Acute Pancreatitis:

Transcription

1 American College of Gastroenterology 2014 Acute Pancreatitis Scott Tenner, MD, MPH, FACG Clinical Professor of Medicine State University of New York Health Sciences Center Director, Brooklyn Gastroenterology and Endoscopy Associates Director, Greater New York Endoscopy Surgical Center No Financial Disclosures Acute Pancreatitis: Banks and Freeman. Am J Gastroenterol. 2006;101: DeFrances, Hall, Podgornik. National Center for Health Statistics, Fagenholz, Fernandez-Del Castillo. Harris, et al. Annals of Epidemiology 2007;17:

2 Acute Pancreatitis: Banks and Freeman. Am J Gastroenterol. 2006;101: DeFrances, Hall, Podgornik. National Center for Health Statistics, Fagenholz, Fernandez-Del Castillo. Harris, et al. Annals of Epidemiology 2007;17: Acute Pancreatitis: Banks and Freeman. Am J Gastroenterol. 2006;101: DeFrances, Hall, Podgornik. National Center for Health Statistics, Fagenholz, Fernandez-Del Castillo. Harris, et al. Annals of Epidemiology 2007;17:

3 Natural History of Acute Pancreatitis Organ failure Mild Severe Infection Death Acute Pancreatitis DEATH Early (< one week) Systemic inflammatory response syndrome (SIRS) Multiorgan failure Late (> one week) Multiorgan failure Pancreatic infections/sepsis 3

4 45 year old gentleman presents with complaints of epigastric pain. Pain began 3 hours ago, radiating to the back, associated with nausea. Past Medical History: none Meds: none Social History: 1-2 glasses of wine per day PE: VSSA, Tender epigastrum Labs: Amylase 220 (30-120) IU/L Lipase 380 (20-45) IU/L Acute Pancreatitis: ACG Guidelines Diagnosis 1. The diagnosis i of AP most often is established by the presence of 2 of the 3 following criteria: (1) abdominal pain consistent with the disease, (2) serum amylase and/or lipase greater than three times the upper limit of normal and/or (3) characteristic findings from abdominal imaging. 2. Contrast t enhanced computed tomographic (CECT) and/or magnetic resonance imaging (MRI) of the pancreas should be reserved for patients in whom the diagnosis is unclear or who fail to improve clinically within the first hours after hospital admission. 4

5 Problems Amylase and/or Lipase elevated in normal persons (as high as 5 times) Amylase will be normal in select populations with acute pancreatitis: Alcoholics (25% of patients) Lipemic serum (hypertriglyceridemia) Patients presenting late in the course Post-ERCP pancreatitis Pain and elevations in amylase/lipase common in absence of disease Acute Pancreatitis: ACG Guidelines Biliary Etiology Trans-abdominal ultrasound should be performed in all patients with acute pancreatitis. ERCP is not needed in most patients with gallstone pancreatitis who lack laboratory or clinical i l evidence of ongoing biliary obstruction. 5

6 Acute Pancreatitis: ACG Guidelines The Role of Surgery in Acute Pancreatitis: In patients with mild AP, found to have gallstones in the gallbladder, a cholecystectomy should be performed prior to discharge to prevent a recurrence of AP. In a patient with necrotizing biliary AP, in order to prevent infection, cholecystectomy is to be deferred until active inflammation subsides and fluid collections resolve or stabilize Severity What is Severe Acute Pancreatitis? Organ Failure (Persistent Organ Failure) Pancreatic Necrosis Can We Predict Severe Acute Pancreatitis? Laboratory Tests Scoring Systems Other Factors 6

7 Mortality In Acute Pancreatitis Overall 6% Banks and Freeman, Am J Gastroenterol 2006;101: Mortality In Acute Pancreatitis Overall 6% Interstitial Pancreatitis 3% Banks and Freeman, Am J Gastroenterol 2006;101:

8 Mortality In Acute Pancreatitis Overall 6% Interstitial Pancreatitis 3% Banks and Freeman, Am J Gastroenterol 2006;101: Mortality In Acute Pancreatitis Overall 6% Interstitial Pancreatitis 3% Necrotizing Pancreatitis 17% Banks and Freeman, Am J Gastroenterol 2006;101:

9 Mortality In Acute Pancreatitis Overall 6% Interstitial Pancreatitis 3% Necrotizing Pancreatitis 17% Banks and Freeman, Am J Gastroenterol 2006;101: Mortality In Acute Pancreatitis Overall 6% Interstitial Pancreatitis 3% Necrotizing Pancreatitis 17% Infected Necrosis 30% Banks and Freeman, Am J Gastroenterol 2006;101:

