ACUTE PANCREATITIS

Tim Pieh, MD
Maine-Dartmouth Family Practice Residency

OUTLINE
Diagnosis Etiology Assessing severity Treatment Complications

CASE
64 yo woman develops upper abd pain late last night. Band-like with radiation to back. Initially not severe, but awoke and had several episodes of non-bloody emesis. No F/C, no dark urine The first 8 hours in ED/Hospital needs 36 mg MSO4 to control pain.

CASE
PMHx: HTN, Hyperlipidemia PSurgHx: TAH-BSO MEDS: Estrace, Plendil SOCIAL: no tobacco or ETOH BP: 94/45 160/90, HR: 76, T: 97.9, GEN: awake alert HEENT: no icterus, mouth is dry CARDIO: RRR ABD: SNT, no rebound, no bruising

CASE
ABD CT: marked peripancreatic fluid, streaking around pancreas, normal enhancement, no clear gallstones, CBD not dilated LABS: AST/ALT both slightly elevated. T.bili normal Amylase 2620 lipase 26,625 Hct normal WBC 14.8

MORTALITY
Mild Acute Pancreatitis
< 5%

Severe Acute Pancreatitis

25%

Nearly 20% of all pts with AP develop SAP 25% of SAP pts die

DISEASE COURSE
Deaths occur in 2 phases: PHASE 1 (with in first few days):
SIRS ARDS

PHASE 2 (after second week):

Sterile necrosis Infected necrosis Multiple organ dysfunction

DIAGNOSIS
FAIRLY SUDDEN ONSET UPPER ABD PAIN RADIATION TO BACK N/V ELEVATED AMYLASE ELEVATED LIPASE CULLEN SIGN (PERIUMBILICAL BRUISING) GREY-TURNER SIGN (FLANK BRUISING)

CAUSES
The Big Three:
Gall Stones Alcohol Idiopathic (40%) (35%) (20%)

CAUSES
The Others:
Trauma (pancreatic duct injury) Post-ERCP Drugs (rare)
30 meds identified
Azathioprine (Imuran immune suppressant) Valproic acid (Depakote seizures/mood stabilizer) Didanosine (Videx HIV med) Pentamidine (HIV pneumocystis carinii Tx) Mesalamine (Asacol ulcerative colitis Tx)

CAUSES
Organ transplant, major surgery Hypertryglycerides (rare)
Greater than 1000 mg/dL

Pregnancy
Third trimester until 6 weeks post partum

HIV
35 to 800 times greater risk of AP c/w general pop.

Hypercalcemia
Most often secondary to hyperparathyroidism

Scorpion, spider, and Gila Monster lizard bites

PREDICTING CAUSES
Gallstones:
ALT > 150 IU/dL PPV >95% Ultrasound will see gallstones in 60-80% of cases (Less reliable for stones in CBD) MRCP sensitivity 90-100%

ETOH
Lipase > amylase

SEVERITY
Early identification of severity and appropriate ICU care has significantly reduced mortality over the last 20 yrs
Bedside eval (compared to severity scoring) missed over 50% of severe cases

SEVERITY
When do you do early transfer to ICU? When do you consult critical care team? When do you start antibiotics? When do you get a CT scan? They say people crash fast who are these people? What is aggressive fluid resuscitation?

SEVERITY
APACHE II
Best test
Can be done at 24 hrs, can be repeated

Ransons Criteria (1974!)

Needs to be done at 24 and 48 hrs

Balthazars (CT scan criteria) Glascow Single Markers of Severity

APACHE II
http://www.sfar.org/scores2/apache22.html

8 is severe

Ransons Criteria
3 is severe

SINGLE MARKERS

CASE
At 36 hrs you are night float and get a call from RN. Pt with increased work at breathing, crackles at bases of lungs. She is 4 liters ahead on fluids. What do you want to do?

TREATMENT
Vigorous intravenous hydration alone is the best available option in the prevention of pancreatic necrosis.
Pitchhumoni et al. Mortality in Acute Pancreatitis, Journal of Clinical Gastroenterology

TREATMENT
AGGRESSIVE FLUID RESUSCITATION
May require 250-500 cc/hr for first 48 hrs
6 L of fluid is sequestered in abdomen alone Third spacing can consume up to 1/3 of total plasma volume

1/3 of people die in the first phase 50% of these are associated to ARDS

PULMONARY EDEMA CHF

TREATMENT
INFLAMMATORY MEDIATORS & PANCREATIC SECRETIONS ARE WASHING THROUGH THE LUNGS
INCREASED PULM. VASCULAR PERMEABILITY PULMONARY EDEMA

TREATMENT
How do you know you are resuscitated?
Blood pressure Heart rate Urine output SPO2/ABGs show good oxygenation and no acidemia

TREATMENT
AGGRESSIVE FLUID RESSUCITATION
You may create electrolyte imbalances that need to be corrected You may need CVP monitoring (central line) CXRs help (CHF vs ARDS) ABGs help (still hypoxic need more fluids?)
23% of SAP pts get ARF 80% mortality 0.5 cc/kg/hr urine output is goal (need a Foley)

TREATMENT
OXYGENATE
Give O2 (spO295%) Liberal intubation/ventilation to treat ARDS

