Acute PancreatitisATLANTA Classification & Management

Seneeth PeramunaFinal year medical student

2015-Jun

Definition

• Acute pancreatitis is an inflammatory condition of the pancreas, clinically characterized by acute abdominal pain and elevated levels of pancreatic enzymes in the blood

Pathogenesis

• Auto digestion of pancreatic substance by inappropriately activated pancreatic enzymes (especially trypsinogen)

Etiology• Gallstones (30 – 40%)

• Alcohol

• Hypertriglyceridemia

• ERCP

• Smoking

• Drugs

• Infections

• Trauma

• Vascular disease

Diagnosis

• Most often established by the presence of two of the three following criteria:

(i) abdominal pain consistent with the disease,

(ii) serum amylase and/or lipase greater than three timesthe upper limit of normal, and/or

(iii) characteristic findings from abdominal imaging.

_________________________________________________________CT and/or MRI of the pancreas should be reserved for patients

– in diagnostic uncertainty (typical pain with normal enzymes)– In severe AP to distinguish interstitial from necrotizing pancreatitis– who fail to improve clinically within the first 72 h after hospital admission– to evaluate local complications

• No organ failure

• No local complicationsMild

• Transient organ failure <48hrs

• Local complications +/-Moderate

• Persistent organ failure >48hrsSevere

* Local complications : acute peripancreatic fluid collection, pancreatic pseudo cyst,acute necrotic collection, pleural effusion

* Organ failure : failure of 3 main organs, respiratory, cardiac, renal and other organ systems ( hepatic, hematological, Neurological)

Classification of acute pancreatitis – Revised ATLANTA criteria 2012

Initial Management

Initial assessment and risk stratification, ICU care warrant if AP with,

• Pulse <40 or > 150 / min

• SBP <80 mmHg or DBP >120mmHg

• RR > 35 cycles/min

• Severe electrolyte imbalance

• Severe acidosis or alkalosis

• Glucose >800 mg/dl

• Anuria

• coma

Initial ManagementFluid

• 10-20ml/kg/hr isotonic crystalloid(Hartmann preferred)

• Monitor 6 hourly for volume overload and UOP > 0.5ml/kg/hr

• in 1st 12 - 24 hrs

• If not : Necrotizing pancreatitis

Pain management

• Fentanyl/ Pethidinepreferred over morphine

• If not : hemodynamic instability

Monitoring

• SpO2 and ABG

• UOP

• Electrolytes including Ca+2 and Mg+2

• Blood glucose

• If in ICU : bladder pressure ( for Abdominal compartment Xd)

Nutrition and Antibiotics

• Nutrition,Nasogastric feeding is preferred as Nasojejunal feeding over TPN,provided patient is tolerating

• Antibiotics, Start on suspicion and omit if cultures negative

Management of Local complications

• Pleural effusion/ Peripancreatic fluid collection– No special intervention needed

• Pancreatic necrosis – CT guided aspiration, Culture & ABST– Start in Antibiotics – Carbapenams + metraniadazole– Percutaneous CT guided catheter drainage/ Necrostomy

• Peripancreatic vascular complications– Splanchnic venous thrombosis – resolve spontaneously, but if symptomatic,

Anticoagulation

• Abdominal compartment syndrome– Sustained intra abdominal pressure >20mmHg with new onset organ failure,

due to tissue edema, peripancreatic inflammation & ascites– careful observation and supportive care, abdominal compartment

decompression may required

Management of systemic complications

• Careful for exacerbations of underlying co morbidities ( CAD, Chronic lung disease)

• Treat for alcohol withdrawal if necessary

• Educate on diabetes risk and lifestyle modifications

Management of etiology

1. Gall stone pancreatitis– If suspected ERCP within 1st 24 hrs– Cholecystectomy performed after recovery

2. Advise on alcohol abstinence

3. Hypertriglyceridemia– risk for pancreatitis when levels are >1000 mg/dL– therapeutic plasma exchange (TPE)

Summery

• Definition

• Etiology & pathogenesis

• Revised ATLANTA classification

• Initial risk assessment

• Management according to Fluid, Pain, Monitoring, Nutrition and antibiotics

• Management of local and systemic complications

• Management of common etiological factors

References

• Up todate.com

• Classification of acute pancreatitis—2012: revision of the Atlanta Classification and definitions by international consensushttp://www.nghd.pt/nghd/images/stories/classification_of_pancreatitis.pdf

• American association of Gastroenterologists' guidelines 2013

Thank you !

BISAP score• BUN >25 mg/dL (8.9 mmol/L) (1 point)BUN

• Abnormal mental status with a Glasgow coma score <15 (1 point)

Impaired mental status

• Evidence of SIRS (systemic inflammatory response syndrome) (1 point)SIRS

• age >60 years old (1 point)Age

• Imaging study reveals pleural effusion (1 point)Pleural effusion

0-2 Points: Lower mortality (<2 percent)

3-5 Points: Higher mortality (>15 percent

Modified Marshall score