Acute Pancreatitis

Some important issues revisited

Dr Arth Shah, Resident, Dept of Surgery,
karamsad Medical college
Dr Manoj K Ghoda

M.D., M.R.C.P.

Consultant Gastroenterologist

22 years old male

Sudden onset of epigastric pain radiating to back
No significant past history
No drugs, no alcohol, no heavy meals
On examination:
In pain
Pulse 82/min, B.P.120/80
RR: 16/min, no cyanosis
Abdomen: Tenderness +, no guarding, No rigidity,
peristalses +

? Acute pancreatitis:
Issues:
1.
2.
3.
4.
5.
6.

Diagnosis
Defining various terminology
Assessing severity
Role of antibiotics
Role of nutrition
Role of surgery

? Acute pancreatitis: Diagnosis

Investigations
Blood
Amylase
Lipase

Diagnosis

Amylase

and lipase are the

cornerstone lab parameters for the
diagnosis.

"It is usually

not necessary to
measure both amylase and lipase
(3).

Diagnosis
Lipase may be preferable
It remains normal in some nonpancreatic
conditions that increase serum amylase
including macroamylasemia, parotitis, and
some carcinomas.
Lipase is thought to be more sensitive and
specific and superior to amylase[3, 4, 5]
In one large study, there were no patients
with pancreatitis who had an elevated
amylase with a normal lipase [5].

Diagnosis
Lipase starts to rise by 4-8 hours,

peaks in 24 hours and normalizes by

8- 14 days.

Amylase and Lipase

Higher the numerical value more

certain is the diagnosis.

Although

severe pancreatitis could

also exist without significant rise in
these enzymes.

Numerical value of these enzymes

have no prognostic value

neither they reflect severity

and

Diagnosis: Imaging
USG is cornerstone
CT
MR
EUS/ ERCP

100 acute pancreatitis.20%

severe= 20
20% of severe become infected= 4
Infection usually sets in 2nd week or
3rd week
Surgeons would want to delay
surgery till about 4 weeks
Infected necrosis will always be
clinically manifest
So why CT scan in first week ????

Issues:
Assessing severity at the bedside

Clinical features
Scoring systems

Clinical features useful in

assessing severity
Toxic Look
Severe pain
Persistent

tachycardia
Breathlessness
and Cyanosis
Sub-normal
temperature
Shock

Normal look
Mild pain
Normal Pulse rate
Normal Oxygen

saturation
Adequate urine
output
Flat and soft and
movable abdomen

Acute Necrotizing Pancreatitis

ACG Practice Guidelines

Bedside index of severity in acute

pancreatitis (BISAP) score
This calculator evaluates the following Clinical Criteria:
BUN >25 mg/dL (8.9 mmol/L)
Impairment of mental status with a Glasgow coma score <15
SIRS (systemic inflammatory response syndrome)
Age >60 years old
Pleural effusion

Each determinant is given one point

The MedCalc 3000 module Bedside index of severity in acute pancreatitis (BISAP) score is available in MedCalc 3000 Complete Edition.

SIRS is defined as 2 or more of the following variables;

Fever of more than 38C (100.4F) or less than 36C (96.8F)
Heart rate of more than 90 beats per minute
Respiratory rate of more than 20 breaths per minute or arterial carbon dioxide tension (PaCO 2) of less than 32mm Hg
Abnormal white blood cell count (>12,000/L or < 4,000/L or >10% immature [band] forms)

BISAP Score
BISAP Score Observed Mortality
0
0.1%
1
0.4%
2
1.6%
3
3.6%
4
7.4%
5
9.5%
Wu et al, Gut 2008

BISAP scores of 3 predict the development of organ failure, persistent

organ failure, and necrosis in the prospective cohort of 397 cases
A Prospective Evaluation of the Bedside Index for Severity in Acute Pancreatitis Score in Assessing Mortality and Intermediate Markers of Severity in
Acute Pancreatitis
Vikesh K Singh, Bechien U Wu, Thomas L Bollen, Kathryn Repas, Rie Maurer, Richard S Johannes, Koenraad J Mortele, Darwin L Conwell and Peter A Banks. Am L Gastroenterol

BISAP<3

BISAP>3

OR (95%
CI)

Organ
failure

23

7.4

<0.0001

Persistent
OF

21

12.7

<0..0001

Necrosis

12

34

3,8

0.0004

Comparison of BISAP, Ranson's, APACHE-II, and CTSI scores in predicting organ

failure, complications, and mortality in acute pancreatitis.
Papachristou GI, Muddana V, Yadav D, O'Connell M, Sanders MK, Slivka A, Whitcomb DC. Am J Gastroenterol. 2010 Feb;105(2):435-41; quiz 442. doi:
10.1038/ajg.2009.622. Epub 2009 Oct 27

CONCLUSIONS:
BISAP score is an accurate means for risk
stratification in patients with AP.
Its components are clinically relevant and
easy to obtain.
The prognostic accuracy of BISAP is similar to
those of the other scoring systems.

