acute pancreatitis: current aspects in diagnosis and...

Acute Pancreatitis:

Current aspects in

Diagnosis and Treatment

Tercio De Campos, MD, PhD, FACS

Associate Professor

Faculdade de Ciências Médicas da Santa Casa de São

Paulo

Introduction

Acute Pancreatitis

Common disease

Incidence

50-80 patients/year/100,000 inhabitants USA

Toouli et al - J Gastroenterol Hepatol, 2002

Acute pancreatitis in Brazil - 2006

Brasil: 27,077 15.9 patients/100,000 inhabitants/year

São Paulo: 1,999 19.2 patients/100,000 inhabitants/year

De Campos et al. Rev Col Bras Cir, 2008

Introduction

Acute pancreatitis

Santa Casa:

2 patients / week

2 severe patients / month

Serviço de Emergência FCM Santa Casa SP

Introduction

Treatment of Acute Pancreatitis

Controversial in many topics

Difficulties in clinical trials

Small number of severe AP patients per center

How you define severity in acute pancreatitis? What’s your choice for nutrition in patiens with acute pancreatitis? What’s the best period to perform an operation in a patient with

severe acute pancreatitis?

De Campos et al. Rev Col Bras Cir, 2008 / DDW 2008 - San Diego, CA

Rev. Col. Bras. Cir. 2008; 35(5): 304-310

Topics to discuss

How to confirm the diagnosis

How to determine severity

How to determine etiology

How to treat these patients

Antibiotics

Nutrition

ERCP

Surgical treatment

Diagnosis

Clinical presentation

AMILASE / LIPASE > 3x

CT (ultrasound / MR)

2 out of 3 = acute pancreatitis

Banks PA & Freeman ML - Am J Gastroenterol, 2006

Current definition

Topics to discuss




How to treat these patiens

Antibiotics

Nutrition

ERCP

Surgical treatment

• Death in acute pancreatitis

1-2nd week after 2nd week X

SIRS

Organic failure

Necrosis +

Infection

Severity

Deitch et al, Surg Clin North Am 1999

Schmidt et al, Gut 1999 Toouli et al - J Gastroenterol Hepatol, 2002

Clancy et al - J Gastrointest Surg, 2005

De Campos et al - World J Emerg Surg, 2006

Severity • 2 factors determine the prognosis of a patient

with acute pancreatitis

Organic failure Necrosis/Infection


Werner – Pancreatology, 2003

Clancy et al - J Gastrointest Surg, 2005


Classifications of severity

Classification of Acute

Pancreatitis

Marselha

Meeting

1963

Marselha

Meeting 2

1984

Atlanta

Meeting

1992

Severity evaluation

Phase 1 - SIRS and

Organic failure

DDW 2008

C Reactive Protein CT scan

Necrosis

Local evaluation Phase 2 - Necrosis and

Infection

CRP - 48 hours

> 150 mg/L

Accuracy 85% for necrosis

Werner – Pancreatology, 2003

Phase 2 - Necrosis and

Infection

Local evaluation

TC – gold standard / not before 72 hs

Peritonitis / Abdominal distention

APACHE II ≥ 8 / SIRS / Marshall ≥ 2 / SOFA ≥ 3

US with peripancreatic fluid or pancreatic alterations

CRP > 150 mg/L

Not improving / worse / difficult to feed

Need to confirm diagnosis

Phase 2 - Necrosis and

Infection

Serviço de Emergência - FCM Santa Casa SP

Local evaluation

TOTAL = 0 - 10

Tomographic Classification (Balthazar-Ranson – Tomographic severity index)

Local severity

Phase 2 - Necrosis and Infection

Local complications

Interstitial edematous pancreatitis

Necrotising pancreatitis (pancreatic /

peripancreatic necrosis)

Acute peripancreatic fluid collection

Acute necrotic collection

Pancreatic pseudocyst

Walled-off necrosis

Early

phase

Late

phase

Interstitial edematous pancreatitis

Local

complications

Peripancreatic necrosis

Local complications

Pancreatic necrosis

Local

complications

Acute peripancreatic fluid collection

Local

complications

Acute necrotic collection

Local

complications

Practical aspects

Assess

-Systemic

complications

-Local complications

How to assess Systemic complications?

-Ranson

-Glasgow

-SIRS

-Apache II

-SOFA

-Marshall

Repeat in 48 hs

(not possible to Ranson and

Glasgow)

Practical aspects

How to assess Local complications

-C Reactive protein

-Computed tomography

Practical aspects

How we do at Santa Casa?

