Acute Pancreatitis. Encourage You to Read!
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1 Acute Pancreatitis Laith H. Jamil, MD, FACG Associate Director of Interventional Endoscopy Cedars Sinai Medical Center Los Angeles, CA Encourage You to Read! Copyright 2015 American College of Gastroenterology 1
2 Acute Pancreatitis Most common GI discharge Dx (2009) Cost $2.6 Billion Hospital admission for AP 40/100,000 (1998) 70/100,000 (2002) Making the Dx Need 2 of 3 criteria: (based on consensus guidelines) Clinical Laboratory Imaging Copyright 2015 American College of Gastroenterology 2
3 Pain : Clinical Constant, severe epigastric pain Exceptions (usually with hypotension) : post op, critically ill, dialysis, organophosphate poisoning, Legionnaire s disease Other symptoms: N/V, bloating, dyspnea (severe pancreatitis) Lankisch PG et al Am J Gastroenterol. 1991;86(3):322 Lankisch PG et al Am J Gastroenterol Jul;85(7):872-5 Kesavan CR et al Am J Gastroenterol Mar;88(3):468-9 Laboratory Elevated Amylase &/or Lipase 3X ULN Lipase Amylase Lipase is more sensitive Can have AP with normal pancreatic enzymes Yadav D et al Am J Gastroenterol. 2002;97(6):1309 Clavien PA et al Ann Surg Nov;210(5): Shah AM et al JOP Jul 5;11(4): Copyright 2015 American College of Gastroenterology 3
4 High Amylase & Lipase AMYLASE LIPASE Acute pancreatitis Acute pancreatitis Diseases that might mimic acute Diseases that t might mimic i acute pancreatitis pancreatitis Pancreatic pseudocyst Chronic pancreatitis Pancreatic carcinoma Biliary tract disease (cholecystitis, cholangitis, choledocholithiasis) Intestinal obstruction, pseudoobstruction, ischemia, or perforation Acute appendicitis Ectopic pregnancy AGA technical review Gastroenterol 2007;132: Pancreatic pseudocyst Chronic pancreatitis Pancreatic carcinoma Biliary tract disease (cholecystitis, cholangitis, choledocholithiasis) Intestinal obstruction, pseudoobstruction, ischemia, or perforation Acute appendicitis Other disorders High Amylase & Lipase AMYLASE Renal failure Parotitis Macroamylasemia Ovarian cyst or cystic neoplasm Carcinoma of the lung Diabetic ketoacidosis Human immunodeficiency virus infection Head trauma with intracranial bleeding LIPASE Other disorders Renal failure AGA technical review Gastroenterol 2007;132: Copyright 2015 American College of Gastroenterology 4
5 Contrast-enhanced CT and / or MRI Reserved for Unclear diagnosis Failure to improve within the first hrs Evaluate for complications Tenner S et al Am J Gastroenterol doi: /ajg Management Etiology (goal is to prevent a future attack) Severity (appropriate triage) Treatment (avoid complications) Copyright 2015 American College of Gastroenterology 5
6 Etiology of Acute Pancreatitis IDIOPATHIC ALCOHOL HYPERTGN OTHER BILIARY Autoimmune Metabolic Iatrogenic Neoplastic IBD-relate Structural Infectious Traumatic Inherited Vascular Etiology / Work up Gall stones (40-70%): All patients with AP should undergo an abdominal US ETOH (25-35%): > 5 years of heavy alcohol consumption Other causes: Primary and secondary hypertriglyceridemia (>1000 mg/dl) Benign or malignant lesions (imaging in patients >40) Medications, infectious agents, metabolic (check Calcium), trauma, AIP Iatrogenic post ERCP Tenner S et al Am J Gastroenterol doi: /ajg Copyright 2015 American College of Gastroenterology 6
7 Tsuang W et al AJG 2009;104:984. AP Severity Revised Atlanta Classification 2013 Mild AP Absence of organ failure Absence of local complications Moderately severe AP Local complications AND / OR Transient organ failure ( < 48 h) Severe AP Persistent organ failure > 48 h Banks PA et al Gut. 2013;62(1):102 Copyright 2015 American College of Gastroenterology 7
8 Predicting Severe AP No laboratory test is practically available or consistently it tl accurate to predict ditseverity in patients with AP Tenner S. Am J Gastroenterol 2004 ; 99 : Clinical Findings Associated With a Severe Course Patient: > 55 yo, BMI > 30, AMS, comorbid dz Clinical features: 2 SIRS Labs: BUN > 20 mg/dl or rising BUN HCT > 44 % or rising i HCT Elevated creatinine Radiology Pleural effusions Pulmonary infiltrates Multiple l or extensive extrapancreatic collections Tenner S. Am J Gastroenterol 2004 ; 99 : Copyright 2015 American College of Gastroenterology 8
