Clinical Management of Patients With Acute Pancreatitis

The diagnosis of acute pancreatitis requires
at least 2 of the following: typical upper abdominal
pain, serum levels of amylase or lipase 3 times the upper
limit of normal, and confirmatory findings from crosssectional
imaging analysis.

differential: acute cholecystitis, choledocholithiasis, DU, perforated viscus, ischaemia bowel, MI

The Revised Atlanta Classification
-consensus conference in 1992
 Interstitial pancreatitis involves acute collection of
peripancreatic fluid-usually sterile and resolved or formation of pancreatic pseudocysts.
Necrotizing pancreatitis involves acute collection of
necrosis and walled-off necrosis.
 can be in pancreas or peripancreatic. can be sterile or infected.
 After 4 or more weeks, become smaller but rarely
disappears completely and usually evolves into walled-off
necrosis.

 systemic complications
are defined as exacerbations of preexisting comorbidities
such as chronic lung disease, chronic liver
disease, or congestive heart failure, recognizing the failure
of respiratory, cardiovascular, and renal organ systems

 The modified Marshall system classifies disease severity on
a scale from 0 to 4,
 Mild disease is defined as acute pancreatitis
not associated with organ failure, local complications,
or systemic complications. Most patients with mild
acute pancreatitis do not require pancreatic imaging analysis
and are usually discharged within 3 to 5 days of onset
of illness.
Moderately severe acute pancreatitis is defined by the presence of transient organ failure (48h), local complications, or systemic complications. require extended hospitalization but have lower
mortality rates
Severe acute pancreatitis is defined by the presence of
persistent organ failure (>48h). Most
patients have pancreatic necrosis.meta-analysis 30% mortality rate; the risk of
in-hospital death doubles when they have persistent organ failure and infected necrosis.

The best use of an early-stage CT scan is to confirm a diagnosis, can't differentiate interstitial or necrosis
The best use of a CT scan after the 5 to 7 days is to evaluate the presence of local
complications in patients with moderately severe or severe pancreatitis to guide ongoing care.

 MRCP has used for identifying retained common
bile duct stones. It also helpful in distinguishing walled-off
necrosis from a pseudocyst.

 EUS is a highly sensitive test
for detecting cholelithiasis and choledocholithiasis.
MRCP, which has limited accuracy for detecting smaller gallstones or sludge

 Risk factors for severe pancreatitis include
age (mortality increases among patients 60 years of age or older),
comorbid illnesses(cancer, heart failure, and chronic kidney and liver disease), a history of chronic alcohol consumption, and obesity (body mass index 30 kg/m2 increases the risk of
severe pancreatitis 3-fold and mortality 2-fold).

The initial 12 to 24 hours of hospitalization is critical, because the highest incidence
of organ dysfunction.

Ranson score, Glasgow score
bedside index of severity of acute pancreatitis
 blood urea nitrogen (BUN) level 25 mg/dL,
impaired mental status, systemic inflammatory response
syndrome (SIRS), age 60 years or older, and pleural effusion
if >2 in 24 hours, 7-fold increase in risk
of organ failure and 10-fold increase in risk of mortality.
Harmless acute pancreatitis score-normal HCT, normal creat, no rebound tendrness, unlikely severe pancreatitis
Acute Physiology and Chronic Health Examination (APACHE) II score

 presence of SIRS?,
 2 or more :
temperature 38.3¡ãC or 36¡ãC, pulse 90 beats/
min, respirations 20 beats/min, and white blood cell
count 12,000 or 4000 cells/mm3 or 10% immature
(bands) forms.
25% to 60% of patients have SIRS when they are
admitted,but  resolves in more than half
of these patients within 24 hours when they are given
appropriate fluid resuscitation.

 An increasing number of SIRS criteria during the initial 24 hours increases the risk of persistent organ failure and necrosis
 Patients with persistent SIRS (beyond 48 hours) have 11% to 25% mortality.

