acute pancreatitis steven b. goldin, md university of south florida

Acute PancreatitisAcute Pancreatitis

Steven B. Goldin, MDSteven B. Goldin, MD

University of South FloridaUniversity of South Florida

J.H.J.H.

• JH is a 64-yr-old male admitted to an outside JH is a 64-yr-old male admitted to an outside hospital with a 4 day history of progressively hospital with a 4 day history of progressively worsening epigastric pain without radiation. worsening epigastric pain without radiation.

History

What other points of the history do you want to know?

History, J.H.History, J.H.

• Characterization of symptoms

• Temporal sequence• Alleviating /

Exacerbating factors:

• Pertinent PMH, ROS, MEDS.

• Relevant family hx.• Associated signs and

symptoms

Consider the Following

HPI J.H.HPI J.H.

• Pain is constant and unremitting, going Pain is constant and unremitting, going through to his backthrough to his back

• Pain started after beer and pizza 4 days prior, Pain started after beer and pizza 4 days prior, progressively worsening sinceprogressively worsening since

• Nausea and vomiting x 3Nausea and vomiting x 3

• Some indigestion history, never like thisSome indigestion history, never like this

• No relief with OTC Pepcid, Mylanta or AdvilNo relief with OTC Pepcid, Mylanta or Advil

History, J.H.

• No significant past medical or surgical history

• No medications

• No allergies to medications

• Smokes 1ppd x 40 yrs, and drinks ethanol heavily. He denies drug use.

• Family history was noncontributory.

What is your Differential Diagnosis?What is your Differential Diagnosis?

Differential DiagnosisBased on History and Presentation

• Cholecystitis• Choledocholithiasis• PUD• Gastritis• Pancreatitis• Bowel obstruction• Mesenteric ischemia• Gastroenteritis

• Appendicitis• Hepatitis• Diabetes• Rectus hematoma• Pneumonia• Pyelonephritis• Trauma w/ duodenal

hematoma.

Physical Examination

What would you look for on physical examination?

Physical Examination, J.H.

• Vital Signs: T 38.5 BP 120/70 P 100 R18• Appearance: lying still in moderate distress. Not

jaundiced and sclera were anicteric. His mucous membranes were dry.

• Resp: His lungs were clear to auscultation.• CV: heart was regular and without murmurs,

rubs, or gallops.

Physical Examination, J.H.

• Abdomen: soft, moderately distended, tender in the mid-epigastric region and right upper quadrant. No palpable masses. Bowel sounds were positive.

• Extremities: without cyanosis, clubbing, or edema.

• Rectal exam: no masses, guaiac neg.

Would you like to revise your Differential Diagnosis?

Revised Differential

• Cholecystitis• PUD• Pancreatitis• Bowel obstruction• Mesenteric ischemia

• Gastroenteritis• Hepatitis• Rectus hematoma• Pneumonia

Laboratory

What would you obtain?

LabsConsider the following

• CBC, Electrolytes, LFT’s, CMP, LDH, Amylase, Lipase, PT, PTT, Urinalysis, ABG,

Lab Results, J.H.CBC: Hb /HematocritCBC: Hb /HematocritWBCWBC

10/3010/30

1717

ElectrolytesElectrolytes :: Na 135, K3.0, Chloride 98, Na 135, K3.0, Chloride 98, CO2 37, BUN 15, Cr 1.1, CO2 37, BUN 15, Cr 1.1, Glu 100, Calcium 8.1Glu 100, Calcium 8.1

LFT’sLFT’s :: AST 260, ALT 220, Total AST 260, ALT 220, Total Bili 1.9, Alk phosphatase Bili 1.9, Alk phosphatase 110110

Amylase:Amylase:

Lipase:Lipase:

326326

245245

PT/PTT:PT/PTT: NormalNormal

U/A:U/A: NormalNormal

Other: LDHOther: LDH 375375

Lab Results, Discussion

• This patient has a hypokalemic hypochloremic metabolic alkalosis from vomiting.

• He has an elevated amylase and lipase consistent with pancreatitis.

• On admission he has 4 out of 5 of Ranson’s criteria and can be expected to become very sick.

• There are 6 more of Ranson’s criteria that should be tracked over the next 48 hours.

Can you list Ranson’s criteria?

