Diagnosis & Management of Acute Pancreatitis George R Winters III, MD, FACP, FACG

OUTLINE Overview Diagnosis Causes Predicting Severity Treatment Fluids Nutrition Antibiotics Summary

Acute Pancreatitis Over 200,000 new cases annually 80% Interstitial (Edematous) edema & inflamm of parenchyma w/out death of acini 20% Necrotizing extensive parenchymal destruction, frequently w/ peri-pancreatic fat necrosis Necrotizing accounts for most of the morbidity & nearly all the mortality During first week, severity related to presence of organ failure Most patients recover & are d/c’d within one week 15-20% have complicated course characterized by anatomic complications of the disease Incidence is Increasing, but Mortality is decreasing

Q: Over the last three decades, why is the Incidence of Pancreatitis rising? A. Increased alcohol consumption B. Increased prevalence of gallstones C. Increased use of ERCP D. Misdiagnosis

Q: Over the last decade, why is the mortality of Acute Pancreatitis decreasing? A. More aggressive surgical intervention B. Increased use of aggressive hydration C. Increased use of ERCP D. Increased use of antibiotics (Imipenum)

Diagnosis Established by 2 of 3 findings: A. Appropriate clinical symptoms Upper Abd Pain, N/V B. Increased Amylase/Lipase >3x ULN C. Imaging confirmation C/T or MRI So don’t need imaging if A & B positive non-con C/T reliable need contrast to distinguish necrosis C/T poor test for gallstones

45 year old gentleman presents with complaints of epigastric pain 45 year old gentleman presents with complaints of epigastric pain. Pain began 3 hours ago, radiating to the back, associated with nausea. Past Medical History: Diabetes Meds: Glucotrol Social History: 1-2 glasses of wine per day PE: VSSA, Tender epigastrum Labs: Amylase 220 (30-120) IU/L Lipase 80 (20-45) IU/L

What is the next best step with this patient: A. U/S abdomen B What is the next best step with this patient: A. U/S abdomen B. C/T abdomen C. MRCP D. Patient has mild acute pancreatitis, no testing needed.

Diagnosis Problems: Amylase will be normal in select populations – Alcoholics (25% of patients) – Lipemic serum (hypertriglyceridemia) – Patients presenting late in the course Post-ERCP pancreatitis – Pain and elevations in amylase/lipase common in absence of clinical disease

Causes: Two main causes: Gallstones (50%) Alcohol (30%) Others: Idiopathic (up to 20%) Hypertriglyceridemia (1-3%) Medications (1%) Post-ERCP Tumors Pancreas Divisum Hypercalcemia (measure after attack, as falsely low during) Hereditary Autoimmune Infectious

Gallstone Pancreatitis

Medications: Azathioprine (6-MP) Sulfonamides Corticosteroids Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) Antibiotics such as tetracycline Aminosalicylates Diuretics Valproic acid Didanosine Pentamidine Estrogen

45 year old gentleman presents with complaints of epigastric pain 45 year old gentleman presents with complaints of epigastric pain. Pain began 3 hours ago, radiating to the back, associated with nausea. Past Medical History: Diabetes Meds: Glucotrol Social History: 1-2 glasses of wine per day PE: VSSA, Tender epigastrum Labs: Amylase 1320 (30-120) IU/L Lipase 2480 (20-45) IU/L

CT shows no gallstones in the gallbladder CT shows no gallstones in the gallbladder. What is the most likely etiology: A. Alcohol B. Gallstones C. Glucotrol D. Idiopathic

Gallstones

Revised Atlanta Classification Mild Acute Pancreatitis Absence of organ failure AND Absence of local complications Moderately Severe Acute Pancreatitis Local complications AND/OR Transient organ failure (<48 hours) Severe Acute Pancreatitis Persistent organ failure (>48 hours)

Predicting Severity Two Main Scoring Systems Ransons Criteria 11 variables: 5 on admit, 6 at 48 hrs So can’t judge on admission APACHE II 12 variables, completed on admit and updated daily very cumbersome When accurate, severe disease usually obvious Other predictor of poor outcome: CRP >150 at 48 hours

Ranson Criteria 0-3 points 0-3% mortality 3-5 points 11-15% mortality

APACHE II

In a patient with acute pancreatitis, which of the following is associated with the highest mortality rate? A. Necrotizing Pancreatitis B. Infected Pancreatic Necrosis C. Organ Failure: Creatinine of 3 mg/dl D. Organ Failure: ARDS and Creatinine of 3 mg/dl

Mortality in Acute Pancreatitis Overall 6% Interstitial 3% Necrotizing 17% Infected 30% Single Organ Failure 3% Multi-Organ Failure 47%

