Acute pancreatitis Case reports Clinical problems Use of antibiotics? (P 1 & 2) Use of antibiotics? (P 1 & 2) Surgical treatment of AP ? (P 3 & 4) Surgical treatment of AP ? (P 3 & 4) Clinical problems Use of antibiotics? (P 1 & 2) Use of antibiotics? (P 1 & 2) Surgical treatment of AP ? (P 3 & 4) Surgical treatment of AP ? (P 3 & 4)

Acute pancreatitis Case reports Case 1

Acute pancreatitis Case 1 – Patient KD History M, 63 y M, 63 y Obesity – BMI 30.3 kg/m 2 Obesity – BMI 30.3 kg/m 2 Gallbladder stones Gallbladder stones No concomitant diseases No concomitant diseases 1. episode of ABP 1. episode of ABP Time from onset 33.5 h Time from onset 33.5 hHistory M, 63 y M, 63 y Obesity – BMI 30.3 kg/m 2 Obesity – BMI 30.3 kg/m 2 Gallbladder stones Gallbladder stones No concomitant diseases No concomitant diseases 1. episode of ABP 1. episode of ABP Time from onset 33.5 h Time from onset 33.5 h

Acute pancreatitis Case 1 – Patient KD Lab data & prognostic assessment WBC (G/l) WBC (G/l) CRP (mg/l) ND CRP (mg/l) ND RNS (pts)5 RNS (pts)5 AP-O (pts 0-1-2) AP-O (pts 0-1-2) KCE (pts)4 KCE (pts)4 Lab data & prognostic assessment WBC (G/l) WBC (G/l) CRP (mg/l) ND CRP (mg/l) ND RNS (pts)5 RNS (pts)5 AP-O (pts 0-1-2) AP-O (pts 0-1-2) KCE (pts)4 KCE (pts)4

Acute pancreatitis Case 1 – Patient KD ERCP & CT ERCP (day 0) CBD 5 mm, no stones No ES ERCP (day 0) CBD 5 mm, no stones No ES CT (day 1) Mild inflammatory infiltration close to body and tail of the pancreas and in the left prerenal space, no pancreatic necrosis (BLT C, CTSI 2) CT (day 1) Mild inflammatory infiltration close to body and tail of the pancreas and in the left prerenal space, no pancreatic necrosis (BLT C, CTSI 2) ERCP & CT ERCP (day 0) CBD 5 mm, no stones No ES ERCP (day 0) CBD 5 mm, no stones No ES CT (day 1) Mild inflammatory infiltration close to body and tail of the pancreas and in the left prerenal space, no pancreatic necrosis (BLT C, CTSI 2) CT (day 1) Mild inflammatory infiltration close to body and tail of the pancreas and in the left prerenal space, no pancreatic necrosis (BLT C, CTSI 2)

Acute pancreatitis Case 1 – Patient KD

Acute pancreatitis Case reports Case 2

Acute pancreatitis Case 2 – Patient MK History M, 29 y M, 29 y Overweight – BMI 28.5 kg/m 2 Overweight – BMI 28.5 kg/m 2 Gallbladder stones Gallbladder stones No concomitant diseases No concomitant diseases 1. episode of ABP 1. episode of ABP Time from onset 46.5 h Time from onset 46.5 hHistory M, 29 y M, 29 y Overweight – BMI 28.5 kg/m 2 Overweight – BMI 28.5 kg/m 2 Gallbladder stones Gallbladder stones No concomitant diseases No concomitant diseases 1. episode of ABP 1. episode of ABP Time from onset 46.5 h Time from onset 46.5 h

Acute pancreatitis Case 2 – Patient MK Lab data & prognostic assessment WBC (G/l) WBC (G/l) CRP (mg/l) CRP (mg/l) RNS (pts)2 RNS (pts)2 AP-O (pts 0-1-2) AP-O (pts 0-1-2) KCE (pts)2 KCE (pts)2 Lab data & prognostic assessment WBC (G/l) WBC (G/l) CRP (mg/l) CRP (mg/l) RNS (pts)2 RNS (pts)2 AP-O (pts 0-1-2) AP-O (pts 0-1-2) KCE (pts)2 KCE (pts)2