 Prospective studies have shown that the level of BUN at
admission and 24 hours is a strong prognostic factor.
  admission 20 mg/dL increased-have 9% to 20% mortality.
high level of BUN at admission that decreased at least 5 mg/dL - 0% to 3% mortality.
normal level of BUN followed modest increase (2 mg/dL)- 6% to 15% mortality
 normal level of BUN without a subsequent increase <1% mortality.

  creatinine 1.8 mg/dL within the first 24 hours of hospitalization is associated with a 35-fold
increased risk of development of pancreatic necrosis.

persistent increase in hematocrit 44% has also been shown to increase the risk of necrosis and organ failure

 A prospective, randomized, controlled trial assessed
the effects of bolus infusion of 20 mL/kg, followed by continuous infusion of 3
mL · kg 1 · h 1, with interval assessment every 6 to 8
hours (comprising vital sign monitoring, pulse oximetry,
and physical examination).
Repeat volume challenge was administered if the level of BUN did not decrease.
if the BUN level decreased, the rate of the infusion was reduced to 1.5 mL · kg 1 · h 1.

head of the bed elevated, undergo continuous pulse oximetry, and receive supplemental oxygen.

Lactated Ringer¡¯s solution reduces the incidence of SIRS by 80% compared with saline resuscitation, but not for hypercalcaemia

Admit to ICU:
-respiratory failure or hypotension that fail to respond to initial resuscitation
- multiorgan dysfunction
- patients with persistent SIRS, increased levels of BUN or creatinine, increased hematocrit,
or underlying cardiac or pulmonary illness

 Several practice guidelines recommend consideration of patient-controlled analgesia
and administration of intermittent doses of intravenous narcotic analgesics
Monitor saturation

 Nutritional Support
2 randomized controlled trials support early-stage introduction of low-fat solid food as the initial
meal for patients who have developed mild pancreatitis; choledocholithiasis, duration of fasting, and
quickly placing patients on a full diet have been associated with recurrence of pain.

 A Cochrane meta-analysis of 8 randomized controlled trials
found a reduction in mortality, systemic infection, and
multiorgan dysfunction among patients who received enteral
as opposed to parenteral nutrition.Several trials
have proposed enteral nutrition via the nasogastric route
as an alternative to nasoduodenal or nasojejunal
routes.

practice guidelines and updated meta-analyses did not find sufficient evidence to recommend routine use of prophylactic antibiotics in patients with acute necrotic collections

In a multicenter, randomized, controlled trial from The Netherlands, a step-up approach to management of infected necrosis was compared with open necrosectomy.
-percutaneous drainage catheters in addition to treatment
with antibiotics.
-72 hours, minimally invasive debridement
was performed via a retroperitoneal approach.
-4- 6 weeks after the onset of pancreatitis, an acute necrotic collection develops into walled-off necrosis. Physicians should intervene only if patients have
symptoms that can be attributed to the collection (persistent abdominal pain, anorexia, nausea, or vomiting due to mechanical obstruction or secondary infection).-direct endoscopic
necrosectomy using a transgastric approach for walled-off sterile necrosis
The median time from onset of illness to intervention was 6 to 8 weeks.
Endoscopic treatment reduced levels of inflammatory factors (such as interleukin-6), and the risk of newonset multiorgan failure, intra-abdominal hemorrhage, enterocutaneous or pancreatic fistula, or death decreased by 60%.

Pseudocyst
A longitudinal study of patients with interstitial pancreatitis reported that most collections of
acute fluid resolved within 7 to 10 days; only 6.8% of patients developed discrete pseudocysts.
Recent studies have indicated that symptomatic pseudocysts can be successfully decompressed by endoscopic cyst gastrostomy with endoscopic ultrasound guidance.

 Ductal Disruption
A ductal disruption can result in unilateral pleural effusion, pancreatic ascites, or enlarging fluid collection. Symptoms include shortness of breath, abdominal pain, and even early satiety, with vomiting if the collection compresses the stomach.
 MRCP might be used to identify a large disruption in ducts but detect small disruptions with low levels of sensitivity. ERCP is a valuable tool for treating symptomatic duct disruptions. Placement of a bridging stent across the disruption usually promotes duct healing when there is a focal disruption.
When a ductal disruption occurs in an area of extensive necrosis, a multidisciplinary
team of therapeutic endoscopists, interventional radiologists,
and surgeons should be consulted for optimal management.

Peripancreatic Vascular Complications
Splenic vein thrombosis has been reported in up to 20% of patients undergoing imaging for acute pancreatitis.Although gastric varices are often subsequently detected
in cross-sectional image analysis, the risk of bleeding is
5%. Routine splenectomy is not recommended.
Pseudoaneurysms are rare 4%-10%.The diagnosis can be made through CT angiography.
Rupture of a pseudoaneurysm can lead to life-threatening hemorrhage, with mortalities 50%- 90%. Mesenteric angiography with transcatheter arterial embolization is considered to be the first-line treatment for pseudoaneurysms.

