Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka s17

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA.

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. NAME OF THE CANDIDATE DR.NAGESH V R. AND ADDRESS PG IN GENERAL SURGERY, ROOM NO.115,VIVEK HOSTEL, KIMS, HUBLI-22.

2. NAME OF THE INSTITUTION KARNATAKA INSTITUTE OF MEDICAL SCIENCES, HUBLI-22.

3. COURSE OF THE STUDY AND M.S.GENERAL SURGERY SUBJECT

4. DATE OF ADMISSION TO THE 31-05-2008 COURSE

5. TITLE OF THE TOPIC CLINICAL STUDY OF ACUTE PANCREATITIS AND ITS MANAGEMENT

6. BRIEF RESUME OF INTENDED WORK: 6.1 NEED FOR STUDY: Acute pancreatitis is a common condition involving the pancreas .The estimated incidence is about 3% of cases presenting with pain abdomen. Gall stones and alcoholism together account for 80% of acute pancreatitis. But recent studies show alcoholism as being the main aetiological factor causing acute pancreatitis. The available investigations like serum enzyme levels and CT-Abdomen may be false negative and are not specific for acute pancreatitis. There is increasing evidence towards conservative line of management and early enteral feeding. So the study is undertaken to study the common aetiology, clinical presentation and management of acute pancreatitis in our setup. 6.2 REVIEW OF LITERATURE:

1. Baig SJ, Rahed A, Sen S, et al (2008) 1 studied 45 cases of acute pancreatitis out of which 34 had mild pancreatitis and 11 had severe pancreatitis and found alcoholism as the main aetiological factor. Blunt abdominal trauma was seen as a common cause of severe acute pancreatitis. The out come in mild pancreatitis was good, severe acute pancreatitis leads to more complications and greater mortality, thus requiring careful medical and surgical management. 2. Pupelis G, Zeiza K, Plaudis H, Suhova A, et al (2008) 2 conducted a retrospective study of 274 patients with severe acute pancreatitis and concluded that conservative protocol – based approach is a rational treatment strategy for the management of severe acute pancreatitis and can be successfully implemented in the setting of the university hospital. 3. Rybakov GS, Dibirov MD, Briskin BS, Khalidov OKH, Barsukov MG, Prosperov MA, et al (2008)3 analysed the diagnosis and treatment of 602 patients with destructive pancreatitis and has shown that definition of aetiological and pathogenetic forms of pancreatitis defines strategy of treatment. In this way patients with biliary pancreatitis require emergency operative treatment and in patients with alcoholic or alimentary pancreatitis conservative treatment is proven with use of open or percutaneous invasive methods of intervention in stage of infection or necrotic suppurative inflammation 4. Takacs T, Szabolcs A, Hegyi P, Rakonczay Z Jr, Farkas G, et al (2008)4 analysed and compared the data of patients with acute pancreatitis treated in 1996 (period I) and 2004 (period II) at the Departments of Internal Medicine and Surgery, University of Szeged, to evaluate the concordance with international guidelines during medical and surgical treatment. The authors analysed the clinical data of 126 and 124 patients respectively, with acute pancreatitis observed during the two periods. An increase in the incidence of biliary acute pancreatitis, more frequent use of antibiotics, a higher frequency of therapeutic endoscopies (papillotomy andbiliary stone extraction), the general application of ultrasonography-guided fine needle aspiration and bacterial culturing in cases of suspected infected necrosis, and higher effectiveness in complex surgical and supportive management of infected necrosis cases were detected in period II and concluded that although most of the achievements suggested in international guidelines on medical/endoscopic and surgical treatment of acute pancreatitis have been implemented during the observation period, no significant changes in the morbidity and mortality data of patients were found. 5. Gramlich L, Taft AK,et al (2007) 5 found that 75% to 85% of all pancreatic episodes are mild and self-limiting and do not require intervention with nutrition support. Considering the significant risk of malnutrition in moderate to severe forms of pancreatic injury, enteral nutrition has more recently been documented in its benefit as an adjunct to management. In addition, it may play a role in obviating the systemic inflammatory response syndrome and in modifying the course of the disease. This paper reviews practical considerations in feeding patients with severe acute pancreatitis, including discussion of gastric versus post-pyloric feeding, choice of enteral product, and relative role and optimization of parenteral nutrition support. 6. Papachristou GI, Papachristou DJ, Morinville VD, Slivka A, Whitcomb DC, et al (2006) 6 studied patients in 2 phases . In Phase I: 102 AP patients were prospectively ascertained, of which 77 (mean age 49 yr; 35 women, 42 men) underwent contrast- enhanced computerized tomography (CECT) and were studied. Eleven subjects developed PNEC (14%). Phase II: 1,474 anonymized patients admitted to the hospital with a diagnosis of AP were electronically reviewed to identify 359 subjects (mean age 54 yr; 157 women, 202 men) with AP and CECT. Seventy-six of these patients (21%) exhibited CECT evidence of PNEC and concluded that Chronic alcohol consumption seems to constitute a strong risk factor for PNEC. 7. Sivasankar A, Kannan DG, Ravichandran P, Jeswanth S, Balachandar TG, Surendran R, et al (2006)7 studied Case records of 52 patients with severe acute pancreatitis admitted from October 2000 to September 2005 and retrospectively analysed them to assess the feasibility of conservative management of infected pancreatic necrosis and found that selected patients with infected pancreatic necrosis who are clinically stable with transient end organ dysfunction can be treated conservatively with a favourable outcome. Necrosectomy associated with high morbidity and mortality in these patients can be avoided. The need for intervention should be individualized and based on clinical conditions of the patients 6.3 OBJECTIVES OF STUDY:

