Acute Pancreatitis Steven B Goldin MD University of

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. • • No significant past medical or surgical history No medications No allergies to medications Smokes 1 ppd 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 • • Cholecystitis Choledocholithiasis PUD Gastritis Pancreatitis Bowel obstruction Mesenteric ischemia Gastroenteritis • • 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 R 18 • 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 • • • Cholecystitis PUD Pancreatitis Bowel obstruction Mesenteric ischemia • • Gastroenteritis Hepatitis Rectus hematoma Pneumonia

Laboratory What would you obtain?

Labs Consider the following • CBC, Electrolytes, LFT’s, CMP, LDH, Amylase, Lipase, PTT, Urinalysis, ABG,

Lab Results, J. H. CBC: Hb /Hematocrit WBC 10/30 17 Electrolytes Na 135, K 3. 0, Chloride 98, CO 2 37, BUN 15, Cr 1. 1, Glu 100, Calcium 8. 1 AST 260, ALT 220, Total Bili 1. 9, Alk phosphatase 110 326 245 Normal 375 LFT’s : Amylase: Lipase: PT/PTT: U/A: Other: LDH :

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 Po 2 Base deficit Non-biliary >10% >5 mg/d. L <8 mg/d. L <60 >4 m. Eq/L Biliary >10% >2 mg/d. L <8 mg/d. L. . . >5 m. Eq/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 150 cc/hr – titrate to urine output/volume status • NPO • Foley catheter • NG Tube • Admission to ICU

List common etiologies for Pancreatitis

Pancreatitis • • • Alcohol * Gallstones* Hyperlipidemia Trauma Tumor Ischemia • • • 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 • • Acute Pancreatitis Choledocholithiasis Cholecystitis Perforated ulcer

What next?

Supportive measures • Nothing by mouth • early oral feedings may increase the severity of pancreatic inflammation. Oral feedings should be withheld until resolution of abdominal pain, fever, and leukocytosis • Nutritional support • Proton pump inhibitors • DVT prophylaxis • Fluid and electrolyte repletion • Antibiotics (debated) and resuscitation • Respiratory support • 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? • • 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 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 • • • Fever >101 F Abdominal distention Pneumonia or effusion Leukocytosis (>10, 000/mm 3) Abdominal mass Hypotension (BP <90 mm Hg) Renal failure Coma Elevated serum amylase 100% 94% 89% 78% 71% 39% 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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