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Acute Pancreatitis |
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51 female with acute onset epigastric pain radiating to back. Her HR is 100/m, BP 110/70 and she is afebrile. She has minimal tenderness in epigastric region. How will you mange this patient?
I will suspect acute pancreatitis with a differential diagnosis of acute gastritis, Biliary colic , peptic ulcer disease/ perforation and acute coronary event.
How do you diagnose acute pancreatitis?
Clinical diagnosis
Biochemical diagnosis: if S amylase > 3 times normal value or S Lipase > twice normal value
S lipase more sensitive because of longer ½ life and accurate.(2)
Other causes of hyperamylaessemia:
Perforated viscus
Mesenteric ischaemia/infarction
Acute cholecystitis
Diabetic ketoacidosis
Radiological diagnosis:
If diagnosis not clear by clinical or biochemical assessment than a contrast enhanced Ct abdomen will be helpful to r/o other differential diagnosis. It is better to avoid exploratory laparotomy for diagnosis in patients with acute pancreatitis because of risks of morbidity.(2,5)
Her amylase is 1263 and you have diagnosed acute pancreatitis. What are you aims of initial management?
Steps of management:
Resuscitation: O2, IV fluids, Catheterize
Analgesia: Parenteral morphine with antiemetic
DVT prophylaxis
PPI or H2 antagonist
Preliminary investigations to confirm the diagnosis of acute pancreatitis and predict the severity of attack: FBC, U&E, LFT, S amylase, S Calcium, S LDH, Cardiac enzymes if suspicion of MI, CRP, Plain Xray Chest and abdomen(to r/o hollow viscus perforation and look for pleural effusion/conolidation)
USS: to check for presence of gall stones and biliary tree dilatation (not for diagnosis of pancreatitis)
What are various criterias available to predict the severity of attack?
Glasgow scoring >3
Ranson’s criteria
APACHE 2 score >8
BMI >30
CRP >150 (2)
Glasgow scoring has been validated for the UK population who has gall stones as the most common cause of acute pancreatitis. Score 1 for each of the following:
Age >55 years
White blood cell count >15 +109/l
Glucose >10 mmol/l
Urea >16 mmol/l
PaO2 <60 mm Hg
Calcium <2 mmol/l
Albumin <32 g/l
Lactate dehydrogenase >600 units/l
Asparate/alanine aminotransferase >100 units/
Glasgow scoring and CRP>150 are more helpful after 24-48hrs rather than initial 24 hrs. During initial 24 hr period APACHE 2 > 8, BMI > 30, Pleural effusion on chest x-ray and clinical signs are more useful predictors of severity.(2)
Accuracy of scoring systems in predicting the severity of attack?
Over all accuracy – 80%(2)
Remember scoring systems only help to predict severity. Only presence of complications like organ failure or necrosis confirms severity of attack.
Causes of acute pancreatitis:
Common: Gall stones
Alcohol
Uncommon: Trauma – ERCP
Biliary manometry
Pancreatic duct obstruction eg, cancer
Drugs – Azathioprine
Metabolic- Hypercalcaemia
Hyperlipaemia
Infection – Mumps
Coxsackie B
Vascular – vasculitis
Post op CABG
Heriditary pancreatitis
What if no definite H/O alcohol intake and USS doesn’t show gall stones?
Diagnosis of idiopathic pancreatitis should only be accepted following two negative good quality USS.
Check for H/O prodromal symptoms of viral illness, R/O family H/O pancreatitis and detailed H/O drug intake
Check for fasting Ca and Lipid profile before discharge (2)
For those who return back with recurrent attack:
MRCP or CT pancreas protocol (to R/O any anatomical abnormalities like pancreatic divisum)
EUS (check for small CBD stones)
ERCP bile sample (for microlithiasis) and pancreatic cytology (malignant cells)
Biliary manometry (done in very few specialist centres) (2)
Try to keep idiopathic group < 20% (2)
This patient has had mild biliary pancreatitis. Further management?
Allowed to take fluids and diet as tolerated.
No role for antibiotics
If LFT normal / no biliary dilatation – Lap chole preferably during same admission or with in next 2 weeks (2)
Management of severe biliary pancreatitis?
