8 Severe Acute Pancreatitis

History ,[object Object],[object Object],[object Object],[object Object]

Physical and laboratory examinations ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Which evaluations would you perform to determine if the patient has severe pancreatitis? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Initial tests and treatment ,[object Object],[object Object],[object Object],[object Object]

The patient has severe pancreatitis by CT criteria ,[object Object],[object Object]

Ranson score: a pancreatitis-specific severity of illness score ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Present on admission During the first 48 hours

The patient has eight positive Ranson criteria ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],The predicted mortality rate for a Ranson score of 8 is 60% Eachempati et al. Arch Surg 2002 Figure reproduced with permission from Arch Surg

Would you start prophylactic antibiotics? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Penetration of pancreatic tissue and pancreatic juice by antimicrobial agents ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Bassi et al. Antimicrob Agents Chemother 1994;38:830–836

What is this patient’s risk of developing infection? ,[object Object],[object Object],[object Object],[object Object]

Incidence of peripancreatic infection after acute pancreatitis ,[object Object],[object Object],[object Object],[object Object],Beger et al. Gastroenterology 1986;91:433–438 Beger et al. Pancreatology 2003;3:93–101 Buchler et al. Ann Surg 2000;232:619–625

Pancreatic infections almost never occur before Day 7 The peak incidence is at Day 14 Day 14 Day 7 Day 21 Should prophylaxis be given? for the entire at-risk period? Beger et al. Gastroenterology 1986;91:433 –43 8 99% of data 95% of data 68% of data

How long would you administer antibiotic prophylaxis? ,[object Object],[object Object],[object Object],[object Object],[object Object],Should prophylaxis be administered for the entire risk period?

Prophylactic antibiotics for severe acute pancreatitis First double-blind, placebo-controlled trial ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Isenmann et al. Gastroenterology 2004;126:997

Results: intention-to-treat analysis (n=114) 11 17 Need for operation (%) 7 5 Mortality (%) 23 22 Extra-pancreatic infection (%) 9 12 Infected necrosis (%) Placebo Ciprofloxacin/ metronidazole

Prophylactic antibiotics for severe acute pancreatitis: double-blind, placebo-controlled trial ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Prophylactic antibiotics for severe acute pancreatitis: trial results ,[object Object],0.80 18 20 Mortality 0.48 20 26 Surgical intervention 0.41 12 18 Pancreatic/peri pancreatic infection p-value Placebo % Meropenem % Outcome

The downside of prolonged antibiotic prophylaxis ,[object Object],[object Object],[object Object],[object Object]

Prophylactic antibiotics for severe acute pancreatitis ,[object Object],p<0.0001 Isenmann et al. Gastroenterology 2004;126:997

What antibiotic regimen was prescribed initially? ,[object Object]

The patient’s condition improves ,[object Object],[object Object],[object Object]

The patient develops multiple organ dysfunction syndrome ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Repeat CT scan shows a large peripancreatic fluid collection Small amount of still-perfused pancreas

What action(s) should be taken now? ,[object Object],[object Object],[object Object],[object Object]

What specimen(s) would you collect? ,[object Object],[object Object],[object Object],[object Object]

Incidence of infected pancreatitis when sought by fine-needle aspiration 98 89 Accuracy (%) 98 93 Neg. pred. value (%) 100 83 Pos. pred. value (%) 100 90 Specificity (%) 97 88 Sensitivity (%) > Week 1 All

Results of culture and susceptibility testing ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Microbiology of infected pancreatic necrosis (%) Fernandez-del Castillo et al. Ann Surg 1998;228:676–684 Buchler et al. Ann Surg 2000;232:619–626 10 Not reported Mixed 6 17 Candida spp. 4 2 Anaerobes 36 26 Gram-negative 46 55 Gram-positive Buchler 2000 Fernandez-del Castillo 1998

Therapy ,[object Object],[object Object],[object Object],[object Object],[object Object]

Outcome ,[object Object],[object Object],[object Object],[object Object],[object Object]

Key learning points ,[object Object],[object Object],[object Object],[object Object]

AIM core principles ,[object Object],[object Object],[object Object]

8 Severe Acute Pancreatitis

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8 Severe Acute Pancreatitis