Title: Journal reading Evaluation of Factors That Have Reduced Mortality From Acute Pancreatitis Over the P
1Journal reading Evaluation of Factors That Have
Reduced Mortality From Acute Pancreatitis Over
the Past 20 years
- Presenter ??? Instructor ???VS
2Authors
- Bank, Simmy M.D., F.R.C.P., F.A.C.G. Singh,
Pankaj M.D. Pooran, Nakechand M.D. Stark,
Bernard M.D. - From the Division of Gastroenterology, Albert
Einstein College of MedicineLong Island Jewish
Hospital, New York, New York. - Journal of Clinical Gastroenterology, Volume
35(1), July 2002, pp 50-60
3Background
- Reduced mortality rate of acute pancreatitis in
recent 20 years
4Goals
- Investigate the reasons for the reduction in
mortality.
5Study
- 20-year prospective assessment of mortality as it
relates to the severity of the disease,
compications and current therapy. - Divided into four 4-year periods
6Mortality changes
- Over all 10 to 15 ? 4 to 7
- Severe 15 to 90 ? 20 to 50
- Scottish study 67 of the deaths occurred within
the first week - Most common causes of deathinfective necrosis,
GI bleeding, abscess or cyst formation
7FACTORS THAT HAVE REDUCED MORTALITY FROM ACUTE
PANCREATITIS OVER THE PAST 20 YEARS
- 1. Recognition and use of the severity signs to
direct the place, timing, and type of therapy - 2. Improvement in intensive care unit (ICU) care
of patients with respiratory insufficiency - 3. Computed tomography (CT) scan
- 4. Recognition and treatment of the etiology
- 5. Newer antibiotics
- 6. Treatment of complications
- 7. Infective necrosis and fine-needle aspiration
(FNA) - 8. Treatment of cysts
- 9. Gastrointestinal bleeding
- 10. Ascites, pleural effusion, pericarditis
8RECOGNIZING AND USING SIGNS OF SEVERITY
- Ransons signs
- Biochemically oriented
- Severity assessed at 48 hours
- Sensitivity and specificity 80 to 85
- Require age adjustment for gallstones, hepatic
dysfunction, ascites and renal impairment
9Ranson criteria
10Imries Glasgow classification
Interpretation minimum score 0 maximum score
8 If the score gt3 severe pancreatitis
likely. If the score lt 3 severe pancreatitis is
unlikely.
11RECOGNIZING AND USING SIGNS OF SEVERITY
- Banks clinical criteria
- Clinically oriented.
- Sign or organ dysfunction out sie the abdomen
12Banks clinical criteria
13RECOGNIZING AND USING SIGNS OF SEVERITY
- Balthazars score
- On contrast enhanced CT
- Poor correlation with Apache II score
14Balthazars score
15RECOGNIZING AND USING SIGNS OF SEVERITY
- Others
- CRP
- SIRS
- IL-6
- IL-8
- Pydidinium split product (5 hrs)
- Trypsinogen-activating peptite
- hemoconcentration
16RECOGNIZING AND USING SIGNS OF SEVERITY
- Improved ICU care or the use of severity signs
contributed significantly to a reduction in
mortality associated with acute pancreatitis?
