Acute pancreatitis complications and a method to improve the outcome

Transcription

1 Acute pancreatitis complications and a method to improve the outcome Poster No.: C-2959 Congress: ECR 2017 Type: Authors: Keywords: DOI: Scientific Exhibit B. Angheloiu, A. Leandru; Brasov/RO Abdomen, Emergency, Computer applications, CT, MR, Ultrasound, Complications, Abscess, Acute, Outcomes /ecr2017/C-2959 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 12

2 Aims and objectives Acute pancreatitis refers to acute inflammation of the pancreas and it is one of the most common disease of the gastrointestinal tract that can lead to potentially life threatening conditions. [1] Patients with AP typically present with epigastric or left upper quadrant pain, which is usually described as constant with radiation to the back, chest, or flanks, but this description is non-specific. [5]The intensity of the pain is usually severe, but can be variable. The intensity and location of the pain do not correlate with severity. [6-9] The diagnosis of acute pancreatitis is made by fulfilling two of the following three criteria [8]: Acute onset of persistent, severe epigastric pain (i.e. pain consistent with acute pancreatitis) Lipase/amylase elevation >3x the upper limit of normal Characteristic imaging features on CECT, MRI or US Imaging is crucial for the detection of complications and to help guide treatment. Once the diagnosis of acute pancreatitis is established, the treatment of the patient dependents on the early assessment of disease severity. The assessment, being based on certain parameters, it is very important in predicting clinical complications and for identifying potentially lethal attacks, which are known to occur in 2%-10% of patients with acute pancreatitis.[1,2] Organ failure is frequently observed in severe pancreatitis, so it is recommended to use a multiple factor scoring. [14] Are known systems like Ranson, Imrie, Glasgow, but are large debates around them because can have poor predictive power. [3-5] By comparison with the others scoring systems, the multiple organ system failure seems to have a higher prediction, it has better clinical utility for evaluating patients on admission and at 48 h. It can be performed within a few hours of admission and can be repeated daily to monitor disease progression. [7] Therefore the purpose of this study was to evaluate the complications of acute pancreatitis, the outcome of them, and to reveal methods of improving the end results. Methods and materials Page 2 of 12

3 This is a retrospective study for 6 year period, between Were studied 140 patients (97 males and 43 females), the age between years old, admitted in our hospital: Emergency County Hospital Brasov, with the diagnosis of acute pancreatitis. In order to evaluate the complication's severity was used a multiple organ system failure scoring. Parameters that were taken into account are: Medical history Repeated clinical examination Serological tests Complications The necessity of surgery Final outcome of patients [10] All the patient underwent chest X-ray and ultrasonography; a computed tomography scan of the abdomen was performed whenever needed. A MOSF scoring system was used in order to identify the severity and predicting the course of acute pancreatitis. This system is based on the sum of the failing organ system in the same day, score varied from 0 to 7. Score #1 means severe acute pancreatitis. [17] Criteria for MOSF scale: ORGAN SYSTEM Cardiovascular Criteria for Multiple Organ System Failure (MOSF) Arterial blood pressure less than 50 mm Hg. In need of volume loading and/or vasoactive drugs to maintain systolic blood pressure above 100 mm Hg. Heart rate less 50 beats per minute. Ventricular tachycardia/fibrillation. Cardiac arrest Acute myocardial infarction Renal Serum creatinine #3.5 mg per dl (280 mmol per L). Dialysis/ultrafiltration needed Page 3 of 12