10 Mortality In Acute Pancreatitis Overall 6% Interstitial Pancreatitis 3% Necrotizing Pancreatitis 17% Infected Necrosis 30% Single Organ Failure 3% Banks and Freeman, Am J Gastroenterol 2006;101: Mortality In Acute Pancreatitis Overall 6% Interstitial Pancreatitis 3% Necrotizing Pancreatitis 17% Infected Necrosis 30% Single Organ Failure 3% Multisystem Organ Failure 47% Banks and Freeman, Am J Gastroenterol 2006;101:

11 Mortality In Acute Pancreatitis Overall 6% Interstitial Pancreatitis 3% Necrotizing Pancreatitis 17% Infected Necrosis 30% Single Organ Failure 3% Multisystem Organ Failure 47% No Organ Failure 0% Banks and Freeman, Am J Gastroenterol 2006;101: Correction of Early Organ Failure Prevents Mortality PREVENT: PERSISTENT ORGAN FAILURE 40.00% 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% No Organ Failure 1 Organ Failing At 48 hours Mortality Johnson and Abu-Hilal. Gut 2004;53:

12 A 62 year old hispanic woman arrived to the ER on Friday at 2 pm with complaints of epigastric pain. Pain begain suddenly 6 hours ago while at home. Past Medical History: NIDDM, s/p MI Medications: Glucotrol, ASA, Metoprolol SHx: no alcohol, no tobacco use On physical exam, 5 feet tall, 155 lbs; alert and oriented Temp: 38.9 degrees C, pulse 95 BPM, Bp: 100/70, RR: 18, saturation 93 percent on room air; marked tender abd. Lb Laboratory analysis: Amylase: 2500 Lipase: Admission chest xray: pleural effusion A 62 year old hispanic woman arrived to the ER on Friday at 2 pm with complaints of epigastric pain. Pain begain suddenly 6 hours ago while at home. Past Medical History: NIDDM, s/p MI Medications: Glucotrol, ASA, Metoprolol SHx: no alcohol, no tobacco use On physical exam, 5 feet tall, 155 lbs; alert and oriented Temp: 38.9 degrees C, pulse 95 BPM, Bp: 100/70, RR: 18, saturation 93 percent on room air; marked tender abd. Lb Laboratory analysis: Amylase: 2500 Lipase: Admission chest xray: pleural effusion

13 A 62 year old hispanic woman arrived to the ER on Friday at 2 pm with complaints of epigastric pain. Pain begain suddenly 6 hours ago while at home. Past Medical History: NIDDM, s/p MI Medications: Glucotrol, ASA, Metoprolol SHx: no alcohol, no tobacco use On physical exam, 5 feet tall, 155 lbs; alert and oriented Temp: 38.9 degrees C, pulse 95 BPM, Bp: 100/70, RR: 18, saturation 93 percent on room air; marked tender abd. Lb Laboratory analysis: Amylase: 2500 Lipase: Admission chest xray: pleural effusion A 62 year old hispanic woman arrived to the ER on Friday at 2 pm with complaints of epigastric pain. Pain begain suddenly 6 hours ago while at home. Past Medical History: NIDDM, s/p MI Medications: Glucotrol, ASA, Metoprolol SHx: no alcohol, no tobacco use On physical exam, 5 feet tall, 155 lbs; alert and oriented Temp: 38.9 degrees C, pulse 95 BPM, Bp: 100/70, RR: 18, saturation 93 percent on room air; marked tender abd. Lb Laboratory analysis: Amylase: 2500 Lipase: Admission chest xray: pleural effusion

14 A 62 year old hispanic woman arrived to the ER on Friday at 2 pm with complaints of epigastric pain. Pain begain suddenly 6 hours ago while at home. Past Medical History: NIDDM, s/p MI Medications: Glucotrol, ASA, Metoprolol SHx: no alcohol, no tobacco use On physical exam, 5 feet tall, 155 lbs; alert and oriented Temp: 38.9 degrees C, pulse 95 BPM, Bp: 100/70, RR: 18, saturation 93 percent on room air; marked tender abd. Lb Laboratory analysis: Amylase: 2500 Lipase: Admission chest xray: pleural effusion A 62 year old hispanic woman arrived to the ER on Friday at 2 pm with complaints of epigastric pain. Pain begain suddenly 6 hours ago while at home. Past Medical History: NIDDM, s/p MI Medications: Glucotrol, ASA, Metoprolol SHx: no alcohol, no tobacco use On physical exam, 5 feet tall, 155 lbs; alert and oriented Temp: 38.9 degrees C, pulse 95 BPM, Bp: 100/70, RR: 18, saturation 93 percent on room air; marked tender abd. Lb Laboratory analysis: Amylase: 2500 Lipase: Admission chest xray: pleural effusion

