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

2. OUTLINE Overview Diagnosis Causes Predicting Severity Treatment
Fluids
Nutrition
Antibiotics
Summary

3. 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

4. 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

5. 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)

6. 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

7. 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

8. 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.

9. 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

10. 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

11. Gallstone Pancreatitis

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

13. 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

14. 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

15. Gallstones

16. 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)

17. 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

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

19. APACHE II

20. 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

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

22. 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

23. 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

24. 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

25. 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)

26. 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 liters • cc/hour initially • Titrate to HCT

27. 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

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

29. 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

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

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

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

34. 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

35. 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

36. ERCP

37. ERCP Video

39. 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

40. 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

41. Questions?