Journal reading Evaluation of Factors That Have Reduced Mortality From Acute Pancreatitis Over the P

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Journal reading Evaluation of Factors That Have
Reduced Mortality From Acute Pancreatitis Over
the Past 20 years

• Presenter ??? Instructor ???VS

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Authors

• 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

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Background

• Reduced mortality rate of acute pancreatitis in
  recent 20 years

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Goals

• Investigate the reasons for the reduction in
  mortality.

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Study

• 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

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Mortality 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

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FACTORS 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

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RECOGNIZING 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

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Ranson criteria
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Imries 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.
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RECOGNIZING AND USING SIGNS OF SEVERITY

• Banks clinical criteria
• Clinically oriented.
• Sign or organ dysfunction out sie the abdomen

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Banks clinical criteria
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RECOGNIZING AND USING SIGNS OF SEVERITY

• Balthazars score
• On contrast enhanced CT
• Poor correlation with Apache II score

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Balthazars score
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RECOGNIZING AND USING SIGNS OF SEVERITY

• Others
• CRP
• SIRS
• IL-6
• IL-8
• Pydidinium split product (5 hrs)
• Trypsinogen-activating peptite
• hemoconcentration

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RECOGNIZING 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?

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FACTORS 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

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CT

• Early CT ( within 48 72 hours) has more or less
  the same specificity and sensitivity as Ranson or
  Bank
• Contrast aggravate pancreatitis and sequelae

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FACTORS 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

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Assessment of etiology

• alcohol
• Gallstones
• ERCP
• Idiopathy
• Hyperlipidemia
• Post-operation
• Afferent loop obstruction
• Duodenal Crohns disease, parathion poisoning
• Hypercalcemia

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THE 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

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MEDICAL MANAGEMENT OF ACUTE PANCREATITIS

• Antibiotics
• Nutrition support
• Newer drugs

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Antibiotics

• 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.

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Antibiotics

• 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.

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Nutritional 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

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Nutritional Support

• Jejunal feeding
• route of choice
• NG elemental diets feeding
• May do the same job

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Newer 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

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Complications

• Infected and Sterile Necrosis
• Cyst Formation
• Gastrointestinal Hemorrhage

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Infected and Sterile Necrosis

• FNA timing ?
• Surgical or nonsurgical management of sterile
  necrosis
• Early recognition of infected necrosis

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Cyst 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

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Gastrointestinal 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

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CONCLUSION

• 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