ACG Postgraduate Course Multidisciplinary Approach to Acute Pancreatitis Medical Management of Acute Pancreatitis Timothy B. Gardner, MD MS FACG Assistant Professor of Medicine Geisel School of Medicine at Dartmouth Director, Pancreatic Disorders Medical Director, Islet Cell Transplant Program Section of Gastroenterology and Hepatology Dartmouth-Hitchcock Medical Center Objectives 1. Fluid Resuscitation 2. Antibiotic Therapy 3. Nutritional Support 4.
Case Presentation - Pancreatitis Chief Complaint: Epigastric abdominal pain History of Present Illness: - 52 y/o male - Chronic alcoholism - 24 hours of epigastric pain with radiation to back - WBC count = 21,235 HCT = 49 - Lipase = 1,243 TB = 1.2 AP = 96 - BUN/CR = 52/1.6 AST/ALT = 41/32 Case Presentation - Pancreatitis
Case Presentation - Pancreatitis Questions to Consider What is this entity? What can I do medically to improve this patient s outcome? Objectives 1. Fluid Resuscitation 2. Antibiotic Therapy 3. Nutritional Support
Fluid Resuscitation Acute pancreatitis leads to approximately 210,000 admissions annually most common GI admission Associated with significant morbidity and mortality of approximately 5% There are no pharmacological therapies with a proven clinical benefit for treating acute pancreatitis Fluid Resuscitation Alterations in the Pancreatic Microcirculation Hypovolemia Increased Permeability free radicals Microthrombi Acinar Cell Injury Proinflammatory mediators (TNF, Bradykinin, Il-1, IL-6) Further Capillary Vasconstriction Release of second stage proinflammatory mediators
Fluid Resuscitation Recommendations Based on Expert Opinion Only Gardner et al CGH 2008;6:1070-6 Fluid Resuscitation Prospective Trials of Fluid Resuscitation in AP
Fluid Resuscitation Prospective Trials of Fluid Resuscitation in AP Fluid Resuscitation Mao et al. Chin Med Journal 2010;123:1639-44.
Fluid Resuscitation Prospective Trials of Fluid Resuscitation in AP Praised for large number of patients and only those with SAP included Criticized for a somewhat unusual treatment approach Mao et al. Chin Med Journal 2010;123:1639-44. Fluid Resuscitation Prospective Trials of Fluid Resuscitation in AP
Fluid Resuscitation Study Design Goal-Directed Therapy Standard of Care Therapy LR NS LR NS Group 1 Group 2 Group 3 Group 4 Wu, et al. Clin Gastro and Hepatology. 2011;9:710-7. Fluid Resuscitation Study Design TARGETING BUN BUN BUN Wu, et al. Clin Gastro and Hepatology 2011;9:710-7.
Fluid Resuscitation Wu, et al. Clin Gastro and Hepatology. 2011;9:710-7. Fluid Resuscitation
Fluid Resuscitation Prospective Trials of Fluid Resuscitation in AP Praised for employing standard clinical resuscitation parameters Criticized for small number of patients and surrogate clinical outcomes Wu, et al. Clin Gastro and Hepatology 2011;9:710-7.
Objectives 1. Fluid Resuscitation 2. Antibiotic Therapy 3. Nutritional Support Antibiotic Therapy Admission Antibiotics Do they prevent a bad clinical outcome? Infected Pancreatic Necrosis Can we get away with medical therapy only?
Antibiotic Therapy Admission Antibiotics Do they prevent a bad clinical outcome? IMIPENEM FOR INFECTED NECROSIS Viilatoro, et al. Cochrane Database Sys Rev 2010 Antibiotic Therapy Admission Antibiotics Do they prevent a bad clinical outcome? IMIPENEM FOR INFECTED NECROSIS Imipenem Does Prevent Infected Necrosis Viilatoro et al. Cochrane Database Sys Rev 2010
Antibiotic Therapy Admission Antibiotics Do they prevent a bad clinical outcome? ALL ANTIBIOTICS - MORTALITY Antibiotic Therapy Admission Antibiotics Do they prevent a bad clinical outcome? ALL ANTIBIOTICS - MORTALITY Antibiotics Do Not Improve Mortality
Antibiotic Therapy Infected Pancreatic Necrosis Can we get away with medical therapy only? Garg, et al. Clin Gastro and Hepatology 2010;8:1089-4. Antibiotic Therapy Infected Pancreatic Necrosis Can we get away with medical therapy only? Infected Pancreatic Necrosis Antibiotics and supportive care should be used as first-line therapy against infected necrosis Garg, et al. Clin Gastro and Hepatology 2010;8:1089-4.
Antibiotic Therapy Infected Pancreatic Necrosis Can we get away with medical therapy only? Mouli, et al. Gastroenterology 2013;144:333-40. Antibiotic Therapy Infected Pancreatic Necrosis Can we get away with medical therapy only?
Antibiotic Therapy Infected Pancreatic Necrosis Can we get away with medical therapy only? 64% successfully treated with medical therapy
Objectives 1. Fluid Resuscitation 2. Antibiotic Therapy 3. Nutritional Support Nutritional Support Mild Disease Most patients able to eat within 7 days Initial diet can be low-fat (no need to start with clear liquids) Do not use probiotics
Nutritional Support Severe Disease Start low fat enteral nutrition as soon as possible (Peptamen) Nasogastric tube feedings probably comparable to nasojejunal feedings Avoid TPN unless cannot deliver full nutritional support enterally Nutritional Support Enteral vs Parenteral Nutrition for Acute Pancreatitis: Mortality Al-Omran, et al. Cochrane Database Sys Rev 2010.
Objectives 1. Fluid Resuscitation 2. Antibiotic Therapy 3. Nutritional Support 4.
Thank You