17FACTORS THAT HAVE REDUCED MORTALITY FROM ACUTE
PANCREATITIS OVER THE PAST 20 YEARS
- 1. Recognition and use of the severity signs to
direct the place, timing, and type of therapy - 2. Improvement in ICU care of patients with
respiratory insufficiency - 3. CT scan
- 4. Recognition and treatment of the etiology
- 5. Newer antibiotics
- 6. Treatment of complications
- 7. Infective necrosis and FNA
- 8. Treatment of cysts
- 9. Gastrointestinal bleeding
- 10. Ascites, pleural effusion, pericarditis
18CT
- Early CT ( within 48 72 hours) has more or less
the same specificity and sensitivity as Ranson or
Bank - Contrast aggravate pancreatitis and sequelae
19FACTORS THAT HAVE REDUCED MORTALITY FROM ACUTE
PANCREATITIS OVER THE PAST 20 YEARS
- 1. Recognition and use of the severity signs to
direct the place, timing, and type of therapy - 2. Improvement in ICU care of patients with
respiratory insufficiency - 3. CT scan
- 4. Recognition and treatment of the etiology
- 5. Newer antibiotics
- 6. Treatment of complications
- 7. Infective necrosis and FNA
- 8. Treatment of cysts
- 9. Gastrointestinal bleeding
- 10. Ascites, pleural effusion, pericarditis
20Assessment of etiology
- alcohol
- Gallstones
- ERCP
- Idiopathy
- Hyperlipidemia
- Post-operation
- Afferent loop obstruction
- Duodenal Crohns disease, parathion poisoning
- Hypercalcemia
21THE ROLE OF EARLY ERCP IN ACUTE PANCREATITIS
- Urgent ERCP
- Cholangitis associated with pancreatitis
- Severity signs change from mild to severe
- Elective ERCP
- Indirect evidence of stone exists
- Clearly indicated in
- Stone identified at the ampulla
22MEDICAL MANAGEMENT OF ACUTE PANCREATITIS
- Antibiotics
- Nutrition support
- Newer drugs
23Antibiotics
- Start antibiotics with severe attacks, esp. if
the CT shows 30 necrosis. - Antibiotics penetrating pancreatic tissue and to
sterilize the gut to prevent bacterial
translocation - Imipenem
- Ciprofloxacin
- metronidazole,
- Bacitracin
- Reduction mortality among patients with septic
complications receiving prophylactic antibiotics.
24Antibiotics
- Alcohol increases intestinal macrophage
apoptosis, macrophage-activating factors - Use, timing, type, /- ampho-B, diflucan?
- All acute necrotizing patients should be given
prophylaxis with an antibiotic.
25Nutritional Support
- IV hydration with dextran and NG suction during
an attack of acute pancreatitis. - Prolonged attack (3 5 days) ?
- TPN
- increase the incidence of infection
- Enteral feeding
- maintains the integrity of the mucosa
- Preventing bacterial translocation to the
necrotic pancreas
26Nutritional Support
- Jejunal feeding
- route of choice
- NG elemental diets feeding
- May do the same job
27Newer Drugs
- diets, bile injection, cholecystokinin
stimulation, cerulin stimulation, and ischemic
shock - proglumide, octreotide, gabexate, IL-10 and newer
cytokines, steroids, aprotonin - IL-10 vasodilators, dextran, and possibly
antioxidants
28Complications
- Infected and Sterile Necrosis
- Cyst Formation
- Gastrointestinal Hemorrhage
29Infected and Sterile Necrosis
- FNA timing ?
- Surgical or nonsurgical management of sterile
necrosis - Early recognition of infected necrosis
30Cyst Formation
- Formation result from
- liquefaction of an intra-or extrapancreatic fluid
collection - direct disruption of a duct, with a high-enzyme
pancreatic juice collection, which may
communicate with the ductal system - Important factors
- early recognition,
- careful radiologic follow-up evaluation
- timely drainage of cysts
31Gastrointestinal Hemorrhage
- Mechanisms
- splenic vein compression
- bleeding from short gastric vessels
- erosions of an abscess or cyst into the gastric
duodenal, colonic, or retroperitoneal vessels - bleeding from a preformed cyst from erosion of
vessels in the cyst wall - aneurysm formation of major vessels (e.g.,
splenic, pancreatic, or duodenal) - pressure ulcers in the stomach
- portal hypertension resulting from cyst
compression of the portal vein
32CONCLUSION
- importance the factors most responsible for the
improved prognosis - 1. Improved technology for the diagnosis and
treatment of complications. - 2. Advances in antibiotic therapy, with 3rd- and
4th-generation antibiotics and the recognition of
fungal overgrowth and its therapy - 3. Advances in ICU care
- 4. Urgent ERCP for associated cholangitis or
increasing severity scores esp. if CBD stone can
be documented by sonography and laboratory tests.
- 5. Tailored surgery for sterile necrosis
- 6. Improved nutritional support by the enteral
route