acute pancreatitis what to treat locally and what to refer...
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Acute pancreatitis
What to treat locally and what to refer to a specialist unit
London Cancer Pancreas Update
London - 12th July 2017
R. Valente, S. Zlatkov
Prevalence
• In England, more than 25,000 people admitted to hospital every year for acute pancreatitis
Mechanism
Causes
• 90% alcohol and gallstones
• Other causes • Hyperlipidemia
• Hypercalcemia
• Trauma
• Heredity
• Drugs, venoms
• Iatrogenic (ERCP)
Management of suspected pancreatitis
• Pancreatitis is a serious condition with a potential mortality rate of 10–25% [BMJ Best Practice, 2015]
• Has a worsening prognosis if diagnosis is delayed, and is not amenable to treatment in primary care. [Working Party of the British
Society of Gastroenterology et al, 2005]
• Urgent admission is needed, without delay, for investigations and ongoing specialist management. [Johnson, C.D.
et al., 2014]
AP Clinical key manifestation
• Can be very broad, from mild to severe
• Most commonly mild. Usually self-limiting.
• 15% organ failure involving cardiovascular, renal, and/or respiratory systems: SAP.
• SAP generally divided into two phases 1. Inflammatory response for approximately 1 week. Pancreatic
edema and multiple-organ failure resolve or advance to peripancreatic ischemia and necrosis.
2. Necrotizing process, for weeks to months. Mortality usually associated with secondary infection.
Primary care
• Admit urgently if the person has suspected acute pancreatitis, for further management.
• Do not delay admission by taking blood samples or ordering imaging in primary care!
Secondary care - Goals of initial assessment 1
• Determine the cause
• Remove any ongoing stimulus fueling pancreatitis
• Identify which patients will progress to SAP
Secondary care - Goals of initial assessment 2
• History focussed on identifying the cause • Alcohol, cholelithiasis, hyperlipidemia, prior pancreatitis,
medications. Ages and number of family members afflicted with AP.
• Physical examination • Vital signs, oxygen saturation, and urine output. • Depressed mentation, tachycardia, tachypnea, and low oxygen
saturation are concerning signs of SAP.
• Abdominal examination • upper abdominal tenderness, particularly in the epigastrium,
peritonitis.
• GAS / LAC • FBC, LFT, AMY/LIP, BUN/CREA
Secondary care 1 - Initial treatment
• Resuscitation with intravenous fluids (maintain perfusion)
• Supplemental oxygen (maintain oxygenation) • Pain relief • Antibiotics for treatment of associated cholangitis or
acute infections (i.e. chest or urinary tract infection) • Early nutritional support
• Oral feeding mild acute pancreatitis if no nausea, vomiting, or abdominal pain.
• Enteral feeding otherwise preferable and possible in the majority of people.
• Parenteral feeding is reserved when enteral nutrition is not possible.
Secondary care 2 – Initial investigations
• Lipase or amylase levels
• Assessment for prognostic features to identify those at risk of a potentially severe attack
• Imaging techniques, such as computed tomography, magnetic resonance imaging, or ultrasonography
Secondary care 3
• If pancreatitis and organ dysfunction usually managed in a high-dependency unit or intensive therapy unit
• If acute pancreatitis caused by suspected or proven gallstones, management may include:
• ERCP to relieve the obstruction, within 72 hours of the onset of
pain, for those with cholangitis.
• Cholecystectomy during the same admission. If protracted course of severe disease, cholecystectomy may be delayed until clinically appropriate
AP Natural history
Adapted from Nicholson LJ, Curr Gastroenterol Rep 13(4):336–343, 2011.
Classification 1 – Revised Atlanta criteria
• Two phases • Early <=1 week
• Late > 1 week
• Severity (48h) • Mild
• Moderate
• Severe Banks et al, Gut 2014
Clinical course – Revised Atlanta criteria
• Mild • No organ failure
• Local or systemic complications
• Usually resolves in the first week
• Moderate • Transient organ failure,
• Local complications
• Or Exacerbation of co-morbid disease
• Severe • Persistent organ failure >48 h Banks et al, Gut 2014
RLH Cause and severity (2015/16)
0
5
10
15
20
25
30
35
Severe
Mild
Local complications
• Peripancreatic fluid collections (sterile or infected): 60%, 30% >3
• Pancreatic and peripancreatic necrosis (sterile or infected)
• Pseudocyst and walled-off necrosis (sterile or infected)
• Gastric outlet dysfunction
• Splenic and portal vein thrombosis
• Colonic necrosis
Banks et al, Gut 2014
SV – SMV – PV Thrombosis - Treatment
Risk of bleeding Risk of
thrombus progression
New thrombotic onset
Other signs of procoagulability
Liver / bowel ischaemia
Sentinel bleed
Extent of necrosis
Infection (pseudoaneuirism)
Natural history
Adapted from Nicholson LJ, Curr Gastroenterol Rep 13(4):336–343, 2011.