15 A 62 year old hispanic woman arrived to the ER on Friday at 2 pm with complaints of epigastric pain. Pain begain suddenly 6 hours ago while at home. Past Medical History: NIDDM, s/p MI Medications: Glucotrol, ASA, Metoprolol SHx: no alcohol, no tobacco use On physical exam, 5 feet tall, 155 lbs; alert and oriented Temp: 38.9 degrees C, pulse 95 BPM, Bp: 100/70, RR: 18, saturation 93 percent on room air; marked tender abd. Lb Laboratory analysis: Amylase: 2500 Lipase: Admission chest xray: pleural effusion Predicting Severe Disease at Admission: Poor Results from Scoring Systems Ranson APACHE II Cumbersome Require 48 hours for accuracy When accurate, Severe disease is obvious 15

16 Assessing Risk: Admission Age Comorbid disease Etiology BMI Initial Fluid Status (BUN, Creatinine, HCT) Vital Signs Systemic Inflammatory Response Syndrome Initial Rate of Hydration Organ dysfunction on admission Findings on admission CXR Baillargeon et al., Am J Gastroenterol 1998; 93:

17 Patients with Hemoconcentration (HCT rises during first 24 hrs) Develop Pancreatic Necrosis and/or Organ Failure Baillargeon et al., Am J Gastroenterol 1998; 93: Rising BUN is associated with Mortality N=5,819 Wu et al. Gastroenterology, 2009 F-test ANOVA p<

18 RISING HCT and BUN, FLUID SHIFTS AND PANCREATITIS Extravasation of Fluid to Peritoneum Decreased Intravascular Volume HCT and BUN RISE Increased Third Space Loss Increased TNF, Trypsin, PLA2, Elastase, etc. Decreased Pancreatic Perfusion Increased Pancreatic Necrosis HALT THE CYCLE WITH EARLY AGGRESSIVE HYDRATION Decreased Mortality In Acute Pancreatitis Related to Early Aggressive Hydration Wall et al. Pancreas May;40(4):

19 Decreased Mortality In Acute Pancreatitis Related to Early Aggressive Hydration Wall et al. Pancreas May;40(4): cc/hr v 284 cc/hr Decreased Mortality In Acute Pancreatitis Related to Early Aggressive Hydration Wall et al. Pancreas May;40(4):

20 Decreased Mortality In Acute Pancreatitis Related to Early Aggressive Hydration Wall et al. Pancreas May;40(4): Decreased Mortality In Acute Pancreatitis Related to Early Aggressive Hydration Wall et al. Pancreas May;40(4):

21 Admit to Medicine Acute Pancreatitis Mild Disease Ranson Score 0 No Organ Failure NPO IV NS 150 cc/hr CT Abdomen Interstitial Pancreatitis 150 cc/hr 48 hours later Pain Shortness of Breath Pulse Ox 87% RA ARDS Renal Insufficiency HCT 46 Necrotizing Pancreatitis Acute Pancreatitis: ACG Guidelines Initial Management Aggressive hydration, defined as cc per hour of isotonic crystalloid solution should be provided to all patients, unless cardiovascular and/or renal comorbidites exist. Early aggressive intravenous hydration is most beneficial the first hours, and may have little benefit beyond. In a patient with severe volume depletion, manifest as hypotension and tachycardia, more rapid repletion may be needed. 21

22 Acute Pancreatitis: ACG Guidelines Lactated Ringer s solution may be the preferred isotonic crystalloid replacement fluid. Fluid requirements should be reassessed at frequent intervals within 6 hours of admission and for the next hours. The goal of aggressive hydration should be to decrease the blood urea nitrogen. Sterile Pancreatic Necrosis 15% of Patients Supportive Care 50% have Organ Failure NPO 3-6 weeks Enteric Feeding No Prophylactic Antibiotics Consider Resection at 4 weeks 22

23 Enteral v Parenteral Feeding in Patients with Severe Acute Pancreatitis Animal data Research in other fields Nutrition Intensive Care More physiologic Maintains gut integrity Decreases intestinal permeability Maintain less pathogenic intestinal flora If nasojejunal feeding used, gastric phase of pancreatic stimulation not effected Enteral Nutrition (EN) vs Parenteral Nutrition (PN) Al-Omran et al. Cochrane Database Syst. Rev Jan 20: CD Less Organ Failure (RR 0.5 CI ) Less MOF (RR 0.6 CI ) Less Systemic Infections (RR 0.4 CI ) Less Surgical Interventions (RR 04CI ) 0.7) Fewer days in hospital (decrease 2.4 days) Decreased costs Decrease mortality (RR 0.18 CI ) 23

