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From Pain to Prognosis- Understanding Acute Pancreatitis Bassem AmrClinical Management Severity Prediction Fluids- What and how fast? Antibiotics- When? Nutrition- When and How? ERCP- When and Why? Cholecystectomy- When? Scenario • 41-year-old female presents to A&E with 24-hours history of severe epigastric pain radiating straight through to her back. It is associated with nausea and bile-stained vomiting. • She reports previous similar but less severe episodes of abdominal pain, usually after eating heavy meals, but they always resolved within a few hours. She denies alcohol consumption and last period was 2 weeks ago. • On examination • BP 130/86 mmHg • Pulse 120 beats/min • Afebrile • Respiratory rate is 18/ min • Abdominal examination • Marked epigastric tendernessWhat Is the Differential Diagnosis for Epigastric Pain? • Gastroenteritis • Acute gastritis • Acute cholecystitis • Peptic ulcer disease • Perforated ulcer • Pancreatitis • Appendicitis • Small bowel obstruction • Mesenteric ischemia • Ruptured AAA • Non-Surgical CausesBlood results • WCC : 17.5 • CRP: 80 • Amylase: 1500 u/L • ALT 350 u/L • AST: 260 u/L • Us & Es : within normalWhat Is your Diagnosis? How Do You Diagnose Acute Pancreatitis? • Acute pancreatitis is a clinical diagnosis. • Modified Atlanta definition: Two of Three features • (1) Abdominal pain consistent with acute pancreatitis (acute onset of a persistent, severe, epigastric pain often radiating to the back) • (2) Serum lipase or Amylase at least X3 the upper limit of normal • (3) Characteristic findings of acute pancreatitis on CT or MRI or ultrasound What are the causes of Hyperamylasaemia ? Pancreatic disease • Pancreatitis, pancreatic pseudocyst, trauma, ERCP, pancreatic carcinoma, cystic fibrosis Salivary disease • Parotitis, radiation, ductal obstruction Gastrointestinal disease • Peptic ulcer disease, perforated bowel, mesenteric ischemia, appendicitis, cholecystitis, celiac disease, bowel obstruction Other • Alcohol abuse, renal failure (amylase is renally cleared)What Are the Causes of Acute Pancreatitis? “GET SMASHED” • G – Gallstones • E – Ethanol • T – Tumours • S – scorpion stings • M – Mumps • A – Autoimmune (e.g. Lupus , polyarteritis nodosa) • S – Surgery/Trauma • H – Hyperlipidemia/Hypercalcemia • E – ERCP • D – DugsWhich Medications Can Cause Pancreatitis? • Cardiovascular disease Furosemide, thiazides • Inflammatory bowel disease Sulfasalazine, 5-ASA • Immunosuppression Azathioprine • Seizures Valproic acid • Human immunodeficiency virus (HIV) Didanosine, pentamidine What Is the Pathophysiology of Pancreatitis? • Inappropriate activation of pancreatic enzymes results in peripancreatic inflammation. • Intraparenchymal extravasation of enzymes causes autodigestion of pancreatic parenchyma • Primarily damages the peripancreatic tissues and vasculature. • The inflammatory response is out of proportion to the insult and, with time, potentiates further damage leading to fluid sequestration, fat necrosis,vasculitis, and hemorrhage. How Do Gallstones Cause Acute Pancreatitis? Transient Impaction Theory • Stones, as passes down into the CBD, transiently impacted at the ampulla causes a sudden rise in pancreatic duct pressure. • These stones are usually small causing transient impaction with the surroundingoedema. • Persistence of CBD stone is uncommon, and therefore ERCP is not usually needed. • This differs from gallstones that cause acute cholangitis, where the stones are usually large and usually need ERCP for removal. What Is the Significance of Bruising around the Umbilicus, Flank & Inguinal Ligament? • These are signs of Retroperitoneal bleeding • Deposition of Methemalbumin (albumin+haem pancreatitis.sociation with acute