Ranson’s Early Objective Prognostic Signs that Correlate with the Risk of Major Complications or Death

On Admission

Non-biliary BiliaryAge >55 >70

WBC >16 >18

Glucose >200 >220

LDH >350 >400

SGOT >250 >250


During the Initial 48 Hours Non-biliary Biliary

Hematocrit decrease >10% >10%

BUN increase >5 mg/dL >2 mg/dL

Calcium <8 mg/dL <8 mg/dL

Arterial Po2 <60 ...

Base deficit >4 mEq/L >5 mEq/L

Fluid sequestration >6 L >4 L

Ranson’s Prognostic Signs that Correlate with Ranson’s Prognostic Signs that Correlate with the Risk of Major Complications or Deaththe Risk of Major Complications or Death

Number of Number of Prognostic SignsPrognostic Signs

0-20-2 3-43-4 5-65-6 7-87-8

% spending >7 % spending >7 Days in ICUDays in ICU

44 4040 9090 100100

Mortality (%)Mortality (%) 22 1515 4040 100100


Note

1. The amylase and lipase levels are not prognostic signs and do not relate to the severity of the attack or prognosis.

2. LDH must usually be specifically ordered.

It is not included with most comprehensive metabolic panels or with most liver function tests.

Interventions at this point?

Interventions at this pointInterventions at this point

• IVF – LR Bolus 1-2 liters then LR at 150cc/hr – titrate to urine output/volume status

• NPO

• Foley catheter

• NG Tube

• Admission to ICU

List common etiologies forList common etiologies for Pancreatitis Pancreatitis

PancreatitisPancreatitis

• Alcohol *Alcohol *• Gallstones*Gallstones*• HyperlipidemiaHyperlipidemia• TraumaTrauma• TumorTumor• IschemiaIschemia

• MedicationsMedications• InfectionInfection• Post-op/Post-procedurePost-op/Post-procedure• OtherOther• IdiopathicIdiopathic

StudiesStudies

What would you order ?What would you order ?

StudiesStudies

Obstruction Series/Acute Obstruction Series/Acute Abdominal Series etc.Abdominal Series etc.

CT Scan: Abd/PelvisCT Scan: Abd/Pelvis

CT Scan: OtherCT Scan: Other

Flat/Upright AbdomenFlat/Upright Abdomen HIDA ScanHIDA Scan

PA/Lat ChestPA/Lat Chest MRCPMRCP

RUQ USRUQ US OTHER: EKGOTHER: EKG

US GBUS GB

Discussion of StudiesDiscussion of Studies

• Ultrasound of right upper quadrant is indicated Ultrasound of right upper quadrant is indicated to evaluate gallbladder and bile duct for stones.to evaluate gallbladder and bile duct for stones.

• CT scan should be done after initial CT scan should be done after initial stabilization. IV contrast is useful to assess stabilization. IV contrast is useful to assess pancreatic viability. Use of IV contrast on pancreatic viability. Use of IV contrast on presentation is debated.presentation is debated.

His initial CT Scan is shown below:

Discussion of imaging studyDiscussion of imaging study

• This is a CT scan of the abdomen done with both oral This is a CT scan of the abdomen done with both oral and IV contrast. It demonstrates edema surrounding and IV contrast. It demonstrates edema surrounding the pancreas and is consistent with the laboratory the pancreas and is consistent with the laboratory results suggesting pancreatitis. No significant results suggesting pancreatitis. No significant pancreatic necrosis is noted.pancreatic necrosis is noted.

• My preference is to not use IV contrast on admission if My preference is to not use IV contrast on admission if pancreatitis is suspected due to the toxic nature of the pancreatitis is suspected due to the toxic nature of the dye and the rarity of finding infection on presentation. dye and the rarity of finding infection on presentation. I do use IV contrast later on in the hospitalization to I do use IV contrast later on in the hospitalization to better discern the amount of necrosis that has resulted better discern the amount of necrosis that has resulted as long as the patients renal function is acceptable.as long as the patients renal function is acceptable.

Would you like to revise your Would you like to revise your differential diagnosis?differential diagnosis?

Revised Differential DiagnosisRevised Differential Diagnosis

• Acute PancreatitisAcute Pancreatitis• CholedocholithiasisCholedocholithiasis• CholecystitisCholecystitis• Perforated ulcerPerforated ulcer

What next?What next?