24 Nasojejunal vs Nasogastric? Difference Eatock et al. Am J Gastro 2005; 100: Singh et al. Pancreas 2012;41: Piciucchi et al. World J Gastroenterology 2010; 16: Eckerwall et al. Ann Surg 2006; 244: Kumar et al., J Clin Gastroenterology 2006; 40: Acute Pancreatitis: ACG Guidelines In severe AP, enteral nutrition is recommended to prevent infectious complications. Parenteral nutrition should be avoided, unless the enteral route is not available, not tolerated or not meeting caloric requirements. Naso-gastric delivery and naso-jejunal delivery of enteral feeding appear comparable in efficacy and safety (Strong Recommendation) 24

25 A 66 year old gentleman who was admitted for acute pancreatitis complicated by necrotizing disease. He was doing well until his 12 th day of hospitalization when he develops a fever and recurrent pain. Physical exam: T 38.8 C, Pulse 115, Bp 130/70 Abdomen mildly tender in the periumbilical region. Laboratory analysis: leukocytosis 14K. CT: Acute Pancreatitis: ACG Guidelines The use of antibiotics in patients with sterile necrosis to prevent the development of infected necrosis is not recommended. Infected necrosis should be considered in patients with pancreatic or extra-pancreatic necrosis, who deteriorate or fail to improve after 7-10 days of hospitalization. In these patients, either a) initial CT guided fine needle aspiration (FNA) for gram stain and culture to guide use of appropriate antibiotics or b) empiric use of antibiotics without CT FNA should be given. 25

26 Pancreatic Necrosis: Suspected of Infection Obtain CT-guided FNA (usually after 7-10 days from admission) Negative Grams stain or culture Sterile Necrosis: Supportive Care, repeat FNA every 5-7 days if clinically indicated Clinically Stable Continue Antibiotics and Observe Delayed Surgical, Radiologic, or Endoscopic debridement In Select Patients:?No Debridement Positive Gram stain or culture Targeted Antimicrobial Therapy Pancreatic Penetrating Antibiotics Clinically Unstable Prompt Surgical Debridement 26

27 Pancreatic Necrosis: Suspected of Infection Targeted Antimicrobial Therapy Pancreatic Penetrating Antibiotics Clinically Stable Continue Antibiotics and Observe Delayed Surgical, Radiologic, or Endoscopic debridement In Select Patients:?No Debridement Clinically Unstable Prompt Surgical Debridement 27

28 45 year old gentleman was hospitalized 3 weeks ago for acute pancreatitis. Discharged after cholecystectomy. Now presents with abdominal pain, fever, leukocytosis. CT aspiration shows gram negative rods, Imipenem begun. After 3 days, the patient is persistently hypotensive, tachycardic. What is the best next step? Need to Differentiate Between Pancreatic Necrosis and Pseudocyst Hounsefield Units The Same on CT Pseudocyst Fluid, can be drained early Pancreas Pancreatic Necrosis (WOPN) Not Fluid Until 5-6 weeks Pancreas 28

29 Need to Differentiate Between Pancreatic Necrosis and Pseudocyst Hounsefield Units The Same on CT Pseudocyst Fluid, can be drained early Pancreas Pancreatic Necrosis (WOPN) Not Fluid Until 5-6 weeks Pancreas Need to Differentiate Between Pancreatic Necrosis and Pseudocyst Hounsefield Units The Same on CT Pseudocyst Fluid, can be drained early Pancreas Pancreatic Necrosis (WOPN) Not Fluid Until 5-6 weeks Pancreas 29

30 Acute Pancreatitis: ACG Guidelines In stable patients with infected necrosis, surgical, radiologic, i and/or endoscopic drainage, should be delayed by preferably for 4 weeks to allow liquafication of the contents and the development of a fibrous wall around the necrosis (Walled Off Necrosis) Where Do We Stand 2014 Acute Pancreatitis Increasing Incidence (>400,000 patients in 2014) Emotional and Financial Costs - $4 billion per year Diagnosis and Management Issues Complex Complex Early Management based on Aggressive Hydration No Drug Available for Treatment Caution Needed for Invasive Procedures Decreasing Morbidity and Mortality 30