Transcript Acute Necrotizing Pancreatitis

Acute Necrotizing
Pancreatitis
Yoram 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 2025% pts .
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20-30% will develop local or systemic
complications
 Approx 1 in 4 pts who develop
complications will die
AP & QUESTIONS
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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?
OBJECTIVE
To give pts of AP best chance of
survival, from the outset to be managed
by surgeon
Identification of pts likely to develop
complications
Management (prevention)of systemic
complications
Timing and choice for surgical Intervention
for gall stones or local complications
PANCREATITIS (terminology)
MILD-uncomplicated recovery
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SEVERE-AP with evidence of failure of
one or more systems , or local
complication.
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These terms are defined retrospectively,when
outcome is known
Prospectively defined on the basis of scoring
systems.Predicted Mild or Predicted Severe
ACUTE PANCREATITITSTERMINOLOGY
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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
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Pancreatic necrosis;
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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
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Infected pancreatic necrosis; Necrosis with
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Pancreatic abscess;Loculated walled off
positive bacterial cultures
collections of pus as a late complication of AP, usually
after 3 weeks
MANIFESTATIONS OF AP
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LOCAL;
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MILD;
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EDEMA, INFLAMMATION, NECROSIS
SEVERE;
 PHLEGMON, NECROSIS, INFECTION, FLUID
COLLECTION, ABSCESS
Bacterial contamination
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Risk of bacterial infection on necrotic
tissue
 60% in proven cases of NP
 Risk in ist
week =25%
nd week = 35-40%
 Risk in 2
rd week =60%
 Risk in 3
Organisms are Gram negative
E-coli,Proteus,Pseudomonas,staphylococci
SYSTEMIC COMPLICATIONS
o
Respiratory-Interstitial pulmonary edema;gas
o
Renal-oliguria-require aggressive circulatory
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Cardiovascular-Hypotension, edema,aggressive
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transfer impairment,Pt may need ventilation
support,#Dialysis
fluid therapy and Ionotropes
Haemopoiesis, Coagulation system, Endocrine
systems
PANCREATITIS
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How to diagnose it?
How to evaluate severity?
RANSON CRITERIA
IMRIES CRITERIA
APACHE scoring
GLASGOW Criteria
Lab and Radiology Help ;
Diagnosis of Pancreatitis
Clinical Diagnosis
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Lab studies;
Serum amylase;Levels Rise within 2-12hrs,
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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
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Initial 24 hrs
1.Age >55 years
2.Glucose >than
200 mgm/dl
3.WBC > 16,000
cells/mic L
4.LDH >350
IU/liter
5.AST
>250IU/liter
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Subsequent 48 hrs
1.Art o2tension
<60mmHg
2.Bun Increase
>8mg/dl
3.Ca < 8mg/dl
4.Base deficit
>4meq/liter
5.Estimated fluid
sequestration >6liters
6.Fall n Hct >10%
Mortality prediction (as per
Ranson criteria)
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A. < 3 signs = 1%
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B. Three to Four signs=11%
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C. Five to six signs=33%
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D. >Six signs= 100%
APACHEII
1.
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3.
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5.
6.
Temp
Mean Art Pressure
Heart Rate
Resp rate
Oxygenation(Pao2)
Arterial Ph
1.
2.
3.
4.
5.
6.
Serum sodium
SerumPottasium
Serum creatinine
Haematocrit
WCC
Glasgow coma
scale
Apache II score(Sum of
A+B+C)
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A=+4 to 0 points
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TEMP>41=4,<29=4
Mean Art Pr>160=4
<49=4
Heart & Resp rate
OXYGENATION
ART PH
Ser Na,K,Creat,
HCT,WBC
GLASGOW COMA Score
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B=Age <44=0 pts
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C=Chronic Health
points
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>75=6points
H/o organ insufficiency
Liver,CVS,Resp,Renal,
,Immunocompromised
APACHE SCORE42=90%
Mort
GLASGOW CRITERIA
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Any time during First 48hrs after
admission
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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
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Any time during
First 48hrs after
admission;
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WBC >15000 Cu/mm
Blood
glucose>10mmol/l
BUN >16mmol/L
Art po2,< 60mmHg
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Ser ca. <2.0 ml/l
Ser Albumin<32gm/l
Ser LDH
>600u/L(n=250)
AST Or ALT >200u/l
Comparsion Of Scales
Predicti
on of
complic
Few
hours
48hrs
Apache
More
Less
accurate
88%
69%
Less
72 hrs
+++
++
++
Falling
Falling
Dying pt Rising
Ranson
Glasgow
84%
INTERSTITIAL AND NECROTIZING
PANCREATITIS (Discrimination)
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Markers of Necroses
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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
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Plain Films
Ultrasonography
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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
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Enlargement of Gland
Ill defined margins
Abnormal enhancement
Thickening of
peripancreatic planes
Blurring of fat planes
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Intra &
retroperitoneal fluid
collection
Pleural effusion
Pancreatic gas
indicative of necrosis
/abscess
Pseudocyst
formation
ERCP; Indications In AP
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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
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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
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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
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Traditional teaching Prophylactic
antibiotics do not prevent abscessMezlocillin, 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 AP
A.Diagnostic laparotomy
B.To limit the severity of pancreatic
inflammation
Biliary operations
C.To interrupt the pathogenesis of
complications
Pancreatic drainage
Pancreatic resection
Peritoneal drainage
Operative measures(contg)
D.To support the patient and treat
complications
Drainage of pancreatic abscesses
Feeding jejunostomy
To prevent recurrent pancreatitis
Surgical treatment-indications
Diagnostic
uncertainty
Gall stone induced
pancreatitis
Pancreatic drainage
and defunctioning
Pancreatic resection
Peritoneal Lavage
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Operation for
complications
Bile duct stones-strategy
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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
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Mild pancreatitis: Operated At Any Stage
during first admission
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Severe disease.Cholecystectomy during first
admission, timing depends on clinical
indicators
Timing of Surgery-contd
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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
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Surgical acute
abdomen
Sepsis syndrome
Shock syndrome
Non response to ICU
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Morphologic
+Bacteriologic
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Infected necroses
Extended pancreatic
necrosis>50%
Extnd.
intrapancreatic
+retroperitoneal
necroses
Technique of Debridement
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Closed cavity Lavage
Open abdomen
Surgical drainage
Posterior approach
Pancreatic resection
Pseudo cyst
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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
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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