Acute Pancreatitis Management

2. Gallstones continue to be the most common
cause of acute pancreatitis in most series
Alcohol is the second most common cause

3. "GET SMASH'D"
 Gallstones,
 Ethanol,
 Trauma,
 Steroids,
Mumps,
 Autoimmune,
 Scorpion bites,
 Hyperlipidemia,
 Drugs(azathioprine, diuretics)

5. Abdominal pain
Nausea and vomiting
signs may vary from mild tenderness to
generalised peritonitis.
Grey-Turner's sign
Cullen's sign

6. MOF- Respiratory,cardiovascular failure
&acute renal failure.
Metabolic
(hypocalcaemia,hypomagnesaemia,
hyperglycaemia)
Haematological (DIC)
Fever - systemic inflammation, or acute
cholangitis, due to bacterial infection-LATE

7. a recognised entity
occurs in cases of shock of unknown origin,
during the postoperative period,
in renal transplant
peritoneal dialysis patients,
and in diabetic ketoacidosis.

9. Typical clinical features
+ a high plasma concentration of pancreatic
enzymes
serum amylase concentrations decline quickly
over two to three days
Relate it to onset of abdominal pain

10. several non-pancreatic diseases (visceral
perforation, small bowel obstruction and
ischaemia, leaking aortic aneurysm, ectopic
pregnancy),
tumours also secrete amylase

11. superior sensitivity and specificity
preferable to serum amylase for the
diagnosis of acute pancreatitis

12. History
physical examination,
liver function tests,
and biliary ultrasonography will indicate the
correct cause in most cases.
If not, follow-up investigations, should
include fasting plasma lipids and calcium, viral
antibody titres, and repeat biliary
ultrasonography.

14. detect free air in the abdomen,
colon cut-off sign, a sentinel loop, or an ileus.
calcifications within the pancreas - chronic
pancreatitis.

15. Plain radiographs clues
alternative abdominal emergency,
detect and stage complications of acute
severe pancreatitis, especially pancreatic
necrosis

16. pancreatic necrosis cannot be appreciated
until at least three days after the onset of
symptoms.
Patients with persisting organ failure,
signs of sepsis,
clinical deterioration occurring after an initial
improvement
Follow-up scans

17. also provide prognostic information based on
the following grading scale developed by
Balthazar:
A - Normal
B - Enlargement
C - Peripancreatic inflammation
D - Single fluid collection
E - Multiple fluid collections

18. The chances of infection and death are
virtually nil in grades A and B
steadily increase in grades C through E.
Patients with grade E pancreatitis have a 50%
chance of developing an infection and a 15%
chance of dying.

19.  only be used in the following situations:
 severe acute pancreatitis secondary to stones
 biliary pancreatitis - worsening jaundice and
clinical deterioration despite maximal supportive
therapy.
 with sphincterotomy and stone extraction, may
reduce the length of hospital stay, the
complication rate, and, possibly, the mortality
rate.
 in the setting of suspected SOD (sphincter of
oddi dysfunction)

20.  PRSS1 genetic testing is recommended in symptomatic
patients with any of the following features
 n
 Recurrent attacks of acute pancreatitis for which no cause
has been found
 Idiopathic chronic pancreatitis
 A family history of pancreatitis in a first or second degree
relative
 Unexplained pancreatitis occurring in a child

22.  Supplemental oxygen
 adequate fluid resuscitation
 A urinary catheter
 Central venous monitoring
 All patients with severe acute pancreatitis
should be managed in a high dependency unit or
intensive therapy unit.
 opiate analgesia.
 A nasogastric tube is not useful routinely but
may be helpful if protracted vomiting occurs in
the presence of a radiologically demonstrated
ileus.

23. All patients with severe acute pancreatitis
should be managed in a high dependency
unit or intensive therapy unit with full
monitoring and systems support
(recommendation grade B).

24. no proven therapy for the treatment of acute
pancreatitis.

25. Patients with alcohol-induced pancreatitis
may need alcohol-withdrawal prophylaxis.
Lorazepam, thiamine, folic acid, and multi-vitamins
are generally used in this group of
patients.

27.  imaging of the common bile duct is required.
 If the presence of stones in the common bile duct
is confirmed, a cholecystectomy with common
bile duct exploration (either surgical or
postoperatively with endoscopic retrograde
cholangiopancreatography [ERCP]) should be
performed during the same hospitalisation in
mild to moderate disease soon after the attack
resolves.
 A longer delay, even of a few weeks, is associated
with a high recurrence (80%) of acute pancreatitis
and re-admission

28. If the pancreatitis is severe, some allow a few
months for the inflammation to completely
resolve before performing a cholecystectomy

29. In patients who are not candidates for surgery
because of comorbidities with a high American
Association of Anesthesiology (ASA) index,
sepsis, or severe disease,
 ERCP must be considered.
 Urgent ERCP is indicated in patients with biliary
sepsis and obstructive jaundice that show no
improvement in 48 hours after the onset of the
attack.
 ERCP is a diagnostic and therapeutic
intervention

30. If mild to moderate pancreatitis is found,
cholecystectomy with intra-operative
cholangiogram should be performed but the
pancreas should be left alone.
For severe pancreatitis, the lesser sac should
be opened and the pancreas fully inspected.
Some surgeons place drains and irrigating
catheter around the pancreas.