Supportive measuresSupportive measures

• Nothing by mouthNothing by mouth• early oral feedings may increase the early oral feedings may increase the

severity of pancreatic inflammation. severity of pancreatic inflammation. Oral feedings should be withheld until Oral feedings should be withheld until resolution of abdominal pain, fever, and resolution of abdominal pain, fever, and leukocytosisleukocytosis

• Fluid and electrolyteFluid and electrolyte repletion and resuscitationrepletion and resuscitation

• Respiratory supportRespiratory support

• Nutritional supportNutritional support

• Proton pump inhibitorsProton pump inhibitors

• DVT prophylaxisDVT prophylaxis

• Antibiotics (debated)Antibiotics (debated)

• AnalgesicsAnalgesics

Timing of cholecystectomyTiming of cholecystectomy

• Gallstones are present in 60% of non-Gallstones are present in 60% of non-alcoholic patients with pancreatitis and alcoholic patients with pancreatitis and if allowed to persist, 36 - 63% will if allowed to persist, 36 - 63% will develop recurrent bouts of pancreatitis. develop recurrent bouts of pancreatitis. Cholecystectomy reduces this risk to Cholecystectomy reduces this risk to 2 - 8%.2 - 8%.


• 75% of patients with acute abdominal pain, 75% of patients with acute abdominal pain, gallstones, and elevated amylase have no gross gallstones, and elevated amylase have no gross evidence of significant pancreatitis. evidence of significant pancreatitis. Cholecystectomy is safe in this group.Cholecystectomy is safe in this group.

• In patients with gross evidence of pancreatitis, In patients with gross evidence of pancreatitis, 80% have mild disease and cholecystectomy is 80% have mild disease and cholecystectomy is safe but does not alter the course of the safe but does not alter the course of the pancreatitispancreatitis

Intra-Operative Cholagiogram (IOC) Intra-Operative Cholagiogram (IOC) during Laparoscopic Cholecystectomyduring Laparoscopic Cholecystectomy

The timing of cholecystectomyThe timing of cholecystectomy

• In patients with severe pancreatitis there is an In patients with severe pancreatitis there is an 82.6% morbidity and 47.8% mortality from 82.6% morbidity and 47.8% mortality from cholecystectomy if performed within the initial cholecystectomy if performed within the initial 48 hours. If deferred until the signs of 48 hours. If deferred until the signs of pancreatitis have subsided, morbidity and pancreatitis have subsided, morbidity and mortality fall to 17.8% and 11.8% mortality fall to 17.8% and 11.8% respectively.respectively.


• In patients with severe pancreatitis and an In patients with severe pancreatitis and an obstructed biliary tree secondary to obstructed biliary tree secondary to choledocholithiasis, ERCP and sphincterotomy choledocholithiasis, ERCP and sphincterotomy significantly reduce morbidity related to significantly reduce morbidity related to biliary complications but do not alter the biliary complications but do not alter the course of the pancreatic inflammation.course of the pancreatic inflammation.

ERCPERCP

Hospital CourseHospital Course

• This patient deteriorates with non-operative This patient deteriorates with non-operative treatment. He develops high fevers and treatment. He develops high fevers and hypotension. hypotension.

• What could be happening? What could be happening?

• What would you do next?What would you do next?

Repeat CT Scan is shown belowWhat do you see?

CT FindingsCT Findings

CT scan now shows air in the lesser sac. This is CT scan now shows air in the lesser sac. This is diagnostic of infected pancreatic necrosis.diagnostic of infected pancreatic necrosis.



• Supportive Treatment

• Elective Cholecystectomy if caused by gallstones.

• Endoscopy with ERCP if obstructing stone is identified in the common bile duct.

• OR if infected

ManagementManagement

The patient was started on broad spectrum The patient was started on broad spectrum antibiotics and taken to the operating room for antibiotics and taken to the operating room for pancreatic debridement, cholecystectomy, and pancreatic debridement, cholecystectomy, and placement of large axiom sump drains. A placement of large axiom sump drains. A jejunal feeding tube was also placed at this jejunal feeding tube was also placed at this time.time.

Temporary Abdominal ClosureTemporary Abdominal Closure

Sump Drain


This patient was slowly weaned from his This patient was slowly weaned from his vasopressor agents and ventilator. Tube vasopressor agents and ventilator. Tube feedings were started two days after his feedings were started two days after his debridement. The patient eventually made a full debridement. The patient eventually made a full recovery and was discharged from the hospital recovery and was discharged from the hospital approximately 4 months after presentation.approximately 4 months after presentation.


