1. 2012 Revised Atlanta classification and definitions 소화기내과 R4 이태인 2014.4.10. MGR

2. Gut 2013;62:102-111

3.  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

4.  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

5.  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

6.  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

7.  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

8.  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

10. 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

11.  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

12.  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

13. 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

14.  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

15.  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

16.  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

17.  NSAIDs  Inhibition of PG, phospholipase-A2 and neutrophil-endothelin interaction GIE 2012 Dec;76(6):1152-9

18.  Inhibitition of protease activity  Gabexate mesylate (Foy)  Nafamostat mesylate (Futhan)  Ulinastatin (Uristin) NEJM 1996;335:919-923 J Gastroenterol Hepatol 2006;21:1065-1069

19.  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