Management of Acute Pancreatitis and its Complications Aspirus Grand Rounds June 6, 2017 Eric A. Johnson MD

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1 Management of Acute Pancreatitis and its Complications Aspirus Grand Rounds June 6, 2017 Eric A. Johnson MD Disclosure: None In accordance with the Standards of the Wisconsin Medical Society, all those who are in a position to affect content of this CME activity are required to disclose financial relationships with any commercial interest(s) related to the subject matter of this activity. The speaker, activity Director, and planning committee have no relevant financial relationships or conflicts of interest to disclose. 2 1

2 Objectives 1. Determine best methods to accurately triage acute pancreatitis patients and most important treatments in early acute severe pancreatitis. 2. Updates on use of antibiotics, IV fluids, nutrition, and imaging in acute pancreatitis. 3. How to deal with delayed complications of severe acute pancreatitis (pancreatic fluid collections, compartment syndrome, splenic vein thrombosis. 3 Don t mess with the pancreas 2

3 Pancreatic anatomy Background History of acute pancreatitis Causes of acute pancreatitis Endoscopic ultrasound Anatomy 3

4 Anatomy Anatomy 4

5 History of AP Many deaths, some as early as 320 BC, have been attributed to AP (Alexander the Great). First systematic analysis 1880s, by Dr. Fitz (pathologist at Mass General) Acute Pancreatitis is the most terrible of all the calamities that occur in connection with the abdominal viscera. The suddenness of its onset, the illimitable agony which accompanies it, and the mortality attendant upon it, all render it the most formidable of catastrophies Lord Moynihan (1925) Oreilly. J R Soc Med History of AP Most common GI discharge diagnosis $2.6 billion in 2009 Increase in annual incidence Decreased case fatality rate but overall population mortality has remained unchanged Tenner et al. Am J Gastro

6 Causes of AP Gallstones and ETOH (90%) Drugs aza, PIs, estrogen, tetracyclines, thiazides, loop diuretics, ACEi, etc, etc, etc. Hypertriglyceridemia Hypercalcemia Post ERCP Trauma Infection Genetic Pancreas cancer/cysts Pancreas divisum Autoimmune Types of Echo Endoscopes Radial 6

7 Radial Imaging Types of Echo Endoscopes Curvilinear Array 7

8 Curvilinear Imaging: Pancreatitis Diagnosis of acute pancreatitis Triaging acute pancreatitis Management of acute pancreatitis Management of specific complications from severe acute pancreatitis 8

9 Acute Pancreatitis Diagnosis: Atlanta Criteria (Must have 2 of 3) Characteristic abdominal pain Lipase/amylase elevation Imaging showing pancreas inflammation Banks et al. Gut Acute Pancreatitis Classification: Interstitial (80 90%) vs Necrotizing Severity: Mild no end organ failure or local/systemic complications Moderate no organ failure or transient organ failure (<48 hrs) and/or local complications. Severe persistent end organ damage (>48 hours) 9

10 What defines organ failure Shock (SBP <90) Respiratory failure (PaO2 <60) Renal failure (Creat >2 AFTER rehydration) GI bleeding (>500mL/24 hours) Acute Pancreatitis Assessing disease severity: Ranson Criteria needs 48 hours APACHE hard to calculate BISAP BUN >25, impaired MS, SIRS, Age>60, Pleural effusion CT severity index necrosis or not (needs contrast and does not help in the first 72 hours) CRP (takes 72 hours to be accurate) ****Lipase does not predict severity and does not need to be followed after initial diagnosis 10

11 Triaging: Don t worry about any scoring system Determine severity based on presence of organ failure and patient comorbidities Reassess often!!! Management of AP: Fluids How much? How long? Does type matter? 11

12 Fluids How much: Aggressive vs Controlled fluid resuscitation 15ml/kg/hr vs 5 10ml/kg/hr Two retrospective trials from Mayo Clinic showed increased SIRS and increased mortality in the Non aggressive groups A prospective study of 247 pts by de Madaria in 2011 showed that resuscitation with more than 4 L in the first 24 hours lead to persistent organ failure and increased risk of fluid collections Gardner et al. Pacreatology Warndord et al. Clin Gastro Hepatol AGA guidelines: Aggressive hydration ( ml/hr) should be provided to all pts unless CV or renal comorbidities exist. This is most beneficial in the first hours and may have little benefit beyond. Tenner et al. Am J Gastro

13 My recommendations: Give 1 liter bolus up front and then give ml per hour for 6 8 hours and then reassess! urine output, BUN, hct, and blood pressure. BUN at hospitalization and change in BUN at 24 hours predict mortality. What type of fluid? 13