SCDs

NECROSIS
Starts to occur within 4 days of disease CT with po & IV contrast is gold standard
Necrotic areas do not enhance You will NOT see it on CT before 48hrs

Once you Dx necrosis mortality jumps

40-60% get secondary infection Mortality then approaches 80%

SECONDARY INFECTIONS
SYMPTOMS:
N/V, epigastric pain, distension, fever, elevated WBC

Diagnosis of sterile vs infected necrosis

CT-guided needle aspiration

This is the most devastating complication and marks the second peak in mortality (@ 2 weeks)

SECONDARY INFECTIONS
FLUID COLLECTIONS PSEUDOCYSTS PANCREATIC NECROSIS Above get infected in 1-10% of all acute pancreatitis, but are source of 80% of deaths

SECONDARY INFECTIONS
What bugs? Gram (-) bacteria cross from gut
E. coli (35%) Klebsiella (24%) Enterococcus (24%) Staph (14%) Pseudomonas, proteus, strep, enterobacter, bacteroides, anaerobes

SECONDARY INFECTIONS
Pathogens colonize gut Intestinal mucosal barrier breaks down Bacteria crosses through

ANTIOBIOTICS
Controversial They DO decrease incidence of infection in necrosis, but do NOT decrease mortality Gotta cover multiple bugs Gotta get into pancreas

If you see necrosis start antibiotics (?)

ANTIOBIOTICS
Imipenem Cipro + metronidazole

One study showed 24% of pts had fungus

Very poor prognosis

NUTRITION
Normal pancreas secretes up to 2 liters/day of secretions Pancreatic stimulation during AP releases proteolytic enzymes autodigestion Oral feeding increases release of secretin and cholecystokinin stim pancreas rest the pancreas NPO

NUTRITION
TRADITION:
Rest the pancreas NPO TPN only after 5-7 days (prevent starvation) Ill pts cant be fed (ileus, aspiration)

NUTRITION
ENTERAL vs TPN Feedings:
If distal to Ligament of Treitz (nasojejunal tube or J-tube) pancreatic secretion = basal rate Both started after 48 hours
Easier to restart po feedings Average length of nutritional support shorter
7 vs 11 days

Fewer septic complications $23/day vs $222/day

NUTRITION
NEW THOUGHTS
Meta-analysis of 15 randomized studies:
Compared early vs delayed ENTERAL feedings in 753 critically ill pts Early was 36 hrs! Improved:
Wound healing Host immune function Preservation of intestinal mucosal integrity Decreased infections

BUT, no decreased mortality

NUTRITION

Feed to maintain gut integrity Protects against transfer of bacteria

ERCP
If there is a stone or cholangitis (biliary sepsis) or persistent jaundice Need urgent ERCP with sphincterotomy and stone extraction Otherwise, ERCP not indicated

SURGERY
Used to be very liberal with early surgery Trauma
If duct damaged

Gallstone etiology and mild

Cholecystectomy in same admission If no chole 25-69% recurrence rate of pancreatitis within 6-18 wks

Sterile necrosis controversial Infected necrosis yes, but delay

CASE REVISITED
By 48 hours pts abd pain is worsening HR is 140, afebrile, BP normal Abd shows very subtle guarding WBC: 27.6 Ca++: 6.6 PO2: 61 Base deficit: 8 BUN rise: 9 LDH: 976 RANSON SCORE: 3 APACHE II SCORE: 8

CASE REVISITED
Pt transferred to ICU Central line Arterial line Repeat Abd CT: new bilateral pleural effusions, pancreas enhances in tail only.

Transferred to Maine Medical Center. Pt died 5 weeks after admission.

SUMMARY
They may look good, but Score severity early Use lots of IVF Go to ICU early Early enteral feedings work better

REFERENCES
1. 2. Swaroop VS. Severe Acute Pancreatitis. JAMA.2004; 291: 2865-2868. Pitchumoni CS. Factors influencing mortality in acute pancreatitis. Can we alter them? J Clin Gastroenerol. 2005; 39: 798-814 3. Mitchell RMS. Pancreatitis. Lancet. 2003; 361: 1447-1445 4. Nathens AB. Management of the critically ill patient with severe acute pancreatitis. Crit Care Med. 2004; 32: 2524-2536. 5. Bentrem DJ. Pancreas: healing response in critical illness. Crit Care Med. 2003; 31: S582-S589 6. Bank S. Evaluation of factors that have reduced mortality from acute pancreatitis over the past 20 years. J Clin Gastroenterol. 2002; 35: 50-60 7. Werner J. Management of acute pancreatitis: from surgery to conventional intensive care. Gut. 2003: 54; 426-436. 8. Pastor CM. Pancreatitis-associated acute lung injury: new insights. Chest. 2003; 124: 2341-2351. 9. Yousef M. Management of severe acute pancreatitis. British Journal of Surgery. 2003; 90: 407420 10. Chari ST. Clinical manesfestations and diagnosis of acute pancreatitis. UpToDate. 2005. 11. Chari ST. Etiology of acute pancreatitis. UpToDate. 2005. 12. Chari ST. Predicting the severity of acute pancreatitis. UpToDate. 2005.