-SIRS

-Apache II

-SOFA

-Marshall

Repeated in 48 hs

and when necessary

Patients with severe

disease have daily scores

Systemic complications

Practical aspects

Aspectos Práticos

How we do at Santa Casa

-C Reactive Protein - 48 hs

-CT 72-96 hs after the onset of

symptoms in selected patients

Local complications

Topics to discuss





Antibiotics

Nutrition

ERCP

Surgical treatment

Etiologia

50,0%

34,8%

6,1%

8,3%

0,8%

Biliary

Alcohol

Biliary + Alcohol

Idiopathic

Hypertriglyceridemia

Serviço de Emergência – FCM Santa Casa SP

Anamnesis

Biliary

Alcohol

Medicines

Previous diseases

Laboratory tests - up to 24 hours

Calcium

Triglycerides

Banks PA & Freeman ML - Am J Gastroenterol, 2006 UK guidelines for the management of acute pancreatitis - Gut, 2005

Etiology

Etiology

Ultrasound

All patients with acute pancreatitis

2nd US if the 1st was negative and there is no obvious

cause

Endoscopic ultrasound if the 1st and the 2nd were

negatives and there is no other cause

Banks PA & Freeman ML - Am J Gastroenterol, 2006 UK guidelines for the management of acute pancreatitis - Gut, 2005

Etiology

Excluir

Biliary

65-85% of patients

Alcohol

Dyslipidemia

Biliary cystic disease

Pancreas Divisum

Chronic pancreatitis

autoimmune 5-6%

Duodenal obstruction

Medicines

Idiopathic pancreatitis

Pancreatic neoplasms

3% < 40 y/o / 25% > 60 y/o

Toxins

insecticides / scorpions

Trauma

Vasculitis

Infections

virus / ascaris

Celiac disease

Genetic (PRSS1 / CFTR / SPINK-1)

Idiopathic Guda & Forsmark, 2008

Topics to discuss





Antibiotics

Nutrition

ERCP

Surgical treatment

There is no specific treatment :(

Topics to discuss





Antibiotics

Nutrition

ERCP

Surgical treatment

Antibiotics

Mild acute pancreatitis

No place

Rare (cholangitis)

Severe acute pancreatitis

Therapeutic

“Prophylactic”

A lot of doubts and discussions

antibiotics in acute pancreatitis

Lack of evidence

x

Group of patients with benefits USA

ACS / SSAT: do no recommend

AGA: split

Europe

UK / Netherlands: do no recommend

Germany / Italy: use

Asia / South Africa / South America: use

IHPBA, Buenos Aires 2010

Hjalmar van Santvoort, M.D

“Although we know that a group of

patients benefits from the use of

prophylactic antibiotics, studies fail to

prove this benefit.”

Acute pancreatitis study group

Gastrão 2011

São Paulo

Santhi Swaroop Vege, M.D

“I use prophylactic antibiotics in

patients with severe acute

pancreatitis with necrosis> 30%

because I see their benefit, despite

Michael Sarr get mad at me”

Reduction in pancreatic necrosis

CONCLUSION: Current evidences do not support prophylactic

antibiotics as a routine treatment for SAP, but the potentially

benefited sub-population requires further investigations.

Conclusion: The current evidence does not support the use of prophylactic

antibiotics as routine in severe acute pancreatitis, but further studies may

show that a sub-population can benefit from its use.

Current position about the use of

antibiotics in acute pancreatitis

There is no definitive conclusion

Probably there won’t be a definitive conclusion

Each hospital have to determine its policy

“On demand” X Routine

No study has shown that the use of antibiotics

impairs the evolution of these patients

• 1- Should we use prophylactic antibiotics?

• Yes (personal opinion). There is no agreement.

• 2- In which patient?

• Pancreatic necrosis > 30%

• When there is the diagnosis of necrosis

• 3- How to use it?

• a) Which one?

• IMIPENEM or CIPROFLOXACIN + METRONIDAZOL

• b) How long?

• 10 – 14 days

Topics to discuss





Antibiotics

Nutrition

ERCP

Surgical treatment

Pancreatite aguda - Nutrição

Enteral nutritional support should be used

as first choice

• Journal of Gastrointestinal Surgery Vol. 9, No. 3, 2005

Parenteral nutrition has not shown advantages in any study

Enteral nutrition

•Lower septic complicationsReduction in organ failureReduction

CRPShorter hospital stay

Prevention of infection

Nutrition in Acute Pancreatitis

• Parenteral nutrition

• It does not stimulate

pancreatic secretion

• Infections complications

• Procedure complications

• High cost

Enteral nutrition

REDUCTION OF BACTERIAL TRANSLOCATION

Physiologic

Lower cost

Some stimulus in pancreatic secretion

Needs to be placed by endoscopy or radioscopy


Parenteral nutrition x Enteral nutrition

Enteral nutrition

Tube placed in the jejunum


• Current position (nutrition within 48 hours)

Enteral nutrition is preferred

No vomits, distention or significant pain

Oral diet - liquid with low-fat

Nasojejunostomy tube

start with 20 ml/h semi-elemental diet

progression 10 ml/h/day

Parenteral if significant intolerance (rare)

