1. Acute Pancreatitis Mini Lecture F ARID J ALALI JANUARY 23, 2014

2. o Establish the Diagnosis of Acute Pancreatitis o Establish the Etiology of Acute Pancreatitis o Initial Management of Acute Pancreatitis A LL RECOMMENDATIONS ARE BASED ON THE LATEST ACG M ANAGEMENT OF A CUTE P ANCREATITIS GUIDELINES PUBLISHED IN 2013. Objectives

3. o Diagnosis of Acute Pancreatitis requires at least 2 of 3 from the following criteria: o Abdominal pain consistent with acute pancreatitis o Serum amylase or lipase greater than 3 times the upper limit of normal o Characteristic findings on abdominal imaging o CT w/ contrast or MRI should be reserved for patients in whom the diagnosis in unclear or fail to improve within 48-72 hours. A. Diagnosis

4. 47 year-old female with recent mild alcohol intake and no history of prior gallstones or acute pancreatitis presents to ER with epigastric abdominal pain radiating to the back. Lipase is 500 on admission. o Diagnosis: Met the following 2 of 3 criteria (1) abdominal pain consistent with acute pancreatitis (2) Lipase > 3 times upper limit of normal – therefore, no CT or MR imaging required to establish diagnosis. Case Vignette

5. o Transabdominal ultrasound should be performed in ALL patient with acute pancreatitis to assess gallstones as etiology of acute pancreatitis. o In absence of gallstones or significant alcohol use, obtain serum triglycerides. o If serum triglycerides > 1,000 mg/dL, consider as etiology of acute pancreatitis. o In patients > 40 years of age, consider pancreatic tumor in absence of other causes. o In patients < 30 years of age and +FH of acute pancreatitis in absence of other causes, consider genetic testing for hereditary pancreatitis. B. Etiology

6. o Etiology: As all patients with acute pancreatitis are recommended to get transabdominal ultrasound, a RUQ ultrasound was done which showed cholelithiasis and CBD dilatation without choledocholithiasis. Likely etiology was gallstone pancreatitis with or without a component of alcohol-induced acute pancreatitis. Case Vignette – cont.

7. o Various methods exist to assess severity of acute pancreatitis. o Next slide describes clinical findings associated with a severe course of acute pancreatitis. o BISAP score is a helpful tool in assessing severity and in-hospital mortality of acute pancreatitis. o BISAP, Ranson’s, APACHE-II and CTSI scores all have similar prognostic accuracy. C. Severity Assessment

8. Severity Scoring of Acute Pancreatitis (BISAP)  Bedside index of severity in acute pancreatitis (BISAP) score P RESENCE OF ORGAN FAILURE AND / OR PANCREATIC NECROSIS DEFINES S EVERE A CUTE P ANCREATITIS. Patients with high severity of initial presentation and/or presence of end-organ failure (shock, AKI, altered mental status, respiratory failure, ARDS, etc) should be admitted to ICU.

9. o Early AND Aggressive IV fluid hydration must be initiated. o How aggressive? o If severe hypovolemia present, bolus IV fluids initially o Then keep maintenance rate of 250 – 500 mL/hr IV fluids o What kind of IV fluids? o Isotonic crystalloid (NS, LR) o LR may be preferred (conditional recommendation) o How soon to start? o Early, early, early !! o Most beneficial in the first 12-24 h o What is my goal with IV fluid hydration? o Decrease BUN (as checked q6h initially) D. Initial Management

10. o Management: NPO, IV fluid hydration at 250-500 cc/hr with monitoring BUN q6h with goal of IVF hydration to decrease BUN in the first 12-24 hours. Case Vignette – cont.

11. o Do NOT #1: Routine use of prophylactic antibiotics for severe acute pancreatitis is NOT recommended. o Do NOT #2: Use of antibiotics to prevent progression of sterile necrosis to infected necrosis is NOT recommended. o Keep in mind that patients with acute pancreatitis often and early have fever but this does not necessarily mean infected necrosis exists. E. Role of Antibiotics

12. o Think of infected necrosis if patient with pancreatic or extra-pancreatic necrosis fails to improve after 7-10 days of hospitalization. o In case of infected necrosis, either FNA with gram-stain and culture to narrow antibiotic regimen or empirically treat with antibacterial antibiotics. o Routine antifungal therapy is not recommended unless specifically indicated based on culture and/or gram-stain. E. Role of Antibiotics

13. o Antibiotics role: Despite spiking one fever to 101 F, no clinical concern for infected necrosis existed and patient improved clinically within 48 hours. No antibiotics were therefore initiated. Case Vignette – cont.

14. o NG versus NJ tube feeding are COMPARABLE in efficacy and safety. o In other words, do NOT delay enteral feeding because NJ tube is not present. o IV nutrition should be avoided unless enteral nutrition is not available, not tolerated, or not meeting caloric requirements. o Enteral feeding is not merely to meet caloric requirements; it also prevents infectious complications. o Timing of enteral feeding? Not mentioned in guidelines, but generally if anticipate patient cannot have PO intake within 48 hours, start enteral feeding with NG or NJ. F. Feeding

15. o Enteral feeding: As patient was able to have PO intake within 48 hours, neither NG nor NJ tube feeding was initiated. Case Vignette – cont.

16. o Mild acute pancreatitis with gallstones  Perform cholecystectomy before discharge o Necrotizing acute pancreatitis with gallstones  Delay cholecystectomy until inflammation subsides o Asymptomatic pseudocysts or sterile necrosis do NOT warrant intervention (i.e drainage) regardless of size or location. o Drainage of infected necrosis should be delayed for at least 4 weeks to allow formation of walled-off necrosis. G. Role of Surgery

17. o Role of Surgery: Given evidence of gallstones and mild acute pancreatitis, cholecystectomy was performed before discharge to prevent recurrent episodes of gallstones pancreatitis. Case Vignette – cont.

18. o Early and accurate diagnosis of acute pancreatitis is crucial. o Early treatment of acute pancreatitis with aggressive IV fluid hydration saves lives and is most beneficial in the first 12-24 hours. o Routine prophylactic antibiotic use is not recommended for acute pancreatitis unless presence of infected necrosis is established clinically or by FNA. o Mild acute pancreatitis due to gallstones warrants cholecystectomy before discharge. Summary

19. o Scott Tenner MD, MPH, FACG, John Baillie MB, ChB, FRCP, FACG, John DeWitt MD, FACG and Santhi Swaroop Vege MD, FACG. American College of Gastroenterology Guideline: Management of Acute Pancreatitis. Am J Gastroenterol 2013; 108:1400–1415; doi:10.1038/ajg.2013.218; published online 30 July 2013. References