4 Pulmonary Hematologic Neurologic Gastrointestinal Respiratory rate less than 5 per minute or more than 50 per minute. Mechanical ventilation for 3 or more days or Fio 2 > 0.4 and/or positive end-expiratory pressure > 5 mm Hg Hematocrit #20%. Leukocyte count #300 per mm 3 ( per L). Platelet count # per ml ( per L) Disseminated intravascular coagulation Glasgow Coma Scale #6 (in the absence of sedation) Stress ulcer necessitating transfusion of more than 2 units of blood per 24 hours. Acalculus cholecystitis. Necrotizing enterocolitis. Bowel perforation. Hepatic Total bilirubin level #3.5 mg per dl (51 mmol per L) in the absence of hemolysis. ALT > 100 U per L. [10] Results The most common symptom was represented by epigastric abdominal pain for 137 of cases, the next symptom as frequency was nausea, vomiting or bilious vomiting, followed by fever, jaundice and other symptoms. (Fig. 1) Page 4 of 12

5 Fig. 1: Most common symptoms - acute pancreatitis References: RADIOLOGY, County Clinical Emergency Hospital of Bra#ov - Brasov/ RO Gallstone passage was the most common cause of acute pancreatitis 77patients, followed by idiopathic causes 30 patients, alcohol abuse 22 cases and other causes such as: metabolic disorders, trauma and malignancy 11 patients. (Fig. 2) Page 5 of 12

6 Fig. 2: Most common causes of acute pancreatitis References: RADIOLOGY, County Clinical Emergency Hospital of Bra#ov - Brasov/ RO The most common chest X-ray finding was bilateral pleural effusion seen in 48 patients. From all studied patients diagnosed with acute pancreatitis, 67% patients had a mild attack and severe pancreatitis was seen in 33% of patients. For 106 an abdominal CT scan was needed. The most common local complication was: ascites in 45 % of cases, (Fig.3) Page 6 of 12

7 Fig. 3: Contrast-enhanced CT scan of the upper abdomen showing peripancreatic non-enhancing areas of necrosis of the pancreas and ascites References: RADIOLOGY, County Clinical Emergency Hospital of Bra#ov - Brasov/ RO necrosis 32% (Fig.4) Page 7 of 12

8 Fig. 4: Contrast-enhanced CT scan of the upper abdomen showing peripancreatic and retro peritoneal edema. Large non-enhancing areas of necrosis are visible in the body and tail of the pancreas. Fluid collection with thick walls. References: RADIOLOGY, County Clinical Emergency Hospital of Bra#ov - Brasov/ RO locoregional collections 15% (Fig.4) other complications were: ARDS, renal failure, pancreatic abscesses, and infection of the pancreatic necrosis, vascular erosion, duodenal cystic dystrophy, portal ans splenic thrombosis and the poorest prognosis was encephalopathy. Distant complication was seen in almost 20% patients - pancreatic pseudocyst. (Fig.5) Overall, mortality was seen 9% of cases, with a mortality rate of 33% in severe acute pancreatitis. Although conservative management was done in all patients to start with, then 15 % of patients needed surgery. Page 8 of 12

9 Fig. 5: Contrast-enhanced CT scan of the upper abdomen showing a well-defined fluid collection in the retroperitoneum, just below the level of the pancreas consisting with pancreatic pseudocyst. References: RADIOLOGY, County Clinical Emergency Hospital of Bra#ov - Brasov/ RO Was used a MOSF scoring system in order to assess the severity of acute pancreatitis. This system predicted the attack of severe acute pancreatitis in 56 patients (with a score over 1). Whereas the MOSF scoring system predicted the mild attack of acute pancreatitis in 84 patients. The sensitivity and specificity of the MOSF system in predicting the severity of attack in acute pancreatitis were 95 % and 92%, respectively. CT scan has an important role in diagnosis of acute pancreatitis, its complications and extensive pancreatic necrosis that can be easy correlated with pancreatic sepsis. [10] Conclusion Page 9 of 12