Acute Pancreatitis
Issue:
Definitions of various disease
determinants

Classification of acute pancreatitis--2012:

Revision of the Atlanta classification and definitions by

international consensus.
Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, Tsiotos GG, Vege SS; Acute Pancreatitis Classification Working Group.
Gut. 2013 Jan;62(1):102-11. doi: 10.1136/gutjnl-2012-302779. Epub 2012 Oct 25

Determinants of revised Atlanta

classification
Local
Pancreatic or peripancreatic fluid collection
Sterile
Infected
Necrosis
Sterile
Infected

Pseudocyst and walled-off necrosis (sterile or

infected).

Organ failure

Local Complications

After 4
weeks

Local Complications

Infectio
n

Revised Atlanta......
Acute pancreatitis identified two phases of the disease:

early and late.

Severity is classified as mild, moderate or severe.
Mild:

the most common form,

has no organ failure, local or systemic complications and
usually resolves in the first week.

Moderate:

Presence of transient organ failure, local complications or

exacerbation of co-morbid disease.

Severe:

Persistent organ failure >48 h.

Local complications are peripancreatic fluid collections, pancreatic
and peripancreatic necrosis (sterile or infected),

Objections to revised Atlanta

classification
Mere presence of fluid or necrosis do not determine the outcome
It is the infection that determines the outcome
A number of studies have demonstrated that infectious

(peri)pancreatic complications (IPCs), rather than the presence

of necrosis per se, are a key determinant of the high morbidity
and mortality in patients with acute pancreatitis. (Bchler MW, Gloor B, Mller
CA et al. Acute necrotizing pancreatitis: treatment strategy according to the status of infection. Ann Surg 2000;232:619
626. | Article | PubMed | ISI | ChemPort |Lytras D, Manes K, Triantopoulou C et al. Persistent early organ failure: defining
the high-risk group of patients with severe acute pancreatitis? Pancreas 2008;36:249254. | Article | PubMed) ,Le Me J,
Paye F, Sauvanet A et al. Incidence and reversibility of organ failure in the course of sterile or infected necrotizing
pancreatitis. Arch Surg 2001;136:13861390. | Article | PubMed

Mere organ failure does not determine the outcome

It is the rapidity, the severity, reversibility and number of organs

affected that determines the outcome (5,6,7,8,9)

Determinant-based classification
of acute pancreatitis severity: an
international multidisciplinary
consultation
.

Dellinger EP, Forsmark CE, Layer P, Lvy P, Marav-Poma E, Petrov MS, Shimosegawa T, Siriwardena AK
, Uomo G, Whitcomb DC, Windsor JA;
Pancreatitis Across Nations Clinical Research and Education Alliance (PANCREA). Ann Surg. 2012
Dec;256(6):875-80. doi: 10.1097/SLA.0b013e318256f778

The presence of one determinant can modify

the effect of another such that the presence of

both infected (peri)pancreatic necrosis and
persistent organ failure have a greater effect
on severity than either determinant alone.
The derivation of a classification based on the
above principles results in 4 categories of
severity-mild, moderate, severe, and critical.

Critical Pancreatitis

Acute Pancreatitis: Management

Issue
Fluid replacement
Vigorous hydration to optimize outcomes has been increasingly

recognized.
The ACG guidelines stress, Patients with evidence of significant
third-space losses require aggressive fluid resuscitation.
Many patients sequester substantial amounts of fluid into the
retroperitoneal space, producing very high fluid requirements.
Intravascular volume depletion may lead to tachycardia,
hypotension, renal failure, hemoconcentration, and generalized
circulatory collapse.
More than 6 L of fluid sequestration within the first 48 hours is
considered a marker of increased severity, according to the
Ranson criteria

Acute Pancreatitis:
Issues:
Antibiotics
Time frame:
Severe pancreatitis can be observed in 1520 % of all
cases.
The first two weeks after onset of symptoms are
characterized by the systemic inflammatory response
syndrome (SIRS).
Pancreatic necrosis develops within the first 4 days after the
onset of symptoms to its full extent,
Infection of pancreatic necrosis develops most
frequently in the 2nd and 3rd week

Acute pancreatitis and antibiotics:

Cochrane Review
Objectives:
To determine the efficacy and safety of
prophylactic antibiotics in acute pancreatitis
complicated by CT proven pancreatic necrosis.