9 Systemic Inflammatory Response System Development and persistence of SIRS organ fil failure Patients with persistent SIRS ICU or similar unit for aggressive IV hydration and close monitoring Early SIRS Is Associated With Severe Acute Pancreatitis Figure 1 Number of SIRS criteria within 24 hours of presentation (in legend box ) and corresponding rates of persistent organ failure, pancreatic necrosis, need for ICU, and mortality among the 252 patients. Patients with SIRS = 0 (... Singh VK et al CGH Volume 7, Issue 11, 2009, Copyright 2015 American College of Gastroenterology 9
10 After Dx Aggressive Fluid Resuscitation Author Journal Initial fluid recommendation assuming normal-sized individual without cardiac, pulmonary, or renal compromise Pandol et al Gastro 2007 Severe volume depletion: cc/hr Moderate fluid loss: cc/hr No volume depletion: cc/hr Forsmark and Baillie Gastro 2007 Vigorous fluid resuscitation Urine output >0.5ml/kg/hr Whitcomb NEJM 2006 Fluid bolus to achieve hemodynamic stability then ml/hr crystalloid Banks and Freeman AJG 2006 Aggressive IV fluid Vege et al JAMA 2004 Aggressive fluid resuscitation Tenner AJG 2004 At least cc/h for 48 hrs Gardner TB et al. Clin Gastroenterol Hepatol.2008 Oct;6(10): Fluid therapy in AP Norman J, Am J Surg, 1998 Copyright 2015 American College of Gastroenterology 10
11 ICU Admission Source With Severe AP N= 2462 ICU Admissions Source of admission % Mortality Ward, same hospital Theater and recovery, same hospital HDU, same hospital Emergency department, same hospital Other hospital (not ICU/HDU) Other intermediate care area, same hospital Recovery only, same hospital Radiograph, CT scanner or similar, same hospital 1 44 HDU, other hospital Harrison DA et al Crit Care Med Jul;35(7): LR Reduced SIRS at 24 Hours Compared With Saline in AP Patients Wu BU et al CGH 2011 Aug;9(8): Copyright 2015 American College of Gastroenterology 11
12 GD vs. ST Goal directed therapy: 20mL/Kg bolus then 3mL/kg/hr. /h Reassess in 8 hrs. If fluid refractory repeat. If responded 1.5mL/Kg/hr Alternative 10mL/lb bolus, then 1.5mL/lb/hr then re-assess in 8-12 hours. No response repeat. If response then 1mL/lb/hr / How Much Fluid ml/hr of isotonic crystalloid solution (Lactated Ringer s preferred) unless CVS, renal, or other related comorbid factors exist Patients with severe volume deple on more rapid bolus Fluid requirements should be reassessed at frequent intervals within 6 h of admission and for the next h Most beneficial during the first h Tenner S et al Am J Gastroenterol doi: /ajg Copyright 2015 American College of Gastroenterology 12
13 Monitoring Rehydration Use of hematocrit, BUN, and creatinine as surrogate markers for successful hd hydration Goal: Decrease hematocrit and BUN and maintain a normal creatinine during the first day of hospitalization Pain Control PCA Hydromorphone ( e,g. 0.2mg with 10 min lock) or Fentanyl (25-50mcg 50 with 10 min lock) which is better in renal impairment Copyright 2015 American College of Gastroenterology 13
14 When Should ERCP Be Performed In Suspected Gallstone Pancreatitis? Suspected cholangitis Fever, Leukocytosis, Hypotension URGENT ERCP INDICATED (within 24 hours) Persistent biliary obstruction Rising liver tests ERCP within hours Otherwise MRCP or EUS if choledocholithiasis highly suspected Folsch et al. NEJM 1997, ACG practice guidelines 2006 Arguedas MR et al Am J Gastroenterol 2001 ; 96 : Moretti A et al Div Liver Dis 2008 ; 40 : Nutrition in Mild AP Oral feedings SHOULD be started immediately if No nausea and vomiting, no ileus Type of diet: Low-fat solid diet appears as safe as a clear liquid diet Copyright 2015 American College of Gastroenterology 14
