Role of CT in Acute Pancreatitis

1
Post-ERCP acute pancreatitis
Most common and dreaded serious complication. It
is a clinical syndrome Post ERCP hserum amylase
75 pts. Clinical pancreatitis in 1 - 40
diverse definitions. gt 3 5 times h
amylase Abdominal Pain Pancreatic
Swelling
Sherman S. GI Endoscopy. 1994 Cavallini G.
NEJM, 1996
2
Prevention of post-ERCP pancreatitis

• Trigger for acute pancreatitis starts at the time
  of cannulation of P.D.
• Potential triggers - Papillary edema
• - Increased Hydrostatic Pressure
• - Thermal Injury etc.
• Initiating event is premature intracellular
  activation of the proteolytic enzyme Trypsinogen
• ?
• Trypsin
• ?
• Other Proteolytic Enzymes
• ? Exocrine Pancreatic Secretions

3
Prevention of post-ERCP pancreatitis

• Implication of these observations is
• ?
• Severe acute pancreatitis sets in very early
• To modify the sequence of events.
• Start prophylaxis - Early
• - Preferably before noxious insult occurs

4
Low dose LMW Heparin i risk of Acute
Pancreatitis (Endoscopy 2000 ) Corticosteroids
No role (A.J.G. 1998, GI Endoscopy 2002
May) Gabexate i risk of AP (NEJM 1996)
5
Somatostatin and octreotide
Potent suppressors of pancreatic
secretions Conflicting results, probably because
of small numbers studied, therefore low
statistical power
6
Trials using Somatostatin for preventing
pancreatic injury after ERCP
7
Prophylactic effect of Somatostatin on post ERCP
Pancreatitis randomized controlled trial

• The elevations of amylase, lipase in patients who
  develop AP was similar to those who just develop
  ? enzymes
• The clinical AP so developed was mild, recovery
  was uncomplicated amylase ? to normal in 3 days
• Similar result with one bolus inj. of
  somatostatin
• AP ? sig in ES ERCP 18 vs 0 plt0.05
  
• NS difference in ERCP gr. 6 vs 4

Bordas et al, GI Endoscopy 1998
8
Pharmacological treatment can prevent pancreatic
injury after ERCP a meta - analysis
Angelo Andriulli , GI Endoscopy 2000
9
Clinical trials Somatostatin for preventing
pancreatic injury after ERCP-I
10
Clinical trials Somatostatin for preventing
pancreatic injury after ERCP-II
11
Clinical trials Octreotide for preventing
pancreatic injury after ERCP - I
minutes, before(b) or after(a)
12
Clinical trials Octreotide preventing pancreatic
injury after ERCP - II
minutes, before(b) or after(a)
13
Pharmacological treatment can prevent pancreatic
injury after ERCP a meta - analysis
Andriulli A, GI Endoscopy 2000
14
Pharmacological treatment can prevent pancreatic
injury after ERCP a meta - analysis
Andriulli A, GI Endoscopy 2000
15
Pharmacological treatment can prevent pancreatic
injury after ERCP a meta - analysis
Andriulli A, GI Endoscopy 2000
16
Somatostatin

• A bolus injection 250 mg at the time of
  cannulation
• - Short ½ life 1 2 min
• - Prolonged action 4 6 hours
• Practical for out patient procedures
• Equal reduction in AP if bolus / IV 24 infusion
• iv infusion - Start 30min before ERCP
• - Continue for 24 hrs
• gt Cost
• Hospitalization for all
• Not suited for out patients ERCP

17
Should all patients undergoing ERCP be given SS?

• No, because
• Severe AP is rare 5 / 210 2.4 (NEJM 1996)
• Most AP are mild uncomplicated
• May not be cost effective.

18
Should all patients undergoing ERCP be given SS?

• Yes, because
• All serious AP as complication not reported, not
  being part of a study
• Recent Danish report (Endoscopy 1999)
• Severe AP 20, - Death 7 National
  insurances registry
• Max suits against endoscopists for post ERCP AP
  23/39 claims
• Expertise ? i post ERCP complications
• i Expertise ? h attempts at cannulation,
  inadvertent PD cannulation, repeated PD
  injection of dye
• Even if given to high risk pts, we cant predict
• - Small CBD Size
• - Repeated CBD cannulation attempts
• - Repeated PD entry
• By new less experienced endoscopists

19
Why do all endoscopists not accept that
somatostatin is good prophylactic therapy?

• One or two equivocal studies reduce enthusiasm
• Somatostatin and octreotide are considered the
  same drugs, which is not true
• 5 Somatostatin receptors equal affinity for SS
  14, SS 28
• Variable affinity for octreotide
• Sphincter of Oddi somatostatin relaxes
• octreotide constricts, therefore
• more attempts at cannulation
• difficult cannulation

Binmoeller et al, 1992
20
Should prophylactic somatostatin be given for all
ERCPS ?

• Once cascade of initiation of AP starts by
  triggers, It is difficult to control it by post
  ERCP Rx of SS
• Recommendation for prophylactic somatostatin
• - Less experienced endoscopists ? all patients
• Experienced endoscopists ? use for high risk
  patients

21
Acute severe pancreatitis

• Acute pancreatitis is severe in 20 patients of
  all AP
• gt 40 early overall mortality
• gt Morbidity - SIRS
• - Infection in necrosis
• - Need for surgery
• - ARDS
• - Shock
• Can somatostatin prevent or mitigate the on going
  high morbidity ?

22
Clinical studies of somatostatin in acute
pancreatitis
23
Acute pancreatitis
M. Planas et al., Intensive Care Med (1998) 24
37-39
24
Acute pancreatitis
Mitrovic M et al, Br. J. Surgery 1998
25
Octreotide in acute pancreatitis conflicting
reports
26
Octreotide vs placebo in the prevention of post
ERCP acute pancreatitis Multi-center RCT

• Octreotide does not prevent post-ERCP AP or
  hospital stay
• Post ERCP AP 9.8 vs 13
• Hospital stay 3.6 days vs 4.3 days

S. Manolakopoulos, GI Endosc 2002
27
Meta-analysis of somatostatin-octreotide in the
therapy of acute pancreatitis

• In mild AP no agent proved of value
• In severe AP overall improvement in mortality
• Both SS OCT odds ratios
• 0.36 (95 CI 0.20 0.64, p0.02
• and 0.57 (95 CI 0.35 0.88, p0.006

- Complication - Complication rate Not
effected - Need for surgery
Andriulli, Aliment Pharmacol Ther. 1998
28
Somatostatin-octreotide in acute pancreatitis

• All studies published so far lack in the
  following points
• Not randomized controlled trials
• Only severe acute pancreatitis included
• Timing of start of S.S. / OCT
• All parameters of morbidity / mortality
• Recommendations present data shows that
• Somatostatin and octreotide reduce mortality
• Somatostatin reduces surgical interventions
• More studies are required to use these in
  patients of severe acute pancreatitis