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SOE 492: Pancreatitis

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Introduction

Regarding pancreatitis…

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Question No. 2

Q: What is acute pancreatitis and how is it defined?

Answer No. 2

  • A common presentation and a surgical emergency
  • Results from an inflammatory process in the pancreas leading to a multisystem disease characterized by a systemic inflammatory response and multi-organ dysfunction syndrome

 

Pancreatitis is typically established by the presence of two of the following criteria:

 

1. Abdominal pain consistent with the disease

2. Serum amylase and/or lipase greater than three times the upper limit of normal

3. Characteristic findings from abdominal imaging

Question No. 3

Q: How can severity of acute pancreatitis be classified?

Answer No. 3

Pancreatitis can be classified by severity according to the Revised ATLANTA criteria 2012

Mild
  • No organ failure
  • No local complications
Moderate
  • Transient organ failure (<}48 hours)
Severe
  • Local complications +/-
  • Persistent organ failure

*Local complications include:
Acute peripancreatic fluid collection
Pancreatic pseudocyst
Acute necrotic collection
Pleural effusion

Question No. 4

Q: What is the mortality rate of severe acute pancreatitis?

Answer No. 4

  • Still carries high mortality though overall deaths remain stable despite increased incidence:
    • Reflects recent advances in management
  • Mortality rate of up to 30% reported

Question No. 5

Q: What are the causes of pancreatitis?

Answer No. 5

Obstructive / Mechanical
  • Gall stones (50%)
  • Malignancy:
    • Pancreatic ductal carcinoma
    • Ampullary carcinoma
    • Islet cell tumour
    • Sarcoma
    • Lymphoma
  • ERCP (5% of procedures)
  • Trauma
  • Penetrating duodenal ulcer
  • Congenital abnormalities
  • Cystic fibrosis
Parenchymal
  • Alcohol (20%)
  • Autoimmune / vasculitic disease
  • Scorpion stings
Systemic
  • Hypoxemia / ischaemia
  • Drugs
  • Hypothermia
  • Hypercalcemia
  • Hypertriglyceridemia (>20mmol/L)
  • Viruses (Mumps, HIV, CMV, EBV)
  • Other infections
  • Venovenous - requires an external pump

MEMORY TIP

A commonly used mnemonic is: I GET SMASHED

  • Idiopathic
  • Gall stones (50%)
  • Ethanol (20%)
  • Trauma
  • Steroids
  • Mumps and other viruses (EBV, CMV, HIV)
  • Autoimmune diseases (SLE, polyarteritis nodosa, pregnancy)
  • Scorpion stings
  • Hypercalcemia, hyperlipidemia, hypothermia, hypotension (ischemia)
  • ERCP, emboli
  • Drugs

Question No. 6

Q: Describe the pathophysiology of pancreatitis?

Answer No. 6

Question No. 7

Q: What is the role of Imaging in pancreatitis?

Answer No. 7

  • An ultrasound of the RUQ should be performed in all cases to assess for biliary stones and obstruction
  • After negative routine work-up for biliary aetiology, endoscopic ultrasonography (EUS) is recommended as the first step to assess for occult microlithiasis, neoplasms and chronic pancreatitis
  • If EUS is negative MRCP is advised as a second step to identify rare morphologic abnormalities

Question No. 8

Q: Which scores can be used to assess the severity of pancreatitis?

Answer No. 8

  • A number of systems exist to identify severity and prognosticate pancreatitis
    • Considered advantageous over clinical judgement alone
    • Useful in determining optimum location of care
  • Limitations exist with many of the scoring systems:
    • Cumbersome to complete
    • Require 48 hours to gather variables for some scores
    • Lack accuracy in early stages
    • Limited clinical value
Classification Systems

Atlanta Criteria

  • Divides pancreatitis in to two pathophysiological types:
    • Interstitial oedematous pancreatitis
    • Necrotising pancreatitis
    • Classifies severity as mild, moderate and severe
  • Determined by presence of local features and organ failure
Prognostic Scoring Systems
Disease Specific

Clinical

  • Ransoms:
    • Originally designed for gallstone-induced pancreatitis
    • Uses age, nine laboratory parameters plus fluid requirements to calculate a score over 48 hours
    • A score of >3 at 48 hours indicates the presence of severe pancreatitis
  • Glasgow-Imrie:
    • Requires 48 hours to complete
    • Uses age and seven laboratory parameters to predict severe pancreatitis
  • BISAP

Radiological

  • Balthazar CT grade
Non-Specific
  • APACHE II
    • A score of >8 at 24 hours defines severe acute pancreatitis

Question No. 9

Q: What are the complications associated with acute severe pancreatitis?

Answer No. 9

Local (Pancreatic)
  • Interstitial Oedematous pancreatitis:
    • Peripancreatic collection
    • Pseudocyst (pancreatic fluid surrounded by a wall of fibrous or granulation tissue)
    • Abscess (circumscribed collection of pus)
  • Necrotising pancreatitis:
    • Sterile parenchymal necrosis
    • Infected parenchymal necrosis
  • Pancreatic insufficiency (and Type 3c Diabetes)
Regional
  • Ascites
  • Portal vein / splenic thrombosis
  • Intraperitoneal bleeding
  • Retroperitoneal bleeding
  • Bowel obstruction
  • Enteric fistulas
  • Intrabdominal hypertension
Systemic
  • Sepsis
  • Multiorgan failure
  • Respiratory:
    • Respiratory failure
    • ARDS
    • Effusions
  • DIC
  • Renal failure
  • GI Bleeding

Question No. 10

Q: When should a patient with acute pancreatitis be managed within critical care?

