acute necrotizing pancreatitis yoram klein md. magnitude of the problem the disease may be mild and...
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Acute Necrotizing Acute Necrotizing PancreatitisPancreatitis
Yoram Klein MDYoram Klein MD
MAGNITUDE OF THE PROBLEM
The disease may be mild and self limiting, 70-80% take course of edematous interstitial inflammation
Necrotizing pancreatitis develops in 20-25% pts . 20-30% will develop local or systemic
complications Approx 1 in 4 pts who develop
complications will die
AP & QUESTIONS WHAT IS THE CORRCT DIAGNOSIS? What is the prognosis? Are complications developing? Can an associated condition to be
identified? What is the ideal timing for
surgery?
OBJECTIVETo give pts of AP best chance of survival, from the outset to be managed by surgeon
Identification of pts likely to develop complicationsManagement (prevention)of systemic complicationsTiming and choice for surgical Intervention for gall stones or local complications
PANCREATITIS (terminology)
MILD-uncomplicated recovery
SEVERE-AP with evidence of failure of one or more systems , or local complication.
These terms are defined retrospectively,when outcome is known
Prospectively defined on the basis of scoring systems.Predicted Mild or Predicted Severe
ACUTE PANCREATITITS-TERMINOLOGY COMPLICATED-local or systemic
complications
EDEMATOUS-Swollen, red ,with or without fat necrosis;Histology fluid,debris,leukocytes present
PERIPANCREATIC NECROSIS-Necrosis of retroperitoneal fat, other organs rarely involved, occasionally infarction by vascular thrombosis.This change may be present alone or may coexist with or be absent in presence of pancreatic necrosis
AP-local complications ……contd Pancreatic necrosis;
Patchy or diffuse superficial or parenchymal necrosis, unequivocally demonstrated by inspection after opening of the pancreatic capsule , or histological criteria; local or diffuse areas of non enhancement on CT, sterile necrosis
Infected pancreatic necrosis; Necrosis with positive bacterial cultures
Pancreatic abscess;Loculated walled off collections of pus as a late complication of AP, usually after 3 weeks
MANIFESTATIONS OF AP LOCAL;LOCAL;
MILD; EDEMA, INFLAMMATION, NECROSIS
SEVERE; PHLEGMON, NECROSIS, INFECTION, FLUID
COLLECTION, ABSCESS
Bacterial contamination Risk of bacterial infection on
necrotic tissue 60% in proven cases of NP Risk in ist week =25% Risk in 2nd week = 35-40% Risk in 3rd week =60%
Organisms are Gram negative E-coli,Proteus,Pseudomonas,staphylococci
SYSTEMIC COMPLICATIONSo Respiratory-Interstitial pulmonary edema;gas
transfer impairment,Pt may need ventilation
o Renal-oliguria-require aggressive circulatory support,#Dialysis
Cardiovascular-Hypotension, edema,aggressive fluid therapy and Ionotropes
Haemopoiesis, Coagulation system, Endocrine systems
PANCREATITIS How to diagnose it?
How to evaluate severity?RANSON CRITERIAIMRIES CRITERIAAPACHE scoringGLASGOW CriteriaLab and Radiology Help ;
Diagnosis of PancreatitisClinical Diagnosis Lab studies;
Serum amylase;Levels Rise within 2-12hrs,
o 3x times normal is cut off . (n35-118 IU/liter
o levels normal in 2-3days. o Persistence of ^ levels >10days denote complication like cyst,abscess.
o 5%cases no increase value
Diagnosis of pancreatitis(contd)
Serum lipase ^^ 2x times the normal( 2.3-20.0 IU/L) n=3-5days
CR protein,LDH ,Serum Neutrophil –elastase,IL-6, and alpha macroglobulin
Trypsin like Immunoreactivity
RANSON CRITERIA Initial 24 hrs
1.Age >55 years2.Glucose >than 200 mgm/dl3.WBC > 16,000 cells/mic L4.LDH >350 IU/liter5.AST >250IU/liter
Subsequent 48 hrs1.Art o2tension <60mmHg2.Bun Increase >8mg/dl3.Ca < 8mg/dl4.Base deficit >4meq/liter5.Estimated fluid sequestration >6liters6.Fall n Hct >10%
Mortality prediction (as per Ranson criteria) A. < 3 signs = 1%
B. Three to Four signs=11%
C. Five to six signs=33%
D. >Six signs= 100%
APACHEII
1. Temp2. Mean Art
Pressure3. Heart Rate4. Resp rate5. Oxygenation(Pao
2)
6. Arterial Ph
1. Serum sodium2. SerumPottasium3. Serum creatinine4. Haematocrit5. WCC6. Glasgow coma
scale
Apache II score(Sum of A+B+C) A=+4 to 0 points
TEMP>41=4,<29=4 Mean Art Pr>160=4
<49=4 Heart & Resp rate
OXYGENATIONART PHSer Na,K,Creat,
HCT,WBC GLASGOW COMA
Score
B=Age <44=0 pts
>75=6points C=Chronic Health
points H/o organ
insufficiency Liver,CVS,Resp,Renal, ,Immunocompromised
APACHE SCORE42=90% Mort
GLASGOW CRITERIA Any time during First 48hrs after
admission 1.WBC >15000 Cu/mm 2.Blood glucose>10mmol/l 3.BUN >16mmol/L 4.Art po2,< 60mmHg 5.Ser ca. <2.0 ml/l 6.Ser Albumin<32gm/l 7.Ser LDH >600u/L(n=250) 8.AST Or ALT >200u/l
GLASGOW CRITERIA Any time during
First 48hrs after admission; WBC >15000
Cu/mm Blood
glucose>10mmol/l BUN >16mmol/L Art po2,< 60mmHg
Ser ca. <2.0 ml/l Ser
Albumin<32gm/l Ser LDH
>600u/L(n=250) AST Or ALT >200u/l
Comparsion Of Scales
Prediction of complic
Apache Ranson Glasgow
Few hours
More accurate
Less Less
48hrs 88% 69% 84%
72 hrs +++ ++ ++
Dying pt
Rising Falling Falling
INTERSTITIAL AND NECROTIZING PANCREATITIS (Discrimination)
Markers of Necroses C-reactive protein>120 mgm/L PMN-Elastase>120mgm/L PLA>15U/L PLA2>3.5U/L Dynamic angio –CT Guided needle aspiration of necroses
for detection of bacteria
RADIOLOGY• Plain Films• Ultrasonography
Sens;62-95%,Specif>95%,pancreas not visualized in>
40%pts• CT scan;Sens 90% Specif+100%• ERCP• PTC. Pancreatitis is due to
gallstone? Or Alcoholic?
