ACUTE PANCREATITIS

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ACUTE PANCREATITIS

• Tim Pieh, MD
• Maine-Dartmouth Family Practice Residency

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OUTLINE

• Diagnosis
• Etiology
• Assessing severity
• Treatment
• Complications

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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.

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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

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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

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MORTALITY

• Mild Acute Pancreatitis
• lt 5
• Severe Acute Pancreatitis
• 25
• Nearly 20 of all pts with AP develop SAP
• 25 of SAP pts die

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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

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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)

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CAUSES

• The Big Three
• Gall Stones (40)
• Alcohol (35)
• Idiopathic (20)

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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)

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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

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PREDICTING CAUSES

• Gallstones
• ALT gt 150 IU/dL ? PPV gt95
• Ultrasound will see gallstones in 60-80 of cases
• (Less reliable for stones in CBD)
• MRCP sensitivity 90-100
• ETOH
• Lipase gt amylase

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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

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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?

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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

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APACHE II

• http//www.sfar.org/scores2/apache22.html
• 8 is severe

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Ransons Criteria 3 is severe
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SINGLE MARKERS
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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?

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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

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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

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TREATMENT

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

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TREATMENT

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

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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)

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TREATMENT

• OXYGENATE
• Give O2 (spO295)
• Liberal intubation/ventilation to treat ARDS
• SCDs

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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

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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 (_at_ 2 weeks)

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SECONDARY INFECTIONS

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

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SECONDARY INFECTIONS

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

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SECONDARY INFECTIONS

• Pathogens colonize gut
• Intestinal mucosal barrier breaks down
• Bacteria crosses through

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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 (?)

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ANTIOBIOTICS

• Imipenem
• Cipro metronidazole
• One study showed 24 of pts had fungus
• Very poor prognosis

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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

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NUTRITION

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

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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

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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

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NUTRITION

• Feed to maintain gut integrity
• Protects against transfer of bacteria

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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

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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

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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

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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.

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SUMMARY

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

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REFERENCES

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• Pitchumoni CS. Factors influencing mortality in
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• Mitchell RMS. Pancreatitis. Lancet. 2003 361
  1447-1445
• Nathens AB. Management of the critically ill
  patient with severe acute pancreatitis. Crit Care
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• Bentrem DJ. Pancreas healing response in
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