Acute pancreatitis Case 2 – Patient MK ERCP & CT ERCP (day 0) CBD 12 mm, impacted stone + 4 other stones SE done, stones removed ERCP (day 0) CBD 12 mm, impacted stone + 4 other stones SE done, stones removed TK (day 1) Moderate inflammatory infiltrations in both prerenal spaces, no pancreatic necrosis, small amount of fluid around the liver and mild bilateral hydrothorax (BLT C, CTSI 2) TK (day 1) Moderate inflammatory infiltrations in both prerenal spaces, no pancreatic necrosis, small amount of fluid around the liver and mild bilateral hydrothorax (BLT C, CTSI 2) ERCP & CT ERCP (day 0) CBD 12 mm, impacted stone + 4 other stones SE done, stones removed ERCP (day 0) CBD 12 mm, impacted stone + 4 other stones SE done, stones removed TK (day 1) Moderate inflammatory infiltrations in both prerenal spaces, no pancreatic necrosis, small amount of fluid around the liver and mild bilateral hydrothorax (BLT C, CTSI 2) TK (day 1) Moderate inflammatory infiltrations in both prerenal spaces, no pancreatic necrosis, small amount of fluid around the liver and mild bilateral hydrothorax (BLT C, CTSI 2)

Acute pancreatitis Case 2 – Patient MK TKTK

Acute pancreatitis Cases 1 & 2 SIRS (+) SIRS (+) Mild overweight / obesity Mild overweight / obesity BLT C, no necrosis, CTSI 2 BLT C, no necrosis, CTSI 2 WBC > 15 G/l WBC > 15 G/l CRP > 150 mg/l CRP > 150 mg/l Should antibiotics be administered? Case 2 - MK Case 2 - MK Very good prognosis Very good prognosis Case 1 - KD Moderate prognosis Moderate prognosis

Question Who should receive antibiotics? 1. Both 2. Patient 1 3. Patient 2 4. None

Acute pancreatitis Case 1 – Patient KD Bacteriology Bile - positive Escherichia coli (sensitive to Ciprofloxacin, Imipenem) Bile - positive Escherichia coli (sensitive to Ciprofloxacin, Imipenem) Blood – negative (1x) Blood – negative (1x)Bacteriology Bile - positive Escherichia coli (sensitive to Ciprofloxacin, Imipenem) Bile - positive Escherichia coli (sensitive to Ciprofloxacin, Imipenem) Blood – negative (1x) Blood – negative (1x)

Acute pancreatitis Case 1 – Patient KD

Acute pancreatitis Case 2 – Patient MK Bacteriology Blood – 10 x negative Blood – 10 x negativeBacteriology

Acute pancreatitis Case 2 – Patient MK

Acute pancreatitis Case 1 & 2 Wide-spectrum antibiotics were used in both cases Wide-spectrum antibiotics were used in both cases No complications acc. to Atlanta criteria No complications acc. to Atlanta criteria Probably mild necrosis of peripancreatic fat Probably mild necrosis of peripancreatic fat Hospital stay 22 days in both cases Hospital stay 22 days in both cases Course mild / severe ? Course mild / severe ?

Acute pancreatitis Case reports Case 3

Acute pancreatitis Case 3 – Patient AK History M, 79 y M, 79 y General condition severe Hypertension 20 y Parkinson’s disease? General condition severe Hypertension 20 y Parkinson’s disease? Suspicion of gallstones Suspicion of gallstones Probably 20 h from onset of abdominal pain Probably 20 h from onset of abdominal pain Very severe abdominal pain Very severe abdominal painHistory M, 79 y M, 79 y General condition severe Hypertension 20 y Parkinson’s disease? General condition severe Hypertension 20 y Parkinson’s disease? Suspicion of gallstones Suspicion of gallstones Probably 20 h from onset of abdominal pain Probably 20 h from onset of abdominal pain Very severe abdominal pain Very severe abdominal pain

Acute pancreatitis Case 3 – Patient AK OE Dehydration Dehydration HR 116/min, RR 30/min HR 116/min, RR 30/min No peristalsis No peristalsis Rebound tenderness +- Rebound tenderness +-OE Dehydration Dehydration HR 116/min, RR 30/min HR 116/min, RR 30/min No peristalsis No peristalsis Rebound tenderness +- Rebound tenderness +-