14 Crystalloid vs Colloid Colloids: better with optimizing hemodynamic response and also reduce intraabdominal HTN. Crystalloids: cheaper and more unlimited resource, less risk of intravascular overload. AGA recommends crystalloids unless the hct < 25 or albumin is <2.0 What Crystalloid? Fluids: Wu et al. Clinical Gastro and Hep,

15 Fluids Wu et al. Clinical Gastro and Hep, Summary: Crystalloid > Colloid Fluids Lactated ringers > normal saline Early aggressive hydration.but not too aggressive (3 4 liters in first day is a good goal but use clinical signs) 15

16 Nutrition/Refeeding Management of AP: Nutrition How to refeed in mild AP: RCT with 101 pts Sathiaraj et al. APT

17 Severe Pancreatitis Enteral vs parenteral Nutrition Yi et al. Intern Med 2012 Mortality Nutrition: Yi et al. Intern Med

18 Nutrition Infectious complications Yi et al. Intern Med 2012 Organ failure Nutrition Yi et al. Intern Med

19 Nutrition NJ vs NG Nutrition Metaanalysis of 157 pts Chang et al. Critical Care

20 Nutrition Summary In mild AP: start early, low fat diet In severe AP: Enteral feedings via NG/NJ Management of AP Antibiotics: Treat extra pancreatic infections (20% of AP) NOT recommended for prophylaxis of infected necrosis Used if suspected or proven infected necrosis Consider CT guided aspiration to guide therapy Suspect if known necrosis and clinical deterioration (usually after 10 days) Which abx? Carbapenums, fluoroquinolones + metronidazole Tenner et al. Am J Gastro

21 Management of early complications Splanchnic vein thrombosis Abdominal compartment syndrome Venous anatomy of the abd Nadkarni et al. Pancreas

22 Jiang. WJG Splanchnic vein thrombosis Should we anticoagulate? Only if extension to SMV or portal vein with ischemia to the bowel or liver Risk of variceal bleeding? Only 4% in severe AP with thrombosis Splenectomy? Only for chronic pancreatitis with SVT 22

23 Abdominal compartment syndrome Intraabdominal hypertension = sustained pressure over 15mmHg ACS: abdominal pressure >20mmhg + new organ dysfunction Abdominal Compartment Syndrome Why do patients with pancreatitis get this? Third spacing/ascites Aggressive fluid resuscitation Ileus One study showed that 60% of patients in the ICU with severe AP had IAH and these pts had higher organ dysfunction, longer hospital stays, and higher mortality. Al Bahrani et al. Pancreas

24 Abdominal compartment syndrome How should we monitor this? 24

25 Late Complications Management of Complications Local Complications: Timing and indication for CT scan? 72 hours if severe pancreatitis or clinical deterioration Acute peripancreatic fluid collections 4 wks Pseudocysts Acute necrotic collection 4 wks Walled off necrosis 25

26 Pancreatic Cysts Walled Off Fluid Collections 26

27 Walled off Fluid Collections Expectant management: If asymptomatic (~ 40 60% in some studies) Symptoms: Pain, N/V, early satiety, jaundice, unexplained fever Often takes 6 12 months to resolve, sometimes longer Vitas et al. Surgery Walled off Fluid Collections Drainage options: Surgical drainage Percutaneous drainage Endoscopic drainage Combination of 2 or more of the above 27

28 Surgical Drainage Most invasive and most morbid Laparascopic cystgastrostomy Open necroscetomy NEJM study 2010 Van Santvoort et al. NEJM

29 NEJM 2010 Van Santvoort et al. NEJM 2010 Percutaneous drainage Advantages: Least invasive Successful for most locations Drain can be placed before maturity Disadvantages: Fistula formation External drain Takes a long time Risk of infection 29

30 Endoscopic Cystgastrostomy --Can only be done after the cyst is mature (4-6 weeks from initial pancreatitis) Necrosectomy 30

31 Endoscopic Necrosectomy Advantages: 80 85% successful alone (455 pt systematic review) Typically well tolerated Allows for debridement Disadvantages: Location limited by GI lumen Tedious Risk of bleeding, air embolism 6% mortality (during same systematic review) Brunschot et al. Surg Endosc Miscellaneous management of AP When to do ERCP in gallstone pancreatitis? When should GB come out after pancreatitis? How high are triglycerides that cause AP? Acute on chronic pancreatitis 31

32 Questions? 32