1. To study the age, sex prevalence and actiology of acute pancreatitis in patients presenting at KIMS Hubli.

2. To study the clinical presentation and management of acute pancreatitis in patients presenting at KIMS Hubli.

7. MATERIALS AND METHODS:

7.1 SOURCE OF DATA

All the patients admitted to surgery department, KIMS Hubli with acute pancreatitis during the period of January 2009 to December 2009 will be taken for study, considering the inclusion and exclusion criteria.

7.2 METHODS OF COLLECTION OF DATA

The study is a cross sectional study in which cases will be selected taking into consideration the inclusion and exclusion criteria.

Detailed History will be taken as per the prepared proforma and then complete clinical examination will be done.

INCLUSION CRITERIA

All patients with acute pancreatitis aged above 12 years admitted to surgical department of KIMS, Hubli.

EXCLUSION CRITERIA

 Patients aged below 12 years

 Patients with chronic pancreatitis and acute on chronic pancreatitis SAMPLE SIZE

All cases of acute pancreatitis admitted to surgical department of KIMS Hubli during the period from January 2009 to December 2009 will be taken for study as time bound study.

7.3 DOES THE STUDY REQUIRE ANY INVESTIGATIONS OR INTERVENTIONS TO BE CONDUCTED ON PATIENTS? IF SO, PLEASE SPECIFY.

“Yes”

1. Hb %, TC, DC, ESR

2. B. Urea, S. Creatinine

3. FBS, PPBS

4. USG – Abdomen

5. Serum amylase

6. Chest X-Ray PA view

7. S. Lipase, S.Calcium and CT-Abdomen and other relevant investigations if necessary.

7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITUTION IN CASE OF 7.3?

“YES”, Ethical clearance has been obtained from ethical committee of KIMS Hubli. 8 LIST OF REFERENCES . 1. Baig SJ, Rahed A, Sen S, et al. A prospective study of the aetiology, severity and outcome of acute pancreatitis in Eastern India. Trop gastroenterol. 2008 Jan – Mar; 29(1):20-2. 2. Pupelis G, Zeiza K, Plaudis H, Suhova A, et al. Conservative approach in the management of severe pancreatitis : eight year experience in a single institution. HPB (Oxford). 2008 ; 10 (5) : 347-55. 3. Rybakov GS, Dibirov MD, Briskin BS, Khalidov OKH, Barsukov MG, Prosperov MA, et al. Diagnostic and management algorithm of acute pancreatitis. Khirurgiia (Mosk). 2008; (4); 20 – 6. 4. Takacs T, Szabolcs A, Hegyi P, Rakonczay Z Jr, Farkas G, et al.Changes in diagnostic and therapeutic standards of acute pancreatitis in clinical practice. Epidemiological analysis of data from a regional center of internal medicine and surgery. Orv Hetil. 2008 Apr 6; 149(14):645-54. 5. Gramlich L, Taft AK,et al. Acute pancreatitis: practical considerations in nutrition support. Curr Gastroenterol Rep. 2007 Aug;9(4):323-8. 6. Papachristou GI, Papachristou DJ, Morinville VD, Slivka A, Whitcomb DC, et al. Chronic alcohol consumption is a major risk factor for pancreatic necrosis in acute pancreatitis. Am J Gastroenterol. 2006 Nov;101(11):2605-10. 7. Sivasankar A, Kannan DG, Ravichandran P, Jeswanth S, Balachandar TG, Surendran R, et al. Outcome of severe acute pancreatitis: is there a role for conservative management of infected pancreatic necrosis? Hepatobiliary Pancreat Dis Int. 2006 Nov;5(4):599-604. 9. SIGNATURE OF THE CANDIDATE

10. REMARKS OF THE GUIDE

DR. M. B. BARIGIDAD. 11. 11.1 NAME AND DESIGNATION OF M. S. PROFESSOR OF SURGERY, THE GUIDE DEPARTMENT OF SURGERY, KIMS, HUBLI.

11.2 SIGNATURE

11.3 CO-GUIDE (IF ANY)

11.4 SIGNATURE

11.5 HEAD OF THE DEPARTMENT DR. B. S. MADAKATTI. M.S. PROFESSOR & HEAD, DEPARTMENT OF SURGERY, KIMS, HUBLI.

11.6 SIGNATURE

12 12.1 REMARKS OF THE CHAIRMAN AND THE PRINCIPAL

12.2 SIGNATURE