Co infection -bloodstream infections, pneumonia, and UTI occur in up to 20% of patients with acute pancreatitis and increase mortality 2-fold. If sepsis is suspected during the
course of pancreatitis, it is reasonable to start antibiotic therapy while waiting for culture results. If culture results are negative, then antibiotics should be discontinued to reduce the risk of fungemia or Clostridium difficile infection.

Comorbid- monitored for exacerbation of underlying conditions such as CCF or COPD. In addition, treatment should be provided for concurrent illnesses such as alcohol withdrawal or diabetic ketoacidosis.

Timing of ERCP for Patients With Biliary Pancreatitis
severe acute biliary pancreatitis with signs of cholangitis should undergo ERCP within 24 hours.  mild gallstone pancreatitis not routinely ERCP because it increase complications.
Elective ERCP with sphincterotomy can be considered for patients with persistent or incipient biliary obstruction, those who are poor candidates for cholecystectomy, or those suspected of
having bile duct stones after cholecystectomy

Drug induced pancreatitis-only 30 can cause pancreatitis when rechallenge

Hypertriglyceridemic - 1% to 4%
 Serum triglyceride levels greater than 1000 mg/dL(=25.6 mmol/l) are considered necessary to
attribute an attack of pancreatitis to hypertriglyceridemia.
 Case series studies have suggested use of insulin, combined with heparin or apheresis,
for treatment. Administration of fibrates should begin as early as possible.
niacin or omega-3 fatty acids can be used as second-line agents.

Hypercalcemia
hyperparathyroidism or, metastatic tumors. to treat the underlying cause of hypercalcemia to
prevent recurrence

Autoimmune Pancreatitis
Although lymphoplasmacytic sclerosing or type 1 autoimmune pancreatitis is more common, the idiopathic duct-centric type 2 form of the disease has been more frequently associated with acute pancreatitis (5% vs 34%, respectively).
Patients with type 2 autoimmune pancreatitis are less likely to have increased serum levels of
immunoglobulin G4 or significant increases in numbers of immunoglobulin G4–positive cells based on histologic analysis.
-treated with glucocorticoids (typically prednisone 40 mg/day for 4 weeks, followed by a taper of 5 mg/wk).
-For relapse, treatment with immunomodulators or possibly rituximab should be considered.






Prevention
Post-ERCP Pancreatitis
A meta-analysis of 8 randomized controlled trials calculated a pooled odds ratio of 0.22 for
development of post-ERCP pancreatitis with stent placement.
 large-scale, multicenter, randomized, controlled trial showed a 45% reduction in
pancreatitis when rectal indomethacin was administered

Secondary Prevention
16.5% to 25% of patients have a repeated attack within the first several years
Continued alcohol consumption, smoking, and recurrent biliary complications are the major risk factors
-Alcohol abstinence with repeated counseling sessions at 6-month intervals is more effective than a
single counseling session
-Multiple societies recommend early cholecystectomy to prevent recurrent episodes
of gallstone-associated pancreatitis based on early recurrence rates as high as 30% among patients awaiting cholecystectomy.
- For poor candidates for surgery, endoscopic sphincterotomy can reduce the
likelihood of recurrent pancreatitis but is not as effective as cholecystectomy in reducing further biliary complications.

Factors to Consider for Outpatients
exocrine insufficiency 12% to 65%,
 Patients with necrotizing pancreatitis, pancreatic
ductal obstruction, or steatorrhea should receive pancreatic enzyme supplementation while
they recover. Fecal elastase assays should be performed after 2 to 3 weeks
 If exocrine insufficiency is confirmed, patients’ meals should each include pancreatic
enzyme extracts at doses of 40,000 to 50,000 IU lipase.
The dose should be determined based on patients’ symptoms,
anthropometry data, and results from biochemical
tests
 For extensive necrosis, significantly higher doses may be required to achieve adequate
digestion.

Small cross-sectional studies -endocrine dysfunction of 30%-35%
Up to 30% of patients(pancreatogenic or type 3 diabetes) require insulin
Current practice guidelines do not comment on the role of screening for diabetes following acute pancreatitis.
Patients with extensive necrosis or symptoms that indicate hyperglycemia should be tested for levels of HBA1c or undergo glucose tolerance testing.
Studies using standardized quality of life instruments such as the Short Form-36 or
European Organisation for Research and Treatment of Cancer survey instrument have concluded that physical function improves over time despite persistence of mental disability.
 Long-term quality of life, even among patients who have had severe episodes of acute pancreatitis,
appears to be comparable to that of the general population.