Transcript Acute Pancreatitis - Medical University of South Carolina

Acute Pancreatitis
Steven B. Goldin, MD
University of South Florida
J.H.
• JH is a 64-yr-old male admitted to an outside
hospital with a 4 day history of progressively
worsening epigastric pain without radiation.
History
What other points of the history do you
want to know?
History, J.H.
Consider the Following
• Characterization of
symptoms
• Temporal sequence
• Alleviating /
Exacerbating factors:
• Pertinent PMH, ROS,
MEDS.
• Relevant family hx.
• Associated signs and
symptoms
HPI J.H.
• Pain is constant and unremitting, going
through to his back
• Pain started after beer and pizza 4 days prior,
progressively worsening since
• Nausea and vomiting x 3
• Some indigestion history, never like this
• No relief with OTC Pepcid, Mylanta or Advil
History, J.H.
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No significant past medical or surgical history
No medications
No allergies to medications
Smokes 1ppd x 40 yrs, and drinks ethanol
heavily. He denies drug use.
• Family history was noncontributory.
What is your Differential Diagnosis?
Differential Diagnosis
Based on History and Presentation
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Cholecystitis
Choledocholithiasis
PUD
Gastritis
Pancreatitis
Bowel obstruction
Mesenteric ischemia
Gastroenteritis
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Appendicitis
Hepatitis
Diabetes
Rectus hematoma
Pneumonia
Pyelonephritis
Trauma w/ duodenal
hematoma.
Physical Examination
What would you look for on
physical examination?
Physical Examination, J.H.
• Vital Signs: T 38.5 BP 120/70 P 100 R18
• Appearance: lying still in moderate distress. Not
jaundiced and sclera were anicteric. His mucous
membranes were dry.
• Resp: His lungs were clear to auscultation.
• CV: heart was regular and without murmurs,
rubs, or gallops.
Physical Examination, J.H.
• Abdomen: soft, moderately distended, tender in
the mid-epigastric region and right upper
quadrant. No palpable masses. Bowel sounds
were positive.
• Extremities: without cyanosis, clubbing, or
edema.
• Rectal exam: no masses, guaiac neg.
Would you like to revise your
Differential Diagnosis?
Revised Differential
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Cholecystitis
PUD
Pancreatitis
Bowel obstruction
Mesenteric ischemia
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Gastroenteritis
Hepatitis
Rectus hematoma
Pneumonia
Laboratory
What would you obtain?
Labs
Consider the following
• CBC, Electrolytes, LFT’s, CMP, LDH,
Amylase, Lipase, PT, PTT, Urinalysis, ABG,
Lab Results, J.H.
CBC: Hb /Hematocrit
WBC
10/30
17
Electrolytes
Na 135, K3.0, Chloride 98,
CO2 37, BUN 15, Cr 1.1,
Glu 100, Calcium 8.1
LFT’s :
Amylase:
Lipase:
PT/PTT:
U/A:
Other: LDH
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AST 260, ALT 220, Total
Bili 1.9, Alk phosphatase
110
326
245
Normal
Normal
375
Lab Results, Discussion
• This patient has a hypokalemic hypochloremic metabolic
alkalosis from vomiting.
• He has an elevated amylase and lipase consistent with
pancreatitis.
• On admission he has 4 out of 5 of Ranson’s criteria and
can be expected to become very sick.
• There are 6 more of Ranson’s criteria that should be
tracked over the next 48 hours.
Can you list Ranson’s criteria?
Ranson’s Early Objective Prognostic Signs that Correlate
with the Risk of Major Complications or Death
On Admission
Non-biliary
Age
WBC
Glucose
LDH
SGOT
>55
>16
>200
>350
>250
Biliary
>70
>18
>220
>400
>250
Ranson’s Early Objective Prognostic Signs that Correlate
with the Risk of Major Complications or Death
During the Initial 48 Hours
Hematocrit decrease
BUN increase
Calcium
Arterial Po2
Base deficit
Non-biliary
>10%
>5 mg/dL
<8 mg/dL
<60
>4 mEq/L
Biliary
>10%
>2 mg/dL
<8 mg/dL
...
>5 mEq/L
Fluid sequestration
>6 L
>4 L
Ranson’s Prognostic Signs that Correlate with
the Risk of Major Complications or Death
Number of
Prognostic Signs
0-2
3-4
5-6
7-8
% spending >7
Days in ICU
4
40
90
100
Mortality (%)
2
15
40
100
Ranson’s Early Objective Prognostic Signs that Correlate
with the Risk of Major Complications or Death
Note
1. The amylase and lipase levels are not prognostic
signs and do not relate to the severity of the attack
or prognosis.
2. LDH must usually be specifically ordered.
It is not included with most comprehensive
metabolic panels or with most liver function tests.
Interventions at this point?
Interventions at this point
• IVF – LR Bolus 1-2 liters then LR at 150cc/hr – titrate
to urine output/volume status
• NPO
• Foley catheter
• NG Tube
• Admission to ICU
List common etiologies for
Pancreatitis
Pancreatitis
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Alcohol *
Gallstones*
Hyperlipidemia
Trauma
Tumor
Ischemia
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Medications
Infection
Post-op/Post-procedure
Other
Idiopathic
Studies
What would you order ?
Studies
Obstruction Series/Acute
Abdominal Series etc.
CT Scan: Abd/Pelvis
CT Scan: Other
Flat/Upright Abdomen
HIDA Scan
PA/Lat Chest
MRCP
RUQ US
OTHER: EKG
US GB
Discussion of Studies
• Ultrasound of right upper quadrant is indicated
to evaluate gallbladder and bile duct for stones.