Acute pancreatitis Case 3 – Patient AK Angio-CT (day 0) No mesenteric ischemia No mesenteric ischemia Extensive atheromatosis Extensive atheromatosis Extensive inflammatory infiltration of peripancreatic fat, non-enhancement area (up to 1/3) in body and tail Extensive inflammatory infiltration of peripancreatic fat, non-enhancement area (up to 1/3) in body and tail BLT C, necrosis < 1/3?, CTSI 4 BLT C, necrosis < 1/3?, CTSI 4 Angio-CT (day 0) No mesenteric ischemia No mesenteric ischemia Extensive atheromatosis Extensive atheromatosis Extensive inflammatory infiltration of peripancreatic fat, non-enhancement area (up to 1/3) in body and tail Extensive inflammatory infiltration of peripancreatic fat, non-enhancement area (up to 1/3) in body and tail BLT C, necrosis < 1/3?, CTSI 4 BLT C, necrosis < 1/3?, CTSI 4

Acute pancreatitis Case 3 – Patient AK Angio-CT (day 0)

Acute pancreatitis Case 3 – Patient AK ERCP (day 1) Extensive swelling of D2 of moderate severity, bluish discoloration of mucosa, severe duodenopathy Extensive swelling of D2 of moderate severity, bluish discoloration of mucosa, severe duodenopathy Papilla very small and tight Papilla very small and tight No deep CBD cannulation despite pre-cut No deep CBD cannulation despite pre-cut CDB narrow (< 4 mm) CDB narrow (< 4 mm) ERCP (day 1) Extensive swelling of D2 of moderate severity, bluish discoloration of mucosa, severe duodenopathy Extensive swelling of D2 of moderate severity, bluish discoloration of mucosa, severe duodenopathy Papilla very small and tight Papilla very small and tight No deep CBD cannulation despite pre-cut No deep CBD cannulation despite pre-cut CDB narrow (< 4 mm) CDB narrow (< 4 mm)

Acute pancreatitis Case 3 – Patient AK Lab data WBC (G/l) WBC (G/l) PLTS (G/l) – 72 PLTS (G/l) – 72 HCT (%) HCT (%) paO2 (mm Hg) paO2 (mm Hg) Cre (mg/dl) Cre (mg/dl) AT III (%)ND - ND – 42 AT III (%)ND - ND – 42 CRPND! CRPND! Lab data WBC (G/l) WBC (G/l) PLTS (G/l) – 72 PLTS (G/l) – 72 HCT (%) HCT (%) paO2 (mm Hg) paO2 (mm Hg) Cre (mg/dl) Cre (mg/dl) AT III (%)ND - ND – 42 AT III (%)ND - ND – 42 CRPND! CRPND!

Acute pancreatitis Case 3 – Patient AK Prognostic assessment RNS (pts)6 RNS (pts)6 AP-II (pts 0-1-2) (death risk 85%) AP-II (pts 0-1-2) (death risk 85%) AP III J (pts 0-1-2) (death risk 67%) AP III J (pts 0-1-2) (death risk 67%) KCE (pts)7 KCE (pts)7 OFS (Bernard, pts 0-2)1 - 6 (death risk 85%) OFS (Bernard, pts 0-2)1 - 6 (death risk 85%) Prognostic assessment RNS (pts)6 RNS (pts)6 AP-II (pts 0-1-2) (death risk 85%) AP-II (pts 0-1-2) (death risk 85%) AP III J (pts 0-1-2) (death risk 67%) AP III J (pts 0-1-2) (death risk 67%) KCE (pts)7 KCE (pts)7 OFS (Bernard, pts 0-2)1 - 6 (death risk 85%) OFS (Bernard, pts 0-2)1 - 6 (death risk 85%)

Acute pancreatitis Case 3 – Patient AK CT (day 2) Mild progression Mild progression BLT E, necrosis < 1/3, CTSI 6 BLT E, necrosis < 1/3, CTSI 6 CT (day 2) Mild progression Mild progression BLT E, necrosis < 1/3, CTSI 6 BLT E, necrosis < 1/3, CTSI 6

Acute pancreatitis Case 3 – Patient AK CT (day 2)

