1 / 90

Acute Pancreatitis Evidence Based Approach

Acute Pancreatitis Evidence Based Approach. Pankaj Singh MD Director of Gastrointestinal Endoscopy Central Texas VA Health System, TX Assistant Professor Texas A&M University. Clinical Case. 32-year-old man c/o acute onset abdominal pain (presumed pancreatic origin) h/o alcohol intake.

onella
Download Presentation

Acute Pancreatitis Evidence Based Approach

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Acute PancreatitisEvidence Based Approach Pankaj Singh MD Director of Gastrointestinal Endoscopy Central Texas VA Health System, TX Assistant Professor Texas A&M University

  2. Clinical Case • 32-year-old man • c/o acute onset abdominal pain (presumed pancreatic origin) • h/o alcohol intake

  3. What do you think? • Amylase or lipase • Ultrasound or CT scan • If yes, When? • ICU or medical ward • Enteral nutrition or TPN • Antibiotics • ERCP • Surgery

  4. Evidence • A. Proven • > 2 well designed trials, randomized • B. Possible/ Probable • 1 well designed study, randomized • C. Consensus • agreed opinion with no supportive evidence

  5. Guidelines • Atlanta • British Society of Gastroenterology • International Association of Pancreas • Santorini Conference • World Congress of Gastroenterology

  6. Background • Potentially fatal • Mortality – 0-25% • Necrosis determines the prognosis Panreas 1998 307-11

  7. Background • Mild AP (no necrosis) – 0% • Sterile necrosis – 10% • Infected necrosis – 25%

  8. Diagnosis • Laboratory • Amylase • Lipase • Radiological • US • CT scan

  9. Blood tests • Amylase and lipase • Plasma level peak within 24 hours • t1/2 of amylase << lipase Gut 1997,41:431-35; Br J Surg 1998,84:1665-69.

  10. Lipase has slightly higher sensitivity and specificity and greater overall accuracy than amylase (Evidence category A)

  11. Ultra Sound (US) • Little part in the diagnosis of the acute pancreatitis • Role in biliary pancreatitis • Stones in gallbladder • Common Bile Duct dilation Br J Surg 1982;69:369-72

  12. US findings should be examined in all patients with possible acute pancreatitis on admission (Evidence category B)

  13. CT scan • Not necessary for the diagnosis • Diagnostic doubt • Atypical presentations • Asymptomatic hyperamylasaemia or hyperlipasemia Gastroenterol Clin N Am 1990;19:811-42

  14. Routine use of CT scan within 24-48 hours of admission (Evidence category C)

  15. Initial Management • Monitoring – temp., pulse, blood pressure, and urine output • Treatment – • Cardiopulmonary care • Sufficient fluid resuscitation • Pain control

  16. Severity Stratification Rationale • Differentiate mild from severe acute pancreatitis

  17. Desirable features of Markers of Severity • Accuracy - High sensitivity & PPV • Predictability within 24 hours of admission • Easy to use

  18. Clinical Features • Clinical examination • Age > 70 years • Abdominal findings • increased tenderness • rebound • distension • hypoactive bowel sounds • In first 24 hours of admission - unreliable • After 48 hours- as accurate as Ranson score

  19. Multiple Factors Scoring System • Ranson • Separate for alcohol and gallstone etiology • Score > 3 = severe acute pancreatitis • Glasgow • valid in all types of pancreatitis Both of these systems require 48 hours from the admission for full assessment Can J Gastroent 2003 325-328

  20. APACHE II • Acute Physiology and Chronic Health Evaluation • as good as the Ranson or Glasgow at 24 and 48 hours of the admission • APACHE II score > 8 = Severe acute pancreatitis • Cumbersometo use if one does not use a pc or palm - where the formula is easily downloaded Br J Surg 1997,84:1665-69

  21. If a multiple factor scoring system is to be used, the best choice at present appears to be APACHE II calculated at 24 hours - Evidence category A

  22. Tests • Trypsinogen Trypsinogen activation peptide (TAP) I • Trypsin • Inflammatory cascade (IL6, IL-8, TNF-) II C - reactive proteinIII • Pancreatic injury • Amylase, Lipase, Trypsinogen IV

  23. Markers for Leakage of Pancreatic Enzymes • Amylase/ Lipase • Degree of elevation shows little correlation with disease severity and prognosis • May have an inverse relationship with severity • Trypsinogen 2 • Excreted into the urine • Used as a screening test for acute pancreatitis

  24. Trypsinogen activation peptide (TAP) • Small peptide • Advantage • Appear very early during the disease • Disadvantage • Limited "diagnostic window". • decrease very quickly irrespective of the course of the disease • Not suitable for rapid simple analysis