Role for early ERCP
CT scan between 6-10 days to check for necrosis
Antibiotics only if necrosis > 1/3rd of pancreas or evidence of infection
Nutrition: preferably Enteral (NG route tolerated well by > 80%)
CT guided FNA and culture of necrosis: Necrosectomy in patients with infected necrosis
Role for early ERCP?
Early ERCP with in 72 hrs may not help in patients with mild gallstones pancreatitis but has been shown to reduce morbidity and mortality in patients with severe gall stone pancreatitis (1).
Hence according to BSG guidelines: early ERCP should be considered in patients presenting with gall stones pancreatitis if they have:
Severe pancreatitis (Some gastroenterologist may not agree this as a sole indication for ERCP)
Cholangitis
Jaundice
Dilated CBD
Although most of the trials conducted in the UK showed benefits of early ERCP in all patients with severe pancreatitis, a multicentre trial in Germany showed higher incidence of respiratory failure in patients undergoing early ERCP. This trial was criticised because of recruitment of cases done by gastroenterologists with low volume ERCP. However some gastroenterologists still prefer to perform early ERCP only patients with jaundice and dilated CBD.
Any role for cholecystectomy after ERCP and CBD clearance after resolution of pancreatitis?
Incidence of recurrent biliary symptoms varies between 15-50% after ERCP>
Hence patients who <80yrs and ASA 1- 3 evidence in favour of Laparoscopic cholecystectomy. This should be considered once they recover from pancreatitis (6weeks)
For high risk patients better to observe and consider surgery only if necessary.(1)
Will you start prophylactic antibiotics in patients with acute pancreatitis?
Evidence available in favour of prophylactic antibiotic is conflicting. Majority of earlier trials showed no benefit of prophylactic antibiotics. However, most trials were done by using ampicillin or cephelaxins.
Recent meta-analysis has shown that prophylactic antibiotics reduces sepsis and mortality but doesn’t prevent infection. Sub-group analysis showed reduction in incidence of infected necrosis with prophylactic imipenum (36.4% vs 10.4%). Hence, authors recommended 14 days of imipenum in patients with proven necrosis.(1)
BSG guidelines recommendation: Prophylactic antibiotics of no value in absence of necrosis. However they can be considered for the duration of 7 – 14 days if extent of necrosis is >30%.(2)
Is there any risk of super-added infection in patients who receive prophylactic antibiotics?
Some have raised concerns about increased risk of fungal infection in such patients but recent meta-analysis has shown no difference in incidence of fungal infection in antibiotic vs placebo group. The risk of fungal infection may depend on the extent of necrosis.(1)
Nutrition in acute pancreatitis:
Patients with mild pancreatitis usually can tolerate normal diet with in few days of the onset of attack.
Severe pancreatitis: in patients with severe attack SIRS is maintained by intestinal dysfunction causing bacterial translocation. Hence, enteral nutrition should be considered (unless patient has ileus which often resolves in 5 days.
Most trials have used naso-jejunal route but Glasgow trial has shown that enteral feeding via naso-gastric route is well tolerated by > 80% patients and should be tried as first option. (2)
TPN use increases the risk of central line infection and sepsis. Therefore it is recommended only in patients with prolonged ileus. Complications of Acute Pancreatitis?
Management of necrosis?
Supportive treatment :
Nutritional support
Analgesia
DVT prophylaxis
CT scan 6- 10 days with IV contrast to check the extent of necrosis
? Prophylactic antibiotic if necrosis > 30 % (see above)
CT guided fine needle aspiration (FNA) 2nd – 3rd week & send the sample for culture. If the culture is sterile, continue conservative management. (3)
Infected necrosis: will need drainage and necrosectomy (Conservative management for infected necrosis is associated with 100% mortality) (3)
Timing of necrosectomy: should be deferred till 3-4 weeks. Early necrosectomy associated with >50% mortality).
Various Surgical approaches for necrosectomy:
Open necrosectomy + closed continous lavage (mortality 15-20%)
Endoscopic necrosectomy
Percutaneous necrosectomy using nephroscope
Laparoscopic necrosectomy
Necrosectomy and packing (high mortality) (3,4,6)
Further reading:
5) Acute emergencies of pancreas (Core topics)
6) IAP guidelines for the surgical management of acute pancreatitis(Free online) |
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