Acute pancreatitis Case 3 – Patient AK Clinical course No improvement within 48 hours No improvement within 48 hours Rapidly evolving multiorgan failure Rapidly evolving multiorgan failure Patient transferred to ICU Patient transferred to ICU Surgical consultation Surgical consultation Clinical course No improvement within 48 hours No improvement within 48 hours Rapidly evolving multiorgan failure Rapidly evolving multiorgan failure Patient transferred to ICU Patient transferred to ICU Surgical consultation Surgical consultation

Acute pancreatitis Case reports Case 4

Acute pancreatitis Case 4 – Patient ML History F, 50 y F, 50 y No concomitant diseases No concomitant diseases Mild obesity, BMI 31.6 kg/m2 Mild obesity, BMI 31.6 kg/m2 10 months before single episode of biliary colic No gallbladder stones 10 months before single episode of biliary colic No gallbladder stones 1. episode of ABP 1. episode of ABP Time from onset 8 h Time from onset 8 hHistory F, 50 y F, 50 y No concomitant diseases No concomitant diseases Mild obesity, BMI 31.6 kg/m2 Mild obesity, BMI 31.6 kg/m2 10 months before single episode of biliary colic No gallbladder stones 10 months before single episode of biliary colic No gallbladder stones 1. episode of ABP 1. episode of ABP Time from onset 8 h Time from onset 8 h

Acute pancreatitis Case 4 – Patient ML OE Obesity Obesity Jaundice Jaundice Epigastric tenderness Epigastric tendernessOE Obesity Obesity Jaundice Jaundice Epigastric tenderness Epigastric tenderness

Acute pancreatitis Case 4 – Patient ML ERCP (day 0) Duodenum and papilla normal CDB 10 mm, no stones No ES Microscopic bile analysis: CMC+, CaBG+++ Duodenum and papilla normal CDB 10 mm, no stones No ES Microscopic bile analysis: CMC+, CaBG+++ ERCP (day 0) Duodenum and papilla normal CDB 10 mm, no stones No ES Microscopic bile analysis: CMC+, CaBG+++ Duodenum and papilla normal CDB 10 mm, no stones No ES Microscopic bile analysis: CMC+, CaBG+++

Acute pancreatitis Case 4 – Patient ML Lab data WBC (G/l) WBC (G/l) HGB (g/dl) ND (d7) HGB (g/dl) ND (d7) paO2 (mm Hg)73 paO2 (mm Hg)73 TP (mg/dl) TP (mg/dl) CRP (mg/l) (d7) CRP (mg/l) (d7) Lab data WBC (G/l) WBC (G/l) HGB (g/dl) ND (d7) HGB (g/dl) ND (d7) paO2 (mm Hg)73 paO2 (mm Hg)73 TP (mg/dl) TP (mg/dl) CRP (mg/l) (d7) CRP (mg/l) (d7)

Acute pancreatitis Case 4 – Patient ML Prognostic assessment RNS (pts)6 RNS (pts)6 AP-O (pts 0-1-2) AP-O (pts 0-1-2) AP III J (pts 0-1-2) AP III J (pts 0-1-2) KCE (pts)7 KCE (pts)7 OFS (Bernard, pts 0-2)0 - 1 OFS (Bernard, pts 0-2)0 - 1 Prognostic assessment RNS (pts)6 RNS (pts)6 AP-O (pts 0-1-2) AP-O (pts 0-1-2) AP III J (pts 0-1-2) AP III J (pts 0-1-2) KCE (pts)7 KCE (pts)7 OFS (Bernard, pts 0-2)0 - 1 OFS (Bernard, pts 0-2)0 - 1

Acute pancreatitis Case 4 – Patient ML CT (day 2) Enlarged pancreatic head, homogenous enhancement, no necrosis Enlarged pancreatic head, homogenous enhancement, no necrosis Fluid collections at both prerenal spaces, in spleen hilum, between small bowel loops Fluid collections at both prerenal spaces, in spleen hilum, between small bowel loops BLT E, CTSI 4 BLT E, CTSI 4 CT (day 2) Enlarged pancreatic head, homogenous enhancement, no necrosis Enlarged pancreatic head, homogenous enhancement, no necrosis Fluid collections at both prerenal spaces, in spleen hilum, between small bowel loops Fluid collections at both prerenal spaces, in spleen hilum, between small bowel loops BLT E, CTSI 4 BLT E, CTSI 4