31. during the same hospital admission,
unless a clear plan has been made for
definitive treatment within the next two
weeks (recommendation grade C).
should be delayed in patients with severe
acute pancreatitis until signs of lung injury
and systemic disturbance have resolved.

33. infected necrosis -high mortality rate (40%).
diagnosed either by the presence of gas
within the pancreatic collection
or by fine needle aspiration

34. All patients with persistent symptoms and >
30% pancreatic necrosis,
and those with smaller areas of necrosis and
clinical suspicion of sepsis,
should undergo image guided fine needle
aspiration to obtain material for culture 7–14
days after the onset of pancreatitis
(recommendation grade B).

35. sterile necrosis - managed conservatively.
infected necrosis -radiological or surgical
intervention.

37. Some trials show benefit, others do not.
 At present there is no consensus on this
issue. If antibiotic prophylaxis is used, it
should be given for a maximum of 14 days

38. rationale -mortality for infected pancreatic
necrosis is higher than that for sterile
necrosis.

40. No conclusive evidence to support the use of
enteral nutrition in all patients with severe
acute pancreatitis.
enteral route is preferred if that can be
tolerated (recommendation grade A).
nasogastric route effective in 80% of cases
(recommendation grade B).

41. The use of enteral feeding may be limited by
ileus. If this persists for more than five days,
parenteral nutrition will be required.

43. clinical impression of severity,
obesity, or APACHE II>8 in the first 24 hours
of admission, and
C reactive protein >150 mg/l,
Glasgow score 3 or more,
or persisting organ failure after 48 hours in
hospital (recommendation grade B).

44. The definitions of severity, as proposed in the
Atlanta criteria, should be used.
organ failure present within the first week,
which resolves within 48 hours, should not be
considered an indicator of a severe attack
(recommendation grade B).

45.  Bradley reported the criteria for severe acute pancreatitis
developed at the International Symposium on Acute Pancreatitis
held in Atlanta, Georgia.
Criteria for severe acute pancreatitis - one or more
of the following:
 (1) Ranson score on admission >= 3 (or during
the first 48 hours)
 (2) APACHE II score >= 8 at any time during
course
 (3) presence of one or more organ failures
 (4) presence of one or more local complications

46. Scoring systems increase accuracy of
prognosis.
Use of the Glasgow Prognostic
Score/Ranson's Criteria/Acute Physiology and
Chronic Health Evaluation II (APACHE II)
score can indicate prognosis, particularly if
combined with measurement of CRP >150
mg/L.

47. Ranson criteria for pancreatitis at
admission LEGAL:
Leukocytes > 15 x109/l
Enzyme AST > 250
units/l
Glucose > 10mmol/l
Age > 55
LDH > 600 units/l

48.  Ranson criteria for pancreatitis: initial 48
hours "C & HOBBS" (Calvin and Hobbes):
 Calcium < 2mmol/l
 Hct drop > 10%
 Oxygen < 8 kpa
 BUN > 1mmol/l
 Base deficit > 4mmol/l
 Sequestration of fluid > 6L

49. NUMBER OF POSITIVE CRITERIA
0-2 <5% mortality
3-4 20% mortality
5-6 40% mortality
7-8 100% mortality

50. uses age, and 7 laboratory values collected
during the first 48 hours following admission,
to predict severe pancreatitis.
It is applicable to both biliary and alcoholic
pancreatitis.
The score can range from 0 to 8. If the score is
>2, the likelihood of severe pancreatitis is
high. If the score is <3, severe pancreatitis is
unlikely.

51. Age >55 years
WBC >15 x 109/L
Urea >16 mmol/L
Glucose >10 mmol/L
pO2 <8 kPa (60 mm Hg)
Albumin <32 g/L
Calcium <2 mmol/L
LDH >600 units/L
AST/ALT >200 units

52.  The majority of patients with acute pancreatitis will
improve within 3 to 7 days of conservative
management.
 The cause should be identified,
 a plan to prevent recurrence should be initiated
before the patient is discharged.
 In gallstone pancreatitis, a cholecystectomy should be
considered before discharge in mild cases and a few
months after the discharge date in patients with
severe symptoms.
 In patients who are not candidates for surgery,
endoscopic retrograde cholangiopancreatography
(ERCP) must be considered.

53. include:
(1) pancreatic necrosis
(2) pancreatic abscess
(3) pancreatic pseudocyst

54. Organ failures include:
 (1) shock (systolic blood pressure less than 90
mm Hg)
 (2) pulmonary insufficiency (PaO2 <= 60 mm Hg
on room air)
 (3) renal failure (serum creatinine > 2 mg/dL after
fluid replacement)
 (4) gastrointestinal bleeding, with > 500 mL
estimated loss within 24 hours
 (5) DIC (thrombocytopenia and
hypofibrinogenemia and fibrin split products)
 (6) severe hypocalemia (<= 7.5 mg/dL)

55. Thanks !