Prediction of severity - Early Scoring
• Clinical • Ranson (Needs repetition 48h)
• Glasgow Imrie (rapid, on lab tests)
• BISAP
• Procalcitonin
• CT (>72 hours) • Balthazaar score
• CT Severity Index (CTSI)
• Mortele score
- BUN > 25 - Impaired
mental status - SIRS - Age - Pleural effusion
Wu et al. The early prediction of mortality in acute pancreatitis (2008)
Glasgow – Imrie on Discharge summary
Natural history
Adapted from Nicholson LJ, Curr Gastroenterol Rep 13(4):336–343, 2011.
CT imaging Revised Atlanta criteria
• Interstitial edematous pancreatitis
CT imaging Revised Atlanta criteria
• Necrotizing pancreatitis
• Acute peripancreatic fluid collection (APFC)
CT imaging Revised Atlanta criteria
• Necrotizing pancreatitis
• Acute peripancreatic fluid collection (APFC)
CT imaging Revised Atlanta criteria • Walled-off collection
• Pseudocyst (6 weeks)
CT imaging Revised Atlanta criteria
• Infected necrotic collection
Tertiary referral A reasonable pathway
HPB referral
Assessment
On-demand care
Remote management
Transfer: HPB admission
Ward
HDU/ITU
Ward
Outpatients
1. Transfer imaging via PACS
2. HPB involvement: phone & email on clinical condition
3. Imaging expert review
4. Registrar / Consultant documented discussion
Estimating need of HPB intervention failure to progress or deterioration:
- Serial imaging - SIRS response
- Organ support
What to treat locally and what to refer to a specialist unit?
What to treat locally and what to refer to a specialist unit
• Failure to progress without dedicated MDT team.
• Concern without dedicated ITU support
• Need for intervention unavailable locally • IR (Drainage, Embolisation, PTBD)
• Endoscopy (ERCP, Drainage)
• Surgery • VARD, open necrosectomy
• Decompression of ACS
• Haemorrage salvage
AP RLH admissions 2015 - 2016
[VALUE] 74
2
76
94 Admissions
Transfer A&E Elective
Length of stay
Median 6 (1-143)
Treatment of infected necrosis
• A step-up approach starting with minimal invasive drainage techniques and endoscopic necrosectomy
• Significant reduction of morbidity and mortality in necrotising pancreatitis compared to a primarily surgical intervention
Intervention at RLH – 2015/16
72
14
2
2
1
1
20
Intervention
No
IR
IR + End
IR + Surg
End
Surg
Endoscopic versus surgical step up approach
Endoscopic transluminal drainage (ETD) and endoscopic transluminal necrosectomy (ETN
Percutaneous catheter drainage (PCD) and video-assisted retroperitoneal débridement (VARD)
TENSION trial
VARD
• Video assisted retroperitoneal debridement
IACS & Decompressive laparotomy
• No consistent guidelines
• Needs aggressive medical treatments before
• 31 mmHg
• Decompress puss under pressure
• When medical treatments to reduce it fail
• Alternative: superficial laparotomy
Boone et al. Am. Surg. 2013
IACS & Superficial laparotomy
Leppaniemi et al 2006
Summary 1 - Management recommendations at diagnosis
1. Liver function tests and US < 24h of admission (Gallstones?)
2. Initial management: fluid resuscitation and supplemental oxygen
3. Severe acute pancreatitis: >48h organ failure (>30% mortality)
4. If symptoms > 7 days: CT to assess extension of necrosis
5. If gallstones: cholecystectomy or sphyncterotomy < 2 weeks of resolution of symptoms
6. Necrotising pancreatitis should be managed by a specialist team including surgeons, endoscopists, interventional radiologists, and intensivists
Johnson et al. BMJ 2014
Tertiary referral A reasonable pathway
HPB referral
Assessment
On-demand care
Remote management
Transfer: HPB admission
Ward
HDU/ITU
Ward
Outpatients
1. Transfer imaging via PACS
2. HPB involvement: phone & email on clinical condition
3. Imaging expert review
4. Registrar / Consultant documented discussion
Estimating need of HPB intervention failure to progress or deterioration:
- Serial imaging - SIRS response
- Organ support
Thank you