When a patient presents to the Emergency Room, which factor is most important in predicting the risk of developing severe disease (within 6 hours of admission)? A. Ranson Score B. APACHE II Score C. CT Abdomen D. Combination of Other Factors

Assessing Risk: Admission Age Comorbid disease Etiology BMI Initial Fluid Status (BUN, Creatinine, HCT) Vital Signs Initial Rate of Hydration Organ dysfunction on admission Findings on admission CXR

What is the best single laboratory test to assess risk of severe disease early and follow during the initial management of patients with acute pancreatitis? A. Trypsinogen Activation Peptide (TAP) B. BUN C. C-Reactive Protein (CRP) D. Interleukin 6 E. Serum Amylase

Treatment - Interstitial -May be managed in ward (no ICU) -Often all needed is NPO, IV fluids, Pain control -NG tube only for severe N/V, Ileus -No empiric antibiotics -If cause is gallstones, cholecystectomy prior to d/c to prevent recurrent attacks -No pharmacologic agent has been shown to significantly alter clinical course/outcomes (pentoxifylline trial pending)

How Much Fluid Should We Give How Much Fluid Should We Give? • Within 48 hours, typical person needs 5-7 liters. • In hypercatabolic state such as acute pancreatitis, add 1-3 liters. • Assuming “6 liter sequestration” into the peritoneum is Ranson limit for severity . . . • Typical IV Fluid requirement for initial 48 hours in upper limit of Mild Acute Pancreatitis is 12-20 liters • 250 - 400 cc/hour initially • Titrate to HCT

Treatment - Necrotizing Aggressive hydration critical ICU monitoring Used to rec early surgical debridement, but shifted now to aggressive medical Rx Emphasis on preventing infection gets infected in 30%, >80% of mortality Early mortality (1st 2 wks) due to multi-system organ failure

Systemic Complications Include: ARDS, ARF, Shock, Coagulopathy, Hyperglycemia, Hypocalcemia Treatment: Intubation, aggressive fluid resuscitation, FFP, Insulin, Calcium as needed

Rethinking Enteral Nutrition • More physiologic • Maintains gut integrity • Decreases intestinal permeability • Maintain less pathogenic intestinal flora • If nasojejunal feeding used, gastric phase of pancreatic stimulation not effected • Thus, the pancreas remains at rest

Enteral Nutrition (EN) vs Parenteral Nutrition (PN) • Less hyperglycemia • Fewer septic complications • Fewer days in hospital • Decreased costs • Decrease in morbidity • Decrease mortality

Nutrition in Acute Pancreatitis NG or NJ feedings should be started early (within 36-48 hours) in patients with severe acute pancreatitis Can’t use with severe ileus

Sterile Pancreatic Necrosis Supportive Care 50% have Organ Failure NPO 3-6 weeks Enteric Feeding No Prophylactic Antibiotics Consider Resection at 4 weeks

Antibiotics Infection thought to occur due to Bacterial translocation from gut Early studies with benefit to systemic Abx and selective gut decontamination SGD requires oral & rectal Abx so not used IV Abx easier but no mortality benefit Use rec only for necrosis Prev. recs for >30% necrosis New thinking to reserve for documented infection Use C/T guided fine needle aspiration Limit to 7 days to prevent fungal superinfxn

Special Cases If biliary obstruction – needs ERCP Hyperbilirubinemia Clinical Cholangitis Infected Necrosis – requires surgical consult Considered uniformly fatal if not intervened on Begin Antibiotics – must penetrate Imipenum typical choice

ERCP

ERCP Video http://youtu.be/A2cJ7GO_GlQ

Acute Pancreatitis: Pearls Initial Management: Prevent Organ Failure/Necrosis Assess Risk Factors for Severe Disease/Avoid Persistent Organ Failure Adequate Hydration: 250 – 400 cc/hr (Titrate to HCT and BUN) Monitor Patients Closely, Treat Pain! Recognize and Treat Biliary Sepsis Early: ERCP

Late Management – Anatomic Complications: -Pseudocysts: Use Term at >3-4 weeks - Depends on Symptoms -Sterile Necrosis (develops early, within 72 hours): Prevent Infection: Do Not Use Prophylactic Antibiotics Use Enteric Feeding, Avoid TPN, NPO 3-4 weeks If pain, unable to eat at week 4, surgical debridement -Infected Necrosis (an issue after day 7-10): Begin Antibiotics (Necrosis Penetrating) Timing, Type and Need for Surgical Intervention? Delay & use minimally invasive interventions

Questions?