G /L
Sugar (Blood Glucose)> 10 mmol /L (180mg%)
Grading based upon findings on unenhanced CT
Grade Findings Score
A Normal pancreas - normal size, sharply defined, smooth
contour, homogeneous enhancement, retroperitoneal
peripancreatic fat without enhancement
0
B Focal or diffuse enlargement of the pancreas, contour may
show irregularity, enhancement may be inhomogeneous but
there is on peripancreatic inflammation
1
C Peripancreatic inflammation with intrinsic
pancreatic abnormalities
2
D Intrapancreatic or extrapancreatic fluid collections 3
E Two or more large collections of gas in the
pancreas or retroperitoneum
4
Necrosis, percent SCORE
0 0
Less than 33% 2
33-50% 4
More than 50% 6
Necrosis score based upon contrast enhancedCT
AGA Guidelines for CT Scan
Patients in whom the diagnosis is in doubt.
Patients with Ranson >3 or APACHE II ≥8
In patients with predicted severe disease
and those with evidence of organ failure during the
initial 72 hours, rapid-bolus CT should be performed
after 72 hours of illness to assess the degree of
pancreatic necrosis.
Labs adjunct to clinical judgment and the APACHE II .
A CRP level of >150 mg/L at 48 hours is preferred
Other Severity Indices
The APACHE II score
Systemic inflammatory response syndrome score
Bedside index of severity in acute pancreatitis (BISAP) score
Harmless acute pancreatitis score
Organ failure-based scores
Management of Severe Acute Pancreatitis
General Intensive Care
SpecificTreatment Modalities
Surgery or No Surgery
Feeding the patient
Managing the Complications
General intensive care
Supportive therapy of vital organs
Cardiovascular system
Nowadays infection of
pancreatic necrosis
accounts for 50-80% of the
deaths
Splanchnic ischaemia is a 2nd
local hit:
Retroperitoneal necrosis, gut
barrier dysfunction, and
Secondary pancreatic infection
may ensue
Local splanchnic perfusion may be
worsened by abdominal
compartment syndrome-
increased pressure due to intra
abdominal oedema, fluid
sequestration and excessive fluid
resuscitation.
Respiratory system Prevention/correction of hypoxia.
Early physiotherapy and adequate analgesia (perhaps using epidural
analgesia) to ensure free airways and to prevent atelectasis, prevent
pulmonary aspiration by nasogastric decompression.
CPAP/ BIPAP/ Invasive MechanicalVentilation
Renal system Prevent and/or minimize renal injury by
rapid correction of hypovolaemia
If acute renal failure develops, start renal replacement therapy
without delay to ensure optimal fluid and metabolic control and
to enable nutritional support without haemodynamic instability.
CVVHD is preferred.
Gastrointestinal system
Beware of intra-abdominal
hypertension and assess the patient
for this complication regularly.
If abdominal compartment syndrome occurs, consider decompression either
surgically or in cases of colonic distension with a wide bore tube inserted via
the rectum. Abdominal compartment syndrome should be suspected
whenever there is evidence of new or worsening organ dysfunction.
Pain relief
Conventional Analgesics (IV)
Use of MORPHINE
Epidural Analgesia
( mixture of diluted
local anaesthetic solution
(bupivacaine) and opiates)Miscellaneous
Octreotide
Somatostatin
Protease Inhibitors
(Aprotinin & Gabexate Mesilate)
Anti inflammatory Rx
Stress Ulcer Prophylaxis
DVT Prophylaxis
Specific therapeutic modalities
Antibiotics
Systemic Antibiotics
Use antibiotics on demand for sepsis rather than
prophylactically!
Selective Decontamination of
the Digestive system (SDD)
Antibiotics are an adjuvant therapy in infected pancreatic necrosis.
Drainage is mandatory for most if not all pancreatic infections.
Indications for surgery
Controversial indicationsUndisputed indications
Infected pancreatic necrosis when
percutaneous/other techniques not indicated
Severe retroperitoneal haemorrhage
Acute abdomen – peritonitis
Biliary obstruction in case of failure of
Endoscopic Sphincterotomy
Abdominal compartment syndrome where
percutaneous/other drainage techniques not
successful.
