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