Answer No. 10

  • UK guidelines state that all patients with acute severe pancreatitis should be managed on the high dependency unit (HDU):
    • Can be difficult in practice - ensure all referred to the critical care outreach team for regular review and escalation of care if deterioration occurs
  • Particular features which suggest critical care admission may be beneficial include:
    • Age 70 years or older
    • Body mass index over 30 kg/m2
    • Hypotension not responsive to fluid resuscitation
    • >30% necrosis of the pancreas
    • Pleural effusions
    • Three or more of Ranson's criteria
    • CRP > 150 mg/L at 48 hours

 (Adapted from World Association Guidelines)

Question No. 11

Q: How would you manage the patient with severe acute pancreatitis?

Answer No. 11

Key Principles

  • Aggressive fluid resuscitation and pain management
  • Early ERCP if indicated
  • Early enteral feeding (preferably via NG route)
  • Avoid early surgical intervention for necrotic pancreatitis
  • Vigilant supportive care to avoid complications
Initial Resuscitation & Supportive Care
  • ABCDE approach treating abnormalities as found
  • Manage airway and breathing:
    • If intubation may be required, aspiration a major risk
    • Multifactorial causes for respiratory failure (ARDS, diaphragmatic splinting (pain, intra-abdominal oedema or fluid collections) or pleural effusions)
  • Optimise haemodynamics:
    • Early and aggressive fluid resuscitation
    • May require vasopressor support if severe systemic inflammatory response
    • Maintain UO >0.5 ml/Kg
  • Manage electrolyte abnormalities:
    • Vigilance over hypocalcaemia and arrhythmias
  • Ensure optimal analgesia:
    • PCA usually required
    • Some support use of thoracic epidural
    • Aim to prevent further atelectasis
  • Correct coagulopathy in the setting of VTE
  • Optimise nutrition:
    • Early enteral feeding (within 72 hours):
      • Nasogastric - effective in 80%
      • Nasojejunal second line
    • No advantages for early TPN - only after 7 days if enteral fails
  • Vigilance to good supportive care - often long stays and prone to complications
    • Strict glycaemic control
    • DVT prophylaxis (balance against risk of intrabdominal haemorrhage)
    • Stress ulcer prophylaxis
    • VAP bundles
    • Aseptic precautions
Specific Management
  • Management of biliary obstruction
    • Early ERCP indicated to remove gallstone (within 72 hours)
    • Coagulation should be corrected
    • Surgical management of gallstones during same hospital admission or within 2 weeks
  • Management of infected collection / necrosis
    • Prophylactic antibiotics not routinely recommended
    • If clinical sepsis ensure blood cultures taken and treat as per surviving sepsis
    • If >30% pancreatic necrosis, should undergo FNA to obtain material for culture 7–14 days after the onset of the pancreatitis
    • If infected abscess confirmed post-needle aspiration prescribed according to local guidelines
    • If infected will require definitive intervention (Ideally delay until 4 weeks):
      • Radiological drainage first line - successful in 50%
      • Endoscopic drainage
      • Surgical drainage (delay until clear demarcation)
  • If evidence of retroperitoneal gas on CT:
    • Broad spectrum antibiotics
    • Surgical drainage or debridement
    • Delayed surgery (>2 weeks):
      • Associated with increased survival
      • Allows demarcation of necrotic and preserved tissue
Referral & Deposition
  • All patients with sever acute pancreatitis should be manages on HDU
  • Refer all with persisting organ failure or requiring intervention to regional centre

Question No. 12

Q: What nutritional therapy should patients with severe acute pancreatitis receive?

Answer No. 12

  • Early EN is now standard of care in patients with acute pancreatitis
    • Recent research suggests improved outcomes compared with previous strategies of pancreatic rest with TPN
    • Guidance recommends commencing within 72 hours if intolerant of oral intake
  • Enteral nutrition in acute pancreatitis can be administered via either the nasojejunal or nasogastric route:
    • Many recommend early NJ feeding and supported by ESPEN guidance
    • Two trials have also found no difference in outcomes in patients fed gastrically versus jejunally
    • Nasogastric usually successful in 80% of patients
    • Nasojejunal feeding should be used if intra-abdominal pressures are >15mmHg
  • Parenteral nutrition can be administered in acute pancreatitis as second-line therapy if nasojejunal tube feeding is not tolerated (pain, ileus,  nausea)

 

(NICE & ESPEN Guidelines)

Question No. 13

Q: Which patients should receive antibiotics in severe acute pancreatitis?

Answer No. 13

  • Antibiotics should be used in any case of pancreatitis complicated by infected pancreatic necrosis but should not be given routinely for fever, especially early in the presentation:
    • Carbapenem usually the best class due to penetration in to pancreatic tissue
    • Fungal infection should be considered in severe infected pancreatic necrosis
  • Image-guided FNA should be used to gain material for culture when:
    • Necrosis and features of sepsis
    • 30% necrosis and persistent symptoms at 7-14 days
  • Antibiotic prophylaxis in severe pancreatitis is controversial:
    • Trials performed in this area show great heterogeneity with a variety of antibiotics used for different durations
    • Routine use of against infection is not currently recommended
    • If used may increase the risk of fungal superinfection

 

Question No. 14

Q: What are the indications for surgical and radiological interventions in severe acute pancreatitis?

Answer No. 14

  • Relieving biliary obstruction (e.g. ERCP)
  • Removing infected intra- and extra-pancreatic necrosis (Necrosectomy)
  • Pancreatic duct disruption
  • Management of symptomatic masses due to pseudocysts or sterile necrosis:
    • Gastric outlet or intestinal obstruction
    • Persistent pain

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