Controversial indications
Extensive (>50%) sterile pancreatic necrosis
Early ‘routine’ debridement of necrosis
irrespective of its bacteriological status in
order to prevent remote organ dysfunction
and pancreatic infection
Persisting multiple organ failure despite intensive care therapy
Early and repeated removal of necrotic tissue combined
with continuous drainage/lavage have been advocated to
overcome systemic effects.
Neither the extent of sterile pancreatic necrosis, the
clinical severity of the disease or the duration of
intensive supportive therapy should be regarded as
indications for surgery.
NOTE
Feeding the pt of SAP
Nutritional therapy: How, what and when?
Route of nutrient delivery:
Enteral versus parenteral
The more distally that
nutrients are infused in
the gut, the less they
stimulate pancreatic
secretion
The enteral route is safe
in acute pancreatitis, so
whenever possible,
use it!
In order to maximise clinical benefit, enteral
feeding should be initiated as soon as possible
after admission in all attacks predicted to be
severe.
Patients in whom enteral access cannot be
achieved or in whom clear-cut contraindications
(intestinal rupture, obstruction, or necrosis),
intolerance, or exacerbation of the disease
occurs should be considered for partial or total
parenteral nutrition (TPN).
Some Important Aspects of Feeding
Composition of the diet
Prescription and timing of nutrient administration
Issue of Functional Ileus
Oral refeeding
Complications of nutritional therapy
Resuscitation
Severity Index
Severe Disease Mild Disease
Conservative RxCT Scan
Balthazar > 7
Balthazar < 7
Management of Severe Acute Pancreatitis
Balthazar > 7
Aggressive Hydration/Antibiotics/ Entral feeding/TPN
No Improvement Improvement
Continue Same Rx
CT Guided Aspiration Deterioration
CT Guided Aspiration
Infected Sterile
Supportive Rx
Appropriate Antibiotics
Attempt to wait for 3-4
weeks from onset
NO IMPROVEMENT ?
NO IMPROVEMENT ?
Organized Collection Diffuse Collection
Percutaneous/ Endoscopic/
Laparoscopic drainage
Minimal access or Surgical
Debridement
Approach to Treat NECROSIS
Fine Needle Aspiration
SterileInfected
Aggressive
ICU Rx
Improvement
No Improvement
Endoscopic Expertise Available
YESNO
Necrosectomy
Percutaneous
Drainage
Necrosectomy
Necrosis EndoscopicallyAccessible
(posterior gastric or medial
duodenal wall)
Necrosis in peripancreatic,
retrodudenal, perinephric
Endoscopic Necrosectomy Laparoscopic Necrosectomy
No Improvement
Surgical Drainage
Adjuvant Percutaneous Drainage
I think its enough

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Acute pancreatitis basics

  • 1. Acute Pancreatitis Department of Critical Care Medicine King Saud Medical City Riyadh, Saudi Arabia Muhammad Asim Rana MBBS, MRCP, SF-CCM, EDIC, FCCP
  • 2. Learning Objectives Diagnose acute pancreatitis and determine the severity, etiological factors and complications. Recognize the patient at risk. Manage severe acute pancreatitis with appropriate use of supportive therapy for organ function, antibiotics and surgery. Feed the patient with acute pancreatitis. Determine nutritional needs of patients with acute pancreatitis and the optimum mode of delivery. Identify and manage local and systemic complications of acute pancreatitis 1 2 3 4
  • 3. INTRODUCTION 1. Reported incidence ranges from 21 to 900 cases per million, per year. 2. Overall mortality rate ranges from 2 to 10% but reaches 10 to 40% in ANP. 3. Those > 60 years are at the highest risk of death as consequence of co morbidity. The male/female ratio ranges from 1/1.2 - 1/1.5. Females for biliary pancreatitis & males for acute pancreatitis secondary to alcohol abuse. Epidemiology of acute pancreatitis 1 2 3 4
  • 5. Diagnosis of acute pancreatitis Symptoms Signs Grey Turner’s signCullen’s Sign
  • 6. Laboratory Investigations S/AmylaseS/LipaseUrine amylaseOther Enzymes Non enzymatic pancreatic secretory products PAP TAP CAPAP Markers of immune activation & nonspecific markers IL-6, IL-8, IL-10 TNF PMN Elastase CRP
  • 7. Radiological Investigations Plain X-Ray Ultrasound CT Scan MRI Pancreatitis without pain is particularly misleading. Lack of a major symptom is usually attributed to a postoperative situation where analgesics/sedatives are in use. Diagnostic pitfalls Diabetic comasevere hypothermia remote organ failuresSevere GI bleeding
  • 8. Pancreatic swelling Lack of enhancement Peri-pancreatic fluid collection Diagnostic Imaging