Keep enteral nutrition in small volume

Topics to discuss





Antibiotics

Nutrition

ERCP

Surgical treatment

Severe acute pancreatitis x ERCP

Cochrane Review, 2004

Ayub K, Imada R, Slavin J

No clear consensus

Indications:

*cholangitis

*progressive jaundice

ERCP

Cholangitis (jaundice + Biliary dilation +

fever > 38.5oC / leukocytosis > 18,000)

Calculus impacted in the papilla

•*bilirubin curve (> 2.5)

Before cholecystectomy

•*if predictive factors of

choledocholithiasis

Severe Acute Pancreatitis x ERCP

Current position

Topics to discuss





Antibiotics

Nutrition

ERCP

Surgical treatment

Tratamento Cirúrgico

• INFECTION =

SURGERY <5% patients

How to make the diagnosis of infection?

How to decide by the surgical treatment?

How to operate?



Questões

Diagnosis of Infection

Clinical

Laboratory

* Procalcitonin / CRP

Computed Tomography

Fine needle aspiration (gold standard)

"Important the diagnosis at the right time, but

not necessarily very early" Bakker et al. Curr Gastroenterol Rep, 2009

Clinical

Patient at risk (extensive necrosis)

Probable time (from the 2nd week)

Worsening

New organ failure

worsening of organ failure already diagnosed

Diagnosis of Infection

○Study in 5 centers with 104 patients

○Procalcitonin 3-4 days after AP

○ ≥ 3.5 ng / ml on 2 consecutive days

○Sensitivity 93% specificity 88%

○Pancreatic infection with organ failure

Early assessment of pancreatic infections and overall

prognosis in severe acute pancreatitis by procalcitonin

(PCT): a prospective international multicenter study.

Rau BM, Kemppainen EA, Gumbs AA, Buchler MW, Wegscheider K, Bassi C, Puolakkainen PA, Beger HG.

Ann Surg. 2007 May;245(5):745-54.

Procalcitonin x CRP

Computed Tomography

Gas: 30-50%

Fine-needle aspiration

Gold-standard (1980’s)

Guided by CT or US

Gram / Culture

False-negative: 20-50%!!!!

Bakker et al. Curr Gastroenterol Rep, 2009



How to operate?



Questões

Pancreatite Aguda Grave - Cirurgia

Surgical treatment Early versus late necrosectomy in severe

necrotizing pancreatitis Mier J, Leon EL, Castillo A, Robledo F, Blanco R. Am J Surg. 1997 Feb;173(2):71-5.

36 patients with severe acute pancreatitis

Group A (n=25)

○ Necrosectomy 48-72 hours

○ Mortality 58%

Group B (n=11)

○ Necrosectomy after 12 days

○ Mortality 27%

Results with no significance

Odds ratio for mortality: 3,4x greater in Group A

Study discontinued due to high mortality in Group A

Surgical Treatment

Werner – Gut, 2005

Late surgery (after 2 weeks)

Reduces risk of bleeding

Removal of small tissue viable

Reduces endocrine and exocrine insufficiency

Treatment of infected necrosis

Time of intervention

Great tendency to be delayed

Pancreatic necrosis and peri-pancreatic tends to

delimit in 3-4 weeks, which facilitates the

procedure

The impact of an additional immune stress in an

initial stage can be critical to the evolution of the

patient

Average time for intervention now: 26-33 days

Bakker et al. Curr Gastroenterol Rep, 2009

It is possible to treat clinically a patient

with infected necrosis?

INFECTION =

SURGERY???

Clinical treatment 12.5% x 20% Surgical treatment

Mortality

Conservative management of infected necrosis

complicating severe acute pancreatitis

Douglas G. Adler, Suresh T. Chari, Tamela J. Dahl, Michael

B. Farnell, Randall K. Pearson

Am J Gastroenterol, 2003

Avoid early surgery (before 14 days)

Pancreatic infection without organ failure consider

nonoperative treatment

Pancreatic infection with organ failure consider

nonoperative treatment if up to 14 days of evolution

The pancreatic infection is indicative

of immediate surgical treatment in

Severe Acute Pancreatitis?

Early operation

Bowel complications

Necrosis / perforation

Hemorrhagic complications

fail in arteriography and embolisation



How to operate?



Questões

Surgical treatment

• How to operate?

Drain collections

Necrosectomy

M. Yousaf et al. - Br J Surg, 2003

Surgical treatment

Werner – Gut, 2005

Surgical treatment

Serviço de Emergência da Santa Casa - SP

Surgical treatment

Surgical Treatment

Minimally invasive treatment

Transparietal

Laparoscopic

Endoscopy

Retroperitoneal necrosectomy

Conclusion Confirm the diagnosis

Severity assessment

Look for the cause

No specific treatment / Gallbladder stays at the hospital

Antibiotic in necrotizing pancreatitis is controversial

Enteral nutrition!

ERCP in cholangitis

Surgical treatment

Infection + organ failure

Late is better

Step-up approach

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Obrigado!

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