CT findings in Acute Pancreatitis Enlargement of
Gland Ill defined margins Abnormal
enhancement Thickening of
peripancreatic planes
Blurring of fat planes
Intra & retroperitoneal fluid collection
Pleural effusion Pancreatic gas
indicative of necrosis /abscess
Pseudocyst formation
ERCP; Indications In AP Preop evaluation with suspected
traumatic pancreatitis to see Pancreatic duct disruption
Pts with suspected biliary Pancreatitis and severe disease and not clinically improving by 24hrs after admission. Do ERCP for stone extraction
ERCP-indications (contd
In pts >40 with no identifiable disease to rule out occult CBD stones,pancreatic or ampullary Ca or other causes of obstruction;
Pts <40 at a post Cholecystectomy status or more than one attacks of unexplained pancreatitis
SYSTEMIC TREATMENTS Basic principles-ICU,Rest GIT and
Pancreas,analgesia,oxygenation Pancreatic inhibition (Glucagon,
Somatostatin)? Antibiotics Nutrition (Enteral route is safe&
preferred )
Role of Antibiotics in AP Traditional teaching Prophylactic
antibiotics do not prevent abscess- Mezlocillin, Metrionidazole, Imipnem
good concentration in pancreatic juice Cefotaxime, Ceftazidime Clindamycin,
Ciprofloacin good levels in p. juice They can limit rate of infection of this
necr material(Bossi1992)
Operative Measures For APA.Diagnostic laparotomyB.To limit the severity of pancreatic inflammation
Biliary operations
C.To interrupt the pathogenesis of complications
Pancreatic drainagePancreatic resectionPeritoneal drainage
Operative measures(contg)
D.To support the patient and treat complications
Drainage of pancreatic abscessesFeeding jejunostomy
To prevent recurrent pancreatitis
Surgical treatment-indications Diagnostic
uncertainty Gall stone induced
pancreatitis Pancreatic drainage
and defunctioning Pancreatic
resection Peritoneal Lavage
Operation for complications
Bile duct stones-strategy Acosta (1974), recovered gall stones from
Faeces of pts with gall stone pancreatitis. Neptolemos (1989) ;Passage of stone
through ampulla precipitates pancreatitis attack, persistence of stones in CBD; Pt is at risk of complications and death
Early surgery or to deal with CBD stones endoscopically (ERCP) 14 %pts of AP have coexisting cholangitis
Timing OF Operation IN Gall Stone
Pancreatitis Mild pancreatitis: Operated At Any
Stage during first admission
Severe disease.Cholecystectomy during first admission, timing depends on clinical indicators
Timing of Surgery-contd RECOVERING PT.Allow pt to settle
completely before elective early operation is taken prior to discharge.
UNSTABLE PT- Who will require surgery to deal with local complications of pancreas, Cholecystectomy to be performed at this time
Early Cholecystectomy within 48-72 hours of admission is best avoided in these all patients
Indications of Operation IN NP Clinical criteria
Surgical acute abdomen
Sepsis syndrome Shock syndrome Non response to
ICU
Morphologic +Bacteriologic Infected necroses Extended
pancreatic necrosis>50%
Extnd. intrapancreatic +retroperitoneal necroses
Technique of Debridement Closed cavity Lavage Open abdomen Surgical drainage Posterior approach Pancreatic resection
Pseudo cyst Delineation of main Pancreatic duct
by ERP if no communication -drain by ERP
If main duct is abnormal Stricture Or Truncated –Surg. Drainage
Rarely normal P.Duct communicating with Pseudo Cyst –Drain Percut CT control (Recurrence =50%)
Conclusion Management of AP is complex Mortality is high Increasing Dx procedures available has
not simplified decisions about timing of operation or choice of technique.
Individualized approach IS NECESSARY Decision based on clinical judgment
rather than on numerical or imaging. SURGEON IS THE BEST TO MANAGE#He
has CLINICAL AND SURGICAL EXPERTISE