Acute pancreatitis Case 4 – Patient ML Clinical course Intensive conventional management, antibiotics Intensive conventional management, antibiotics SIRS symptoms between days 10 and 16 SIRS symptoms between days 10 and 16 Control CT (d12) – progression, CTSI 4 Control CT (d12) – progression, CTSI 4 Control CT (d26) – progression, no pancreatic necrosis, but extensive necrosis of peripancreatic fat Control CT (d26) – progression, no pancreatic necrosis, but extensive necrosis of peripancreatic fat Second period of fever from day 32, ↑ WBC i CRP Second period of fever from day 32, ↑ WBC i CRP US – fluid collection, bacteriology – Str. faecalis US – fluid collection, bacteriology – Str. faecalis Surgical consultation (d43) Surgical consultation (d43) Clinical course Intensive conventional management, antibiotics Intensive conventional management, antibiotics SIRS symptoms between days 10 and 16 SIRS symptoms between days 10 and 16 Control CT (d12) – progression, CTSI 4 Control CT (d12) – progression, CTSI 4 Control CT (d26) – progression, no pancreatic necrosis, but extensive necrosis of peripancreatic fat Control CT (d26) – progression, no pancreatic necrosis, but extensive necrosis of peripancreatic fat Second period of fever from day 32, ↑ WBC i CRP Second period of fever from day 32, ↑ WBC i CRP US – fluid collection, bacteriology – Str. faecalis US – fluid collection, bacteriology – Str. faecalis Surgical consultation (d43) Surgical consultation (d43)

Acute pancreatitis Case 4 – Patient ML CT (days 2, 12 i 26)

Acute pancreatitis Case 4 – Patient ML CT (days 2, 12 i 26)

Acute pancreatitis Cases 3 & 4 Case 4 – ML Case 4 – ML Day 43 Day 43 Infected necrosis Infected necrosis No MOF No MOF Moderate prognosis Moderate prognosis Case 4 – ML Case 4 – ML Day 43 Day 43 Infected necrosis Infected necrosis No MOF No MOF Moderate prognosis Moderate prognosis Case 3 – AK Day 3 Day 3 Sterile necrosis Sterile necrosis ↑ MOF ↑ MOF Bad prognosis Bad prognosis Who should be operated on?

Question Who should be operated on? 1. Both patients 2. Patient 3 3. Patient 4 4. None

Acute pancreatitis Case 3 – Patient AK Surgery Day 2 of hospitalization Day 2 of hospitalization 2000 ml brown fluid in the abdominal cavity 2000 ml brown fluid in the abdominal cavity Extensive pancreatic necrosis (black pancreas) Necrosectomy. Setonage. Laparostomy Extensive pancreatic necrosis (black pancreas) Necrosectomy. Setonage. Laparostomy Cardiac arrest at the end of the procedure, death Cardiac arrest at the end of the procedure, death Autopsy: Necrosis haemorrhagica pancreatis et telae adiposae. Inflammatio purulenta cum necrosi d. choledochi. Autopsy: Necrosis haemorrhagica pancreatis et telae adiposae. Inflammatio purulenta cum necrosi d. choledochi.Surgery Day 2 of hospitalization Day 2 of hospitalization 2000 ml brown fluid in the abdominal cavity 2000 ml brown fluid in the abdominal cavity Extensive pancreatic necrosis (black pancreas) Necrosectomy. Setonage. Laparostomy Extensive pancreatic necrosis (black pancreas) Necrosectomy. Setonage. Laparostomy Cardiac arrest at the end of the procedure, death Cardiac arrest at the end of the procedure, death Autopsy: Necrosis haemorrhagica pancreatis et telae adiposae. Inflammatio purulenta cum necrosi d. choledochi. Autopsy: Necrosis haemorrhagica pancreatis et telae adiposae. Inflammatio purulenta cum necrosi d. choledochi.