15 Enteral vs. Parenteral Nutrition in Severe AP Enteral nutrition reduces mortality, organ failure, systemic infections No difference between NG and NJ Yi F et al Intern Med.2012;51(6): Early Nasoenteric (24 hrs) versus Oral/On- Demand Nasoenteric Tube (72 hrs) Feeding in AP Bakker OJ et al N Engl J Med.2014 Nov 20;371(21): Copyright 2015 American College of Gastroenterology 15
16 Timing and Impact of Infections in AP Antibiotics should be given for an extra-pancreatic infection Besselink MG et al Br J Surg.2009 Mar;96(3): Prophylactic Antibiotics in AP Not recommended in Mild disease Severe AP Sterile necrosis to prevent the development of infected necrosis NNT: 1,429 for one patient to benefit Routine administration of antifungal agents along with prophylactic or therapeutic antibiotics is not recommended Jiang K et al World J Gastroenterol 2012 ; 18 : Trikudanathan G et al Am J Gastroenterol 2011 ; 106 : Copyright 2015 American College of Gastroenterology 16
17 Necrotizing Pancreatitis RCT n=88 pts Suspected or confirmed infected necrosis Composite endpoint: new-onset organ failure, perforation, bleeding or death 40% step-up vs. 69% open necrosectomy (p=0.006) van Santvoort HC et al N Engl J Med 2010;362: Infected Pancreatic Necrosis Stable patients Conservative Mx (antibiotics and supportive care) drainage should be delayed preferably > 4 weeks (walled-off necrosis) Symptomatic patients minimally invasive methods of necrosectomy are preferred to open necrosectomy Copyright 2015 American College of Gastroenterology 17
18 Endoscopic Transgastric vs Surgical Necrosectomy for Infected Necrotizing Pancreatitis: A Randomized Trial Bakker OJ et al JAMA. 2012;307(10): Bakker OJ et al JAMA. 2012;307(10): Copyright 2015 American College of Gastroenterology 18
19 61 YO Male, 1 week at OSH 2 day after transfer on 4 pressors! ICU Bedside EUS with cystgastrostomy 1 week later off pressor! Copyright 2015 American College of Gastroenterology 19
20 1 week later acute decompensation Cholecystectomy in AP Mild biliary AP Cholecystectomy during index hospitalization 18 % re-admission for recurrent biliary events within 90 days of discharge Compared with interval cholecystectomy, sameadmission cholecystectomy reduced the rate of recurrent gallstone-related complications in patients with mild gallstone pancreatitis, with a very low risk of cholecystectomy-related complications Necro zing biliary AP cholecystectomy deferred Larson SD et al Adv Surg 2006 ; 40 : Uhl W et al Surg Endosc 1999 ; 11 : da Costa DW et al Lancet Sep 26;386(10000): Copyright 2015 American College of Gastroenterology 20
21 ETOH Induced AP Prevention ETOH cessation counseling inpatient vs. repeated outpatient RCT 120 patient with ETOH induced AP Intervention both groups single inpatient counseling session Repeated 6-month 30-min counseling vs. none Repeat intervention led to reduction in AP recurrence 9 episodes (5 patients) vs 20 episodes (13 patients), p=0.02 Nordback I et al Gastroenterology 2009 Mar;136(3): Fluid Collections Asymptomatic pseudocysts and pancreatic and d/ or extrapancreaticnecrosis ti i No intervention Acute fluid /necro c collec on delay intervention ideally >4 weeks Symptomatic pseudocyst / walled off necrosis drain/debride Copyright 2015 American College of Gastroenterology 21
22 Summary Fluids vital in first hours; 10-20ml/Kg bolus, 3ml/kg/hr /h for 8 hours, the if respond 1.5 ml/kg/hr of isotonic crystalloid solution Use heme concentration to monitor Prevent further attacks by findings an etiology Severity; 2 SIRS ICU Control pain Mild biliary AP Choly index hopitalization Summary Cont. ERCP only in Cholangitis/obstructive jaundice Antibiotics: Documented infection Enteral better then parenteral nutrition Mild AP start feeding if no N/V/Ileus Mod-sv start enteral feeding within 72 hrs Step up approach for necrotizing i pancreatitis Copyright 2015 American College of Gastroenterology 22
23 Thank you Copyright 2015 American College of Gastroenterology 23
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