• CT scan should be done after initial
stabilization. IV contrast is useful to assess
pancreatic viability. Use of IV contrast on
presentation is debated.
His initial CT Scan is shown below:
Discussion of imaging study
• This is a CT scan of the abdomen done with both oral
and IV contrast. It demonstrates edema surrounding
the pancreas and is consistent with the laboratory
results suggesting pancreatitis. No significant
pancreatic necrosis is noted.
• My preference is to not use IV contrast on admission if
pancreatitis is suspected due to the toxic nature of the
dye and the rarity of finding infection on presentation.
I do use IV contrast later on in the hospitalization to
better discern the amount of necrosis that has resulted
as long as the patients renal function is acceptable.
Would you like to revise your
differential diagnosis?
Revised Differential Diagnosis
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Acute Pancreatitis
Choledocholithiasis
Cholecystitis
Perforated ulcer
What next?
Supportive measures
• Nothing by mouth
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early oral feedings may increase the
severity of pancreatic inflammation.
Oral feedings should be withheld until
resolution of abdominal pain, fever, and
leukocytosis
• Fluid and electrolyte
repletion and resuscitation
• Respiratory support
• Nutritional support
• Proton pump inhibitors
• DVT prophylaxis
• Antibiotics (debated)
• Analgesics
Timing of cholecystectomy
• Gallstones are present in 60% of nonalcoholic patients with pancreatitis and if
allowed to persist, 36 - 63% will develop
recurrent bouts of pancreatitis.
Cholecystectomy reduces this risk to
2 - 8%.
Timing of cholecystectomy
• 75% of patients with acute abdominal pain,
gallstones, and elevated amylase have no gross
evidence of significant pancreatitis.
Cholecystectomy is safe in this group.
• In patients with gross evidence of pancreatitis,
80% have mild disease and cholecystectomy is
safe but does not alter the course of the
pancreatitis
Intra-Operative Cholagiogram (IOC)
during Laparoscopic Cholecystectomy
The timing of cholecystectomy
• In patients with severe pancreatitis there is an
82.6% morbidity and 47.8% mortality from
cholecystectomy if performed within the initial
48 hours. If deferred until the signs of
pancreatitis have subsided, morbidity and
mortality fall to 17.8% and 11.8%
respectively.
Timing of cholecystectomy
• In patients with severe pancreatitis and an
obstructed biliary tree secondary to
choledocholithiasis, ERCP and sphincterotomy
significantly reduce morbidity related to
biliary complications but do not alter the
course of the pancreatic inflammation.
ERCP
Hospital Course
• This patient deteriorates with non-operative
treatment. He develops high fevers and
hypotension.
• What could be happening?
• What would you do next?
Repeat CT Scan is shown below
What do you see?
CT Findings
CT scan now shows air in the lesser sac. This is
diagnostic of infected pancreatic necrosis.
What next?
What next?
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Supportive Treatment
Elective Cholecystectomy if caused by
gallstones.
Endoscopy with ERCP if obstructing stone is
identified in the common bile duct.
OR if infected
Management
The patient was started on broad spectrum
antibiotics and taken to the operating room for
pancreatic debridement, cholecystectomy, and
placement of large axiom sump drains. A
jejunal feeding tube was also placed at this
time.
Temporary Abdominal Closure
Sump Drain
Management
This patient was slowly weaned from his
vasopressor agents and ventilator. Tube
feedings were started two days after his
debridement. The patient eventually made a full
recovery and was discharged from the hospital
approximately 4 months after presentation.
Management
Operative Options include
• Debridement and drainage-Mortality 13.9%. 58.3%
of patients can be treated with one surgical procedure.
• Debridement & packing, and dressing changes every
2 - 3 days. Mortality 10.7%.
• My preference is to debride and drain if all necrotic
debris can be easily removed. Otherwise I pack and
return to the operating room every 48 hours until the
necrotic tissue is fully debrided. At that time, I place
drains and close the patient.
Management
• Patients who are not infected should not be
operated on.
• Bradley - Neither the existence nor the extent of
necrosis can be used as an indication for
surgery. (90.4% survival in patients treated
conservatively with over 50% necrosis of the
gland and no infection).
Management
• The use of antibiotics in patients with necrosis
without infection is debated. Overall mortality
does not seem to change significantly, but there
is a lengthening of time to develop infection
with the use of antibiotics. Antibiotic use,
however, has been suggested to increase the risk
of infection with resistant organisms.
Management
• The number one determinant of survival is whether
infection of the necrotic tissue occurs.
• Infection is demonstrated by air in the lesser
sac/retroperitoneum. Infection can occur without air
and if suspected, needle aspiration should be attempted.
• Caution is warranted when attempting needle aspiration
due to the risk of passing the needle through the colon
or stomach. Once done, a previously uninfected
collection will likely become infected.
Pancreatic Necrosis
Clinical Signs of Infection
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Fever >101F
Abdominal distention
Pneumonia or effusion
Leukocytosis (>10,000/mm3)
Abdominal mass
Hypotension (BP <90 mm Hg)
Renal failure
Coma
Elevated serum amylase
100%
94%
89%
78%
71%
39%
39%
28%
28%
Discuss Potential Complications of
Acute Pancreatitis
Pleural Effusions
Pancreatic Ascites
Summary
Treatment of Acute Pancreatitis
• On presentation, determine the potential for complications
– Ranson’s criterion are one method.
• Nasogastric suction
• No oral feedings until pancreatitis subsides
• Monitor and maintain intravascular volume
• Respiratory and nutritional support
• Antibiotics (selective)
• Suspect and treat pancreatic sepsis aggressively
• Surgery only for infected pancreatic necrosis
QUESTIONS ??????
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