  • 9. How to recognize the at risk patient System Manifestations Significance General CVS Pulmonary Renal Neurological Abdominal Age > 60 BMI > 30 Kg/m2 Risk of local & systemic complications ↓ BP, ↑HR,↑ Lactate Tachypnea,Cyanosis ↓ OUT PUT ↑ Creatinine Confusion Agitation Tense abdomen ReboundTenderness Risk of local & systemic complications Impending remote organ failure Impending remote organ failure Impending remote organ failure Extent of peritoneal involvement
  • 10. Definition of severe pancreatitis  Acute pancreatitis + organ failure and/or  Acute pancreatitis + local complications  Three or more Ranson Criteria OR  APACHE II > 8
  • 11. Early assessment of severity Ranson’s criteria ON Admission After 48 hours G A L A W Glucose > 200 mg% Age > 55 yrs LDH > 350 AST > 250 WBCs > 16000 C H O B B SCalcium < 8.0 Haematocrit ↓ by > 10% PaO2 < 60 Base Excess > 4 BUN ↑ > 5 mg% Sequestered fluid > 6 liters
  • 12. Glasgow (Imrie) scoring system P A N C R E A S PaO2 < 8kPa Age > 55yrs Neutrophils (WBCs)> 15x 109 / L Calcium < 8mg% (2mmol) Renal – Urea > 16 mmol/L (45 mg/dL) Enzymes LDH > 600 iU/L, AST > 200iU/L Albumin < 32 G /L Sugar (Blood Glucose)> 10 mmol /L (180mg%)
  • 13. Grading based upon findings on unenhanced CT Grade Findings Score A Normal pancreas - normal size, sharply defined, smooth contour, homogeneous enhancement, retroperitoneal peripancreatic fat without enhancement 0 B Focal or diffuse enlargement of the pancreas, contour may show irregularity, enhancement may be inhomogeneous but there is on peripancreatic inflammation 1 C Peripancreatic inflammation with intrinsic pancreatic abnormalities 2 D Intrapancreatic or extrapancreatic fluid collections 3 E Two or more large collections of gas in the pancreas or retroperitoneum 4
  • 14. Necrosis, percent SCORE 0 0 Less than 33% 2 33-50% 4 More than 50% 6 Necrosis score based upon contrast enhancedCT
  • 15. AGA Guidelines for CT Scan Patients in whom the diagnosis is in doubt. Patients with Ranson >3 or APACHE II ≥8 In patients with predicted severe disease and those with evidence of organ failure during the initial 72 hours, rapid-bolus CT should be performed after 72 hours of illness to assess the degree of pancreatic necrosis. Labs adjunct to clinical judgment and the APACHE II . A CRP level of >150 mg/L at 48 hours is preferred
  • 16. Other Severity Indices The APACHE II score Systemic inflammatory response syndrome score Bedside index of severity in acute pancreatitis (BISAP) score Harmless acute pancreatitis score Organ failure-based scores
  • 17. Management of Severe Acute Pancreatitis General Intensive Care SpecificTreatment Modalities Surgery or No Surgery Feeding the patient Managing the Complications
  • 18. General intensive care Supportive therapy of vital organs Cardiovascular system Nowadays infection of pancreatic necrosis accounts for 50-80% of the deaths Splanchnic ischaemia is a 2nd local hit: Retroperitoneal necrosis, gut barrier dysfunction, and Secondary pancreatic infection may ensue Local splanchnic perfusion may be worsened by abdominal compartment syndrome- increased pressure due to intra abdominal oedema, fluid sequestration and excessive fluid resuscitation. Respiratory system Prevention/correction of hypoxia. Early physiotherapy and adequate analgesia (perhaps using epidural analgesia) to ensure free airways and to prevent atelectasis, prevent pulmonary aspiration by nasogastric decompression. CPAP/ BIPAP/ Invasive MechanicalVentilation Renal system Prevent and/or minimize renal injury by rapid correction of hypovolaemia If acute renal failure develops, start renal replacement therapy without delay to ensure optimal fluid and metabolic control and to enable nutritional support without haemodynamic instability. CVVHD is preferred. Gastrointestinal system Beware of intra-abdominal hypertension and assess the patient for this complication regularly. If abdominal compartment syndrome occurs, consider decompression either surgically or in cases of colonic distension with a wide bore tube inserted via the rectum. Abdominal compartment syndrome should be suspected whenever there is evidence of new or worsening organ dysfunction. Pain relief Conventional Analgesics (IV) Use of MORPHINE Epidural Analgesia ( mixture of diluted local anaesthetic solution (bupivacaine) and opiates)Miscellaneous Octreotide Somatostatin Protease Inhibitors (Aprotinin & Gabexate Mesilate) Anti inflammatory Rx Stress Ulcer Prophylaxis DVT Prophylaxis
  • 19. Specific therapeutic modalities Antibiotics Systemic Antibiotics Use antibiotics on demand for sepsis rather than prophylactically! Selective Decontamination of the Digestive system (SDD) Antibiotics are an adjuvant therapy in infected pancreatic necrosis. Drainage is mandatory for most if not all pancreatic infections.