Operative Options includeOperative Options include• Debridement and drainageDebridement and drainage-Mortality 13.9%. 58.3% -Mortality 13.9%. 58.3%

of patients can be treated with one surgical procedure.of patients can be treated with one surgical procedure.• Debridement & packing,Debridement & packing, and dressing changes every and dressing changes every

2 - 3 days. Mortality 10.7%.2 - 3 days. Mortality 10.7%.• My preference is to debride and drain if all necrotic My preference is to debride and drain if all necrotic

debris can be easily removed. Otherwise I pack and debris can be easily removed. Otherwise I pack and return to the operating room every 48 hours until the return to the operating room every 48 hours until the necrotic tissue is fully debrided. At that time, I place necrotic tissue is fully debrided. At that time, I place drains and close the patient.drains and close the patient.


• Patients who are not infected should not be Patients who are not infected should not be operated on.operated on.

• Bradley - Neither the existence nor the extent of Bradley - Neither the existence nor the extent of necrosis can be used as an indication for necrosis can be used as an indication for surgery. (90.4% survival in patients treated surgery. (90.4% survival in patients treated conservatively with over 50% necrosis of the conservatively with over 50% necrosis of the gland and no infection).gland and no infection).


• The use of antibiotics in patients with necrosis The use of antibiotics in patients with necrosis without infection is debated. Overall mortality without infection is debated. Overall mortality does not seem to change significantly, but there does not seem to change significantly, but there is a lengthening of time to develop infection is a lengthening of time to develop infection with the use of antibiotics. Antibiotic use, with the use of antibiotics. Antibiotic use, however, has been suggested to increase the risk however, has been suggested to increase the risk of infection with resistant organisms.of infection with resistant organisms.


• The number one determinant of survival is whether The number one determinant of survival is whether infection of the necrotic tissue occurs.infection of the necrotic tissue occurs.

• Infection is demonstrated by air in the lesser Infection is demonstrated by air in the lesser sac/retroperitoneum. Infection can occur without air sac/retroperitoneum. Infection can occur without air and if suspected, needle aspiration should be attempted.and if suspected, needle aspiration should be attempted.

• Caution is warranted when attempting needle Caution is warranted when attempting needle aspiration due to the risk of passing the needle through aspiration due to the risk of passing the needle through the colon or stomach. Once done, a previously the colon or stomach. Once done, a previously uninfected collection will likely become infected.uninfected collection will likely become infected.

Pancreatic NecrosisPancreatic Necrosis

Clinical Signs of InfectionClinical Signs of Infection

• Fever >101F 100%Fever >101F 100%• Abdominal distention 94%Abdominal distention 94%• Pneumonia or effusion 89%Pneumonia or effusion 89%• Leukocytosis (>10,000/mm3) 78%Leukocytosis (>10,000/mm3) 78%• Abdominal mass 71%Abdominal mass 71%• Hypotension (BP <90 mm Hg) 39%Hypotension (BP <90 mm Hg) 39%• Renal failure 39%Renal failure 39%• Coma 28%Coma 28%• Elevated serum amylase 28%Elevated serum amylase 28%

Discuss Potential Complications of Acute Pancreatitis

Pleural EffusionsPleural Effusions

Pancreatic AscitesPancreatic Ascites

SummarySummary Treatment of Acute PancreatitisTreatment of Acute Pancreatitis

• On presentation, determine the potential for complications On presentation, determine the potential for complications – – Ranson’s criterionRanson’s criterion are one method. are one method.

• Nasogastric suctionNasogastric suction• No oral feedings until pancreatitis subsidesNo oral feedings until pancreatitis subsides• Monitor and maintain intravascular volumeMonitor and maintain intravascular volume• Respiratory and nutritional supportRespiratory and nutritional support• Antibiotics (selective)Antibiotics (selective)• Suspect and treat pancreatic sepsis aggressivelySuspect and treat pancreatic sepsis aggressively• Surgery only for infected pancreatic necrosisSurgery only for infected pancreatic necrosis

QUESTIONS ??????

Acknowledgment The preceding educational materials were made available through the

ASSOCIATION FOR SURGICAL EDUCATIONASSOCIATION FOR SURGICAL EDUCATION

In order to improve our educational materials wewelcome your comments/ suggestions at:

[email protected]

acute pancreatitis steven b. goldin, md university of south florida

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day history

family history

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physical examination

epigastric pain