10 The most common local complication was ascites and peripancreatic fluid and the systemic one was pleural effusion. Other complication were: ARDS, renal failure, pancreatic abscesses, infection of the pancreatic necrosis, vascular erosion, duodenal cystic dystrophy portal thrombosis and the poorest prognosis was encephalopathy. Fig. 6: Post surgical status (retro peritoneal malignant mass) patient has acute pancreatitis, biliary fistula and biloma. Contrast-enhanced CT scan of the upper abdomen showing a well-defined collection with blood density located in the tail of the pancreas. References: RADIOLOGY, County Clinical Emergency Hospital of Bra#ov - Brasov/ RO The multiple organ system failure scoring correlated with enhanced CT abdominal scan help to identify and to monitories the high risk patients and deciding on therapy in order to avoid risk of complications and decrease mortality.[10] Imaging is crucial for the detection of complications and to help guide treatment. Page 10 of 12

11 Personal information References 1. Bradley EL, III. A clinically based classification system for acute pancreatitis. Arch Surg 1993; 128: CrossRef, Medline 2. Dervenis C, Johnson CD, Bassi C, et al. Diagnosis, objective assessment of severity, and management of acute pancreatitis. Int J Pancreatol 1999; 25: Medline 3. Emil J. Balthazar, MD,Acute Pancreatitis: Assessment of Severity with Clinical and CT Evaluation, Volume 223, Issue 3 3. Fagenholz PJ, Castillo CF, Harris NS et al. Increasing United States hospital admissions for acute pancreatitis, Ann Epidemiol 2007;17: Yadav D, Lowenfels AB. Trends in the epidemiology of the first attack of acute pancreatitis: a systemic review. Pancreas 2006;33: Bradley EL. A clinically based classification system of acute pancreatitis. Arch Surg 1993;128: Banks PA, Bollen TL, Dervenis C et al. Classification of acute pancreatitis-2012: revision of Atlanta classification and definitions by international consensus. Gut 2013;62: Busquets J, Fabregat J, Pelaez N et al. Factors influencing mortality in patients undergoing surgery for acute pancreatitis: importance of peripancreatic tissue and fluid infection. Pancreas 2013;42: Banks PA, Bollen TL, Dervenis C et-al. Classification of acute pancreatitis-2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2012;62 (1): doi: /gutjnl Pubmed citation 9. Wall I, Badalov N, Baradarian R et al. Decreased morbidity and mortality in patients with acute pancreatitis related to aggressive intravenous hydration. Pancreas 2011;40: A clinical study of complications of acute pancreatitis and their outcome Sajjad Hussain, Rakesh Saraf Arch Clin Exp Surg. 2015; 4(1): 1-13» Abstract & References» PDF Fulltext» doi: /aces Page 11 of 12

12 11. Guyatt GH, Oxman AD, Vist GE et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336: Clavien PA, Robert J, Meyer P et al. Acute pancreatitis and normoamylasemia. Not an uncommon combination. Ann Surg 1989;210: Winslet M, Hall C, London NJM. Relation of diagnostic serum amylase levels to aetiology and severity of acute pancreatitis. Gut 1992;33: Malka D, Rosa-Hezode I. Positive and etiological diagnosis of acute pancreatitis. Gastroenterol Clin Biol 2001;25:1S153-11S UK guidelines for the management of acute pancreatitis. Gut 2005;54: Steinberg WM, DeVries JH, Wadden T et al. Longitudinal monitoring of lipase and amylase in adults with type 2 diabetes and obesity: Evidence from two phase 3 randomized clinical trials with the once-daily GLP-1 analog liraglutide. Gastroenterology 2012;121: A Shah AM, Eddi R, Kothari ST et al. Acute pancreatitis with normal serum lipase: a case series. JOP 2010;11: Kiriyama, Gabata T, Takada T et al. New diagnostic criteria of acute pancreatitis. J Hepatobiliary Pancreat Sci 2010;17: Lippil G, Valentino M, Cervellin G. Laboratory diagnosis of acute pancreatitis: in search of the Holy Grail. Crit Rev Clin Lab Sci 2012;49: Balthazar EJ. Acute pancreatitis: assessment of severity with clinical and CT evaluation. Radiology 2002;223: Page 12 of 12