  • 20. Indications for surgery Controversial indicationsUndisputed indications Infected pancreatic necrosis when percutaneous/other techniques not indicated Severe retroperitoneal haemorrhage Acute abdomen – peritonitis Biliary obstruction in case of failure of Endoscopic Sphincterotomy Abdominal compartment syndrome where percutaneous/other drainage techniques not successful. Controversial indications Extensive (>50%) sterile pancreatic necrosis Early ‘routine’ debridement of necrosis irrespective of its bacteriological status in order to prevent remote organ dysfunction and pancreatic infection Persisting multiple organ failure despite intensive care therapy Early and repeated removal of necrotic tissue combined with continuous drainage/lavage have been advocated to overcome systemic effects. Neither the extent of sterile pancreatic necrosis, the clinical severity of the disease or the duration of intensive supportive therapy should be regarded as indications for surgery. NOTE
  • 21. Feeding the pt of SAP Nutritional therapy: How, what and when? Route of nutrient delivery: Enteral versus parenteral The more distally that nutrients are infused in the gut, the less they stimulate pancreatic secretion The enteral route is safe in acute pancreatitis, so whenever possible, use it! In order to maximise clinical benefit, enteral feeding should be initiated as soon as possible after admission in all attacks predicted to be severe. Patients in whom enteral access cannot be achieved or in whom clear-cut contraindications (intestinal rupture, obstruction, or necrosis), intolerance, or exacerbation of the disease occurs should be considered for partial or total parenteral nutrition (TPN).
  • 22. Some Important Aspects of Feeding Composition of the diet Prescription and timing of nutrient administration Issue of Functional Ileus Oral refeeding Complications of nutritional therapy
  • 23. Resuscitation Severity Index Severe Disease Mild Disease Conservative RxCT Scan Balthazar > 7 Balthazar < 7 Management of Severe Acute Pancreatitis
  • 24. Balthazar > 7 Aggressive Hydration/Antibiotics/ Entral feeding/TPN No Improvement Improvement Continue Same Rx CT Guided Aspiration Deterioration
  • 25. CT Guided Aspiration Infected Sterile Supportive Rx Appropriate Antibiotics Attempt to wait for 3-4 weeks from onset NO IMPROVEMENT ?
  • 26. NO IMPROVEMENT ? Organized Collection Diffuse Collection Percutaneous/ Endoscopic/ Laparoscopic drainage Minimal access or Surgical Debridement
  • 27. Approach to Treat NECROSIS Fine Needle Aspiration SterileInfected Aggressive ICU Rx Improvement No Improvement Endoscopic Expertise Available YESNO Necrosectomy Percutaneous Drainage
  • 28. Necrosectomy Necrosis EndoscopicallyAccessible (posterior gastric or medial duodenal wall) Necrosis in peripancreatic, retrodudenal, perinephric Endoscopic Necrosectomy Laparoscopic Necrosectomy No Improvement Surgical Drainage Adjuvant Percutaneous Drainage
  • 29. I think its enough