  25. Markers of Inflammation • TNF-alpha • Major role in mediating inflammatory response • Conflicting reports as a predictor of severity • Interleukin-6 and 8. • Principal cytokine mediator • Measured in serum and urine • Discriminate severe from mild cases on day 1

  26. C-reactive protein (CRP) • Acute phase reactant • Synthesized by the hepatocytes • Synthesis is induced by the release of interleukin 1 and 6 • Peak in serum is three days after the onset of pain • Most popular single test severity marker used today Isenmann et al Pancreas 1993;8:358-61

  27. C-reactive protein (CRP) • Gold standard for the prediction of the necrotizing course of the disease • Accuracy of 86% • Readily available

  28. C-reactive protein (CRP) Advantage • Used to monitor the clinical course of the disease Disadvantage • Not always present on admission • Lack specificity

  29. Recommendations • CRP is currently the gold standard • Amylase and lipase of no value • High likelihood that IL-6/ TAP will replace the CRP

  30. CT Scan • Normal • Homogeneous enhancement of the whole pancreas • Abnormal • Non-visualization of a part of the pancreas • Sensitivity of 90-95% • Specificity – 100%

  31. Recommendation • A dynamic CT scan should be performed in all (predicted) severe cases between 3 and 10 days after admission (Evidence grade B)

  32. Is It Possible to Predict Severity Early in Acute Pancreatitis? • Good clinical judgment • Specificity - 80% • Sensitivity - 40% • Scoring or biochemical methods • Specificity – 60% • Sensitivity – 95%

  33. Etiological Assessment • Needed in all patients • Differentiate biliary from alcoholic pancreatitis • Early abdominal US is recommended in all patients (Evidence category A)

  34. Initial Management of acute pancreatitis • Nutrition • Prophylactic Antibiotics • Acid suppression • ERCP • Surgery

  35. Nutrition - Rationale • Hyper metabolic state • Total energy expenditure 1.5 x resting energy requirement • Nutrition depletion • Starvation • Preexisting protein-calorie malnutrition & micronutrient deficiency Crit care Med 1991;19:484-90; J parenter Enter Nutr 1989;13:26-29.

  36. Nutrition – who needs it? • Mild AP • 70-80% recover within 4-7 days • Moderate to severe AP • Ranson score > 3 • APACHE II > 8 • Necrotic pancreas • Organ failure Windsor et al. Gut 1998,42:431-35; Kalfatentzos et al. Br J Surg 1997,84:1665-69

  37. Parenteral nutrition Rationale for - • Pancreatic rest • Inability to tolerate enteric feeding

  38. Parenteral Nutrition Rationale against • Pancreatic rest • Poorly defined • Increased risk of sepsis • Gut atrophy - increased bacterial translocation • Hyperglycemia • Greater costs

  39. Parenteral Nutrition • Nine uncontrolled retrospective studies • Safe, well tolerated with few complications • No impact on the outcome

  40. TPN Prospective randomized controlled trial 54 TPN IV F • Duration of hospital stay 16 10 • Line sepsis 10 1 Sax et al. Am J Surg 1987,153:117-22

  41. Enteral Nutrition

  42. Enteral Nutrition Rationale for • Minimal effect on pancreatic secretions • Prevention of gut mucosal atrophy • Avoid TPN related complications • Line sepsis • Hyperglycemia Arch Surg 1999;134:287-292

  43. Enteral Nutrition Rationale against • Small degree of pancreatic stimulation • Proximal displacement of the feeding tube may worsen the disease outcome

  44. Enteral nutrition • 4 prospective randomized controlled trials Significantly lower • Line sepsis • Infections per patients • Hyperglycemic episodes Cost was significantly higher in TPN No difference in mortality, ICU admissions, multi-organ failure Gut 1998,42:431-35; Br J Surg 1997,84:1665-69 JPEN 1997,21:14-20; J Submicrosc Cytol Pathol 1996,28:61-74.

  45. Enteric feeding • Enteral nutrition is feasible, well tolerated and improves nutritional status • Enteral nutrition is certainly no worse than TPN and is less costly

  46. How about Nasogastric feeding ? Aim • Assess the safety and practicability of NG feeding in severe acute pancreatitis Methods • Prospective study • 26 patients with severe acute pancreatitis • NG feeding within 48 hours of admission Eatock et al. International Journal of Pancreatology, 2000

  47. Result • Pancreatic necrosis – 15 patients • Severe organ failure - 11 patients • Feeding • Well tolerated in 22 patients • No evidence of clinical or biochemical deterioration on commencing NG feeding

  48. NG feeding appears safe, is well tolerated and is possible in severe acute pancreatitis

More Related