Acute Pancreatitis Flashcards
(Atlanta criteria) Definition of diagnosis of acute pancreatitis
Two of the following
Clinical: abdominal pain consistent with pancreatitis
Biochemical: Amylase/ Lipase >2/3 upper limit
Radiological features of acute pancreatitis
(Atlanta criteria) Definition of types of acute pancreatitis
1) Interstitial oedematous pancreatitis
2) Necrotising pancreatitis
Atlanta classification of severity
Mild: no complications/organ failure
Moderate Severe: local/systemic complications + no persistent organ failure
Severe: Local/systemic complications + organ failure
Definition of systemic complications in (Atlanta classification)
exacerbation of pre-existing comorbidity, such as coronary artery disease or chronic lung disease
Definition of local complications (Revised Atlanta)
inflammatory or necrotic changes around pancreas (pericollection, pseudocyst, acute necrotic collection, walled off necrosis)
Pros and cons of scoring systems
- Ranson: +readily measurable, - lower predictive score 60%, -initially for alcoholic pancreatitis, two time measurements can delay prediction
- APACHE: readily measurable, can be repeated at any time, need complicated measurements more feasible in ICU,
- Glasglow: readily available,, low predictive score, original for alcoholic pancreatitis
- CRP: acute phase protein, peaks at 36 hours after onset (>150 indicates severity)
- Balthazar:
GA LAW
Glucose>10mmol
Age >55
LDH >350 IU/L
AST >250 IU/L
White cell > 16
Acute Pancreatic Fluid Collection (APFC)
peripancreatic fluid associated with interstitial oedematous pancreatitis with no necrosis. Within first 4 weeks after onset
Pancreatic Pseudocyst
-encapsulated fluid collection
-well defined inflammatory wall
-minimal / no necrosis
occurs > 4 weeks after IEP
Acute necrotic collection
collection containing variable amounts of fluid + necrosis involving pancreatic parenchyma + peripancreatic tissue
Walled Off Necrosis
mature encapsulated collection
well-defined inflammatory wall
> 4 weeks after onset
C HOBBS
Calcium < 2
Hematocrit drop >10%
Oxygen (RA paAO2) < 8kPa
Base deficit > 4
BUN increase < 1.8
Ranson’s score
At 0 hours:
Age> 55
WCC > 16
Glucose >11.1 mmol/L
LDH >350 IU/L
AST >250 IU/L
At 48 hours:
Hematocrit fall >10%
BUN rise 5mg/dl
pO2 < 60mmHg
BE >4 mmol/L
Fluid sequestration >6000 mL
APACHE II Physiological parameters
GCS
Temperature
Mean arterial pressure
Heart rate
Respiratory rate
APACHE II Biochemical parameters
White cell count
Sodium
Potassium
PaO2
Creatinine
Hematocrit
pH
CT Severity Index (Balthazar score)
ABCDE
A: normal
B: enlarged pancreas
C: pancreatic inflammation/peripancreatic fat
D: single peripancreatic fluidc collection
E: 2 or more fluid collections
Indication for intervention in necrotizing pancreatitis
1) documented infected NP with clinical deterioration
2) ongoing organ failure for several weeks
Step up approach
Treatment of infected pancreatic necrosis with initial intervention via endoscopic/ percutaneous drainage with progression to retroperitoneal debridement with lavage
Main causes of pancreatitis
- 3 main causes
- Gallstone
- Alcoholic
- Idiopathic
Indication for intervention of pseudocyst
1) Symptomatic
2) Complications: infection, obstruction, haemorrhage, fistulation, pancreatic ascites
3) Growing size
4) Cystic neoplasm suspected
Timing of cholecystectomy after resolution of pancreatitis:
1) mild
2) complications
1) during index admission
2) after collections subsided
What are the indications for antibiotics in pancreatitis
No role for prophylactic antibiotics
1) infected necrotizing pancreatitis
2) suspected secondary infection
Signs of infected necrotizing pancreatitis
Gas locules in pancreatic collection
Fever
Bacteremia
Worsening leukocytosis
Clinical deterioration
Initial management of pancreatitis
- Close monitoring +/- ICU for organ support
- Fluid resuscitation
- Pain control
- Nutrition
- ERCP for concomitant acute cholangitis
Types of necrotizing pancreatitis
- Sterile pancreatic or peripancreatic necrosis
- Infected pancreatic necrosis
Step up approach for surgical management of infected pancreatic necrosis
- Percutaneous / endoscopic drainage
- Endoscopic necrosectomy
- Video assited retroperitoneal necrosectomy
- Open retroperitoneal necrosectomy
- Open necrosectomy (if uncontrolled sepsis)
What types of pancreatic fluid collection are there?
- Acute peripancreatic fluid collection
- Pancreatic pseudocyst
- Acute necrotic collection
- Walled off necrosis
Other causes of pancreatitis
- Post ERCP
- Trauma related
- Metabolic: hyperlipidemia, hypercalcemia
- Infection: mumps, TB
- Tumor
- Autoimmune pancreatitis
What are the CT features of interstitial edematous pancreatitis?
- Focal or diffuse pancreatic enlargement
- Peripancreatic stranding
CT features of AFPC
homogenous fluid-attenuated collection that lack a wall
always peripancreatic location
conform to retroperitoneal spaces
CT features of acute necrotic collection
They are poorly organized necrotic collections, therefore often
- multiple
- loculated
- presence of non-liquified debris (distinguishing factor from AFC), ex solid-appearing components of fat lobules
- often seen in lesser sac and pararenal spaces, can track down to pelvis
CT features of wall off necrosis
- organised
- heterogeneous
- gas-containing collections with thick enhancing wall
Scores for assessment of disease severity
- Ranson’s score
- APACHE
- CRP
- Balthazar/ CT Severity Index
PANTER trial
RCT for initial treatment of acute infected necrotizing pancreatitis
Comparison: Minimally invasive step up approach vs maximal necrosectomy by laparotomy
Outcome: reduces major morbidity and mortality
Indication for intervention in NP
1) documented infected NP with clinical deterioration 2) ongoing organ failure for several weeks
