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2012 Revised Atlanta classification and definitions 소화기내과 R4 이태인 2014.4.10. MGR
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Gut 2013;62:102-111
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Acute onset of a persistent, severe, epigastric pain Increased serum amylase or lipase (≥ 3 times greater than the upper limit of normal) Radiologic findings : CECT, MRI, US Gut 2013;62:102-111
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Interstitial oedematous pancreatitis Majority CE-CT ▪ Peripancreatic fluid collection ▪ Homogeneous enhancement of pancreas Usually resolved within the first week Necrotizing pancreatitis 5~10% Evolving over several days CE-CT ▪ Non-enhancing area of pancreas after the first week of the disease Variable clinical course Gut 2013;62:102-111
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Infected pancreatic necrosis Rare during the first week Antibiotics & intervention CE-CT ▪ Extraluminal gas in the pancreac/peripancreatic tissue FNA : positive for bacteria and/or fungi Suppuration Gut 2013;62:102-111
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Definition of organ failure Definition of organ failure (1992) Shock : sBP < 90 mmHg Shock : sBP < 90 mmHg PaO2 < 60mmHg PaO2 < 60mmHg Creatinine > 2.0 mg/dL after rehydration Creatinine > 2.0 mg/dL after rehydration GI bleeding > 500 cc/24hrs GI bleeding > 500 cc/24hrs Gut 2013;62:102-111
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Definition of local complications Acute peripancreatic fluid collection Pancreatic pseudocyst Acute necrotic collection Walled-off necrosis Definition of systemic complications Exacerbation of pre-existing co-morbidity ▪ Coronary artery disease or chronic lung disease Gut 2013;62:102-111
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Early phase (~ 1 st week) The host response to local pancreatic injury SIRS → Organ failure ▪ Within 48hrs : transient organ failure ▪ Over 48hrs : persistent organ failure Clinical > Morphological Late phase (1 st week ~) Systemic inflammation Local complication Clinical + Morphological Gut 2013;62:102-111
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Early phase Late phase ~ 24hrs~48hrs~7days Moderate severe AP Severe AP Local Cx → DDx Infection of necrosis → mortality OF (-) OF (+)Resolved Not resolved 매일 severity 평가 (BISAP) : 24hrs, 48hrs, 7days Mild AP Transient or persistent OF : severe AP 가능성 을 염두하여 초기 치 료 Transient OF = Moderate severe AP Persistent OF = Severe AP 영상 검사로 local complication 확인할 필요 없음 : late phase 에서야 CECT 상 저명하게 구분 가능 : clinical > morphological Gut 2013;62:102-111
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Pain control Demerol Aggressive hydration Stable : 5~10 mL/kg/hr Unstable : 20 mL/kg over 30mins → 5~8 cc/kg/hr for 8 to 12hrs Check Hematocrit, BUN frequently NPO Antibiotics Other medications : anti-protease, somatostatin analogues etc Intervention Clin Gastroenterol Hepatol. 2008;6(10):1070 Gastroenterology 2013;144:1272 Hct : 42 → 50 → 45.5 % BUN : 18 → 32 → 45 mg/dL
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Definition A clinical syndrome of abdominal pain and hyperamylasemia requiring hospitalization Most common serious complication of ERCP (2~10%) Pathogenesis Mechanical injury from instrumentation of the pancreatic duct Hydrostatic injury from contrast injection Chemical and allergic injury by contrast agents Intraluminal activation of proteolytic enzyme GIE 1991;37:383-393 Am J Gastroenterol 1994;89:303
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Patient-relatedProcedure-related Sphincter of Oddi dysfunction Prior ERCP-induced pancreatitis Normal serum bilirubin Normal sized CBD lumen Younger age (< 60) Female Difficult cannulation Pancreatic sphincterotomy Ampullectomy Pancreatic duct injection Biliary balloon sphincteroplasty GIE 2001;54:425-434
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Endoscopic techniques minimization of the number of cannulation attempts : <5 times, <10 mins early pre-cutting percutaneous access, if needed Minimization of the number and volume of contrast injections into the P-duct EPBD : low balloon pressure, short time WGC (Wire guided cannulation) Pancreatic stenting GIE 2005;62:669-674 J Gastroenterol Hepatol 2008;23:867-871
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Wire-guided cannulation A meta-analysis of 12 randomized trials with 3450 patients found that wire-guided cannulation was superior to a contrast-assisted cannulation technique Endoscopy 2013;45(8):605
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Pancreatic stenting Reduction in pancreatic intraductal pressure from papillary edema Sphincter of Oddi dysfunction Patients undergoing pancreatic sphincterotomy or pancreatic endotherapy Gastroenterology 1998;115:1518-1524 Clin Gastroenterol Hepatol 2011;9:851-8
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NSAIDs Inhibition of PG, phospholipase-A2 and neutrophil-endothelin interaction GIE 2012 Dec;76(6):1152-9
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Inhibitition of protease activity Gabexate mesylate (Foy) Nafamostat mesylate (Futhan) Ulinastatin (Uristin) NEJM 1996;335:919-923 J Gastroenterol Hepatol 2006;21:1065-1069
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Reduction of pancreatic enzyme secretion Somatostatin, octreotide Relaxation of SOD spasm NTG, lidocaine, sildenafil Antibiotics Ceftazidime Others : allopurinol, N-acetylcysteine, nifedipine, platelet activating factor GIE 2007;32:624-632 Dig Dis Sci 2010;55:1-7 Aliment Pharmacol Ther 2009;29:1078-1085
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