hemorrhagic • Grey Turner’s sign Blue-black discoloration in the flanks. • Cullen’s sign Blue-red discoloration at the umbiliCus. • Fox’s sign Bruising over the inguinal ligament.Grey Turner’s signCullen’s signFox’s signHow Is the Severity of Pancreatitis Classified? Mild Acute Pancreatitis • 80–90% • No organ failure • No local or systemic complications • It usually resolves in 2–5 day • Rare mortalityModerately Severe Acute Pancreatitis • Transient organ failure (lasting < 48 hours) • And/or local or systemic complications in absence of persistent organ failure Severe Acute Pancreatitis • Persistent organ failure (>48 hours)- Single or Multiple • Mortality 35-50 % What Are the Histopathologic Types of Acute Pancreatitis? Interstitial Oedematous Pancreatitis (>80%) • Pancreatic enlargement due to inflammatory oedema • No inflammation or destructionof pancreatic cells Necrotizing Pancreatitis (< 20%) • Necrotic pancreatic parenchyma can lead to sepsis in >50% • Haemorrhagic pancreatitis: extensive bleeding into the pancreatic parenchyma and surroundingtissuesWhat Is the Natural Disease Course of Acute Pancreatitis? >80 % patients recover in less than 5 days without any complications 20% of patients have a severe presentation with local or systemic complications (including organ failure)What are the Local complications of acute pancreatitis?Acute Peripancreatic Fluid collectionPancreatic pseudocystAcute Necrotic collectionWalled off necrosis How Is the Severity of Pancreatitis Measured? Severity is determined by Scoring systems • Modified Glasgow : PANCREAS • Ranson’s : five admission variables and six criteria after 48 hours • APACHE II: ACUTE PHYSIOLOGY AND CHRONIC HEALTH EVALUATION Major determinants of a severe attack • First 24 hours: Obesity, APACHE Score >8 • After 48 hours: Any of CRP >150, Glasgow Score >3, persisting organ failureWhat Is the Most Common Cause of Mortality in Acute Pancreatitis? • In the first week Multiorgan failure secondary to severe systemic inflammatory response. • After the first week Sepsis secondary to pancreatic (peripancreatic abscesses)osisWhat Is the Diagnostic Imaging of Choice on Admission for Acute Pancreatitis?What Is the Role of Abdominal CT Scan in acute pancreatitis ? • CT scan should not be routinely requested on admission • It does not change the initial management in the majority of cases • Indicated if the diagnosis is in doubt • If patient fails to improve/ of conservative management days (5-7)What Is the Role of Urgent ERCP in Gallstone Pancreatitis? • Rarely needed • Only if suspected concomitant acute cholangitis • ERCP may cause pancreatitis (3%) • Indomethacin rectal suppository reduces risk of ERCP pancreatitisWhat Is the Initial Treatment for Acute Pancreatitis? Supportive • Intravenous fluid resuscitation (maintain urine output >0.5ml/kg/hr) • Analgesics • Close monitoring • Nasogastric tube for ongoing vomiting • 80% will resolve within 3–5 days with conservative management What Is the Subsequent Management Plan? Gallstone Pancreatitis • Cadmission or within2 weeksng the same • Timing of surgery depends on pancreatitis severity • Amylase/ lipase levels should not influence timing of surgery Alcoholic pancreatitis • Counselling • ReferralShould Prophylactic Antibiotics Be Administered for Severe Acute Pancreatitis? • There is no role for antibiotics for mild pancreatitis ( remember: pancreatitis is due to inflammation, not infection) • Prophylactic antibiotic does not decrease mortality. • Antibiotics should be only given with proven infected pancreatitis What is the role of feeding in patient with pancreatitis? • Enteral Vs. Parenteral • Debatable • Enteral ( Oral / NGJ ) is superior and preferable compared to parenteral route • Enteral protects against infection.Summary