Diagnosis and Management of Acute Pancreatitis
Polson Health Lecture Series Nicholas V. Costrini , Program Director, Digestive Health Institute of Montana May 4, 2017
Diagnosis and management of Acute Pancreatitis (AP)
1. Diagnosis: presence of two of three criteria a. abdominal pain consistent with the disease b. serum amylase and/ lipase > 3x ULN c. characteristic findings from abdominal imaging (routine US) Notes: Pain upper abd, radiates to the back, chest, flank , moderate to severe. The intensity and location do not correlate with severity. Amylase may be normal in 25% pt. on admit and may be nl with ETOH, hyperlipidemia. Amylase and lipase may be elevated with extrapancreatic inflammation.An isolated amylase or lipase without the above does not establish an AP dx. CT is not required or recommended unless pt. fails to improve in 48-72hrs
Diagnosis and management of acute pancreatitis
Establishing the cause: If the Ultrasound fails to reveal gallstones and there is no history of alcohol abuse obtain a serum triglyceride. If greater than 1000 that is likely the etiology. Gallstone 50-70%, Alcohol 25-30%, lipids 4%, other. In patients over 40 y/o,( I use over the age of 60) acute pancreatitis can be the presenting sign of pancreatic cancer. In this setting patients will not recover within 48 hours and proceeding to CAT scan is appropriate. Idiopathic pancreatitis is recurrent and requires advanced assessment. If family hx present , genetic testing warranted if no other cause found. Few medications actually cause pancreatitis –Azathioprine.
Diagnosis and management of acute pancreatitis
How sick is your patient? predicting severity of disease mild acute pancreatitis -absence of organ failure, absence of local complications: NO test measures severity better than clinical exam in the first 48 hrs. Moderately severe acute pancreatitis- local complications and /or transient organ failure (less than 48 hours) Severe acute pancreatitis persistent organ failure greater than 48 hours: vs changes, elevated wbc, falling GFR, pancreatic necrosis Establishing The Disease Severity for Acute Pancreatitis Promotes Augmented Care Alerts to a Mortality Risk Stratification
The majority of AP patient will either improve or deteriorate in first 48hrs. Older scores of severity – Ransom Criteria and APACHE II – NO LONGER USED NEWER SYSTEM: BISAP SYSTEM Measures taken at admit or within 48hr B- BUN > 25mg/dl I –Impaired Mental Status S- SIRS A- age >60 P- pl eff. SIRS: Systemic Inflammatory Response Syndrome : fever, tachycardia, tachy- pnea, wbc > 12,000 or > 10% bands. One point for each criteria , 3 or > associated with higher risk of death and of pancreatic necrosis CT SCAN SEVERITY INDEX AT 48-72 HRS: NECROSIS ASSOCIATED WITH 30% MORTALITY AND 50% ORGAN FAILURE Normal CT of the abdomen/pancreas Severe Pancreatic Necrosis Diagnosis and management of acute pancreatitis
Patients with acute , severe pancreatitis should be admitted to ICU. There has been no medication that reverses AP For management attention is : FLUIDS, organ failure support, definition of pancreatic necrosis. Routine ERCP is to be avoided in the absence of biliary occlusion ; today MRCP and EUS are equally sensitive to diagnose choledocholithiasis Monitor the VS, CBC, GFR, I/O, pulmonary status, ABGs, mental status.
Diagnosis and management of acute pancreatitis
Role of antibiotics
Antibiotic should be given for extra pancreatic infection such as: Cholangitis, bacteremia, pneumonia
Routine use of prophylactic antibiotics in patients with severe AP is not recommended
Infected necrosis should be considered in patients with pancreatic necrosis who deteriorate after 7 to 10 days of hospitalization; aspiration for culture is appropriate. Broad-spectrum antibiotics recommended for infected necrosis; antifungal agents not recommended Diagnosis and management of acute pancreatitis
Nutrition considerations in Acute pancreatitis management
The need to place the pancreas and rest (NPO) until complete resolution of AP is no longer recommended
Providing oral feedings shortens hospital stay decreases infectious complications decreases mortality and morbidity. This is true for mild pancreatitis
For mild or severe pancreatitis total parenteral nutrition is to be avoided.
Recent meta-analysis of eight randomized controlled trials found a decrease in infectious complications in patients with severe acute pancreatitis provided enteral nutrition as compared to TPN. Nasogastric feeding appear safe. Nasojejunal tubes are not worth the effort. Diagnosis and management of acute pancreatitis
When to remove the gallbladder in the setting of acute gallstone pancreatitis? In the setting of mild pancreatitis removal of the gallbladder during that hospitalization is indicated.
In the setting of moderately severe or severe pancreatitis cholecystectomy should be deferred in discussion with surgeon and gastroenterologist.
Patients with idiopathic acute pancreatitis if you remove the gallbladder after second attack with no stones or sludge or elevations of liver function tests recurrence of acute pancreatitis occurs in greater than 50% of patients Routine Ultrasound revealing gallstone in the setting of AP reveals “likely dx.” Origin of Gallstone Pancreatitis choledocholithiasis = common duct stone MRCP revealing multiple common duct stone Endoscopic Retrograde Cholangiopancreatography ERCP for removal of common duct stone. ACUTE PANCREATITIS DIAGNOSIS & MANGEMENT
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