Acute pancreatitis Case 4 – Patient ML Surgery Day 49 of hospitalization Day 49 of hospitalization Extensive fat necrosis Extensive fat necrosis Abscess (500 ml) in lesser sac Abscess (500 ml) in lesser sac Fat necrosis from right iliac fossa to diaphragmatic hiatus Fat necrosis from right iliac fossa to diaphragmatic hiatus Necrosectomy, setonage, laparostomy Necrosectomy, setonage, laparostomySurgery Day 49 of hospitalization Day 49 of hospitalization Extensive fat necrosis Extensive fat necrosis Abscess (500 ml) in lesser sac Abscess (500 ml) in lesser sac Fat necrosis from right iliac fossa to diaphragmatic hiatus Fat necrosis from right iliac fossa to diaphragmatic hiatus Necrosectomy, setonage, laparostomy Necrosectomy, setonage, laparostomy

Acute pancreatitis Case 4 – Patient ML Surgery (2) Multiple exchanges of setones (11) days 51 to 68 Multiple exchanges of setones (11) days 51 to 68 Wound abscess in the epigastrium 6 drainage procedures from day 103 to 131 Wound abscess in the epigastrium 6 drainage procedures from day 103 to 131 Gradual improvement Gradual improvement Discharge on day 146 Discharge on day 146 Surgery (2) Multiple exchanges of setones (11) days 51 to 68 Multiple exchanges of setones (11) days 51 to 68 Wound abscess in the epigastrium 6 drainage procedures from day 103 to 131 Wound abscess in the epigastrium 6 drainage procedures from day 103 to 131 Gradual improvement Gradual improvement Discharge on day 146 Discharge on day 146

Acute pancreatitis Indications for surgery Infected necrosis Infected necrosis Local complications of pancreatitis Local complications of pancreatitis Sterile necrosis Sterile necrosis Infected necrosis Infected necrosis Local complications of pancreatitis Local complications of pancreatitis Sterile necrosis Sterile necrosis

No swelling Minor swelling, limited to peripapillary area Severe swelling with extensive involvement of D2, bluish discoloration Moderate swelling with extensive involvement of D2 DGE MUSK DGE MUSK Duodenal swelling

DGE MUSK Duodenal swelling

DGE MUSK Normal duodenum Deformed duodenal loop D2 deformed and narrowed Deformed duodenal loop D2 deformed and narrowed Duodenal swelling

DGE & DPAT MUSK DGE & DPAT MUSK Mucosal hyperemia Edema of submucosal layer Duodenal swelling

Normal duodenum Marked thickening of D2 wall DGE & DRAD MUSK, Helimed mm Duodenal swelling

DGE & DRAD MUSK, Helimed D2 swelling limited to peripapillary area D2 swelling limited to peripapillary area D2 swelling limited to antero-medial wall D2 swelling limited to antero-medial wall Duodenal swelling

DGE & DRAD MUSK, Helimed Severe swelling with circular D2 involvement; lumen barely visible in the most severe cases Severe swelling with circular D2 involvement; lumen barely visible in the most severe cases Duodenal swelling

n (851) % Age (y) Sex (% F) BMI (kg/m2) SE failure (%) n (851) % Age (y) Sex (% F) BMI (kg/m2) SE failure (%) N % N % MLD 40 5% MLD 40 5% MOD 88 10% MOD 88 10% SEV 33 4% SEV 33 4% p p Duodenopathy grade Marek et al., Gut 2005 (abstract) Duodenal swelling

n (851) % CRP max48 mg/L IL-6 max48 pg/mL WBC max48 G/L AP-O cum48 (score) CTSI 72h (score) n (851) % CRP max48 mg/L IL-6 max48 pg/mL WBC max48 G/L AP-O cum48 (score) CTSI 72h (score) N % N % MLD 40 5% MLD 40 5% MOD 88 10% MOD 88 10% SEV 33 4% SEV 33 4% p p Marek et al., Gut 2005 (abstract) Duodenopathy grade Duodenal swelling

n (851) % % severe % surgery % mortality SGS-10 n (851) % % severe % surgery % mortality SGS-10 N % N % MLD 40 5% MLD 40 5% MOD 88 10% MOD 88 10% SEV 33 4% SEV 33 4% p p Duodenopathy grade Marek et al., Gut 2005 (abstract) Duodenal swelling