Main results:
Seven evaluable studies randomised 404 patients.
No statistically significant effect on reduction of

mortality with therapy: 8.4% versus controls 14.4%,

and infected pancreatic necrosis rates: 19.7% versus
controls 24.4%.
Nonpancreatic infection rates and the incidence of
overall infections were not significantly reduced with
antibiotics: 23.7% versus 36%; 37.5% versus 51.9%
respectively.
Operative treatment and fungal infections were not
significantly different. Insufficient data were provided
concerning antibiotic resistance.

With betalactam antibiotic prophylaxis there

was less mortality (9.4% treatment, 15%

controls), and less infected pancreatic necrosis
(16.8% treatment group, 24.2% controls) but
this was not statistically significant.
The
incidence
of
nonpancreatic
infections was nonsignificantly different
(21% versus 32.5%), as was the incidence of
overall infections (34.4% versus 52.8%), and
operative treatment rates.

No significant differences were seen with

quinolone plus imidazole in any of the end

points measured.
Imipenem on its own showed no difference in
the incidence of mortality, but there was a
significant reduction in the rate of pancreatic
infection (p=0.02; RR 0.34, 95% CI 0.13 to
0.84)

Authors' conclusions:
No benefit of antibiotics in preventing
infection of pancreatic necrosis or mortality
was found, except for when imipenem (a beta
lactam) was considered on its own, where a
significantly decrease in pancreatic infection
was found.
None of the studies included in this review
were adequately powered. Further better
designed studies are needed if the use of
antibiotic prophylaxis is to be recommended

Acute Pancreatitis
Issue:
Other pathogenesis inhibiting drugs
To date, inhibition of any known pathogenetic
step (that is, octreotide, gabexate mesilate,
lexipafant) has not effectively reduced
mortality or increased long term survival in
severe acute pancreatitis.8,2830

Acute Pancreatitis
Issues:
Nutrition

Background facts..
Nutritional management during acute pancreatitis has
the purpose to avoid a negative influence on the outcome and to
preserve the morphofunctional integrity of the gut,
preventing bacterial translocation.
Preventing SIRS
When the course of the disease is longer and the severity is

higher, an early artificial nutritional support is advisable.

Caloric needs thought to be useful are 25-30 kcal/kg/d;
40-60% of nutrient mixture should consist of carbohydrates and
20-30% of lipids. Proteins should be approximately 1.0-1.5 g/kg/d
McClave SA, Chang WK, Dhaliwal R, Heyland DK. Nutrition support in acute pancreatitis: a
systematic review of the literature. JPEN J Parenter Enteral Nutr. 2006 Mar-Apr;30(2):143-56.

Fears.
Enteral

diets stimulate enzyme secretion

unless delivered below the jejunum.

Nutrition in Acute pancreatitis

Enteral versus parenteral nutrition for acute
pancreatitis. Cochrane Review.
Cochrane Database Syst Rev. 2010 Jan 20;(1):CD002837. doi: 10.1002/14651858.CD002837.pub2.
Al-Omran M, Albalawi ZH, Tashkandi MF, Al-Ansary LA.
Intern Med. 2012;51(6):523-30. Epub 2012 Mar 15.

Meta-analysis: total parenteral nutrition versus total enteral nutrition in predicted severe acute pancreatitis.
Yi F, Ge L, Zhao J, Lei Y, Zhou F, Chen Z, Zhu Y, Xia B

Objectives:
To compare the effect of TPN versus EN on
mortality, morbidity and length of hospital
stay in patients with acute pancreatitis.

Main results:
Eight trials with a total of 348 participants were included.
Comparing EN to TPN for acute pancreatitis,
the relative risk (RR) for death was 0.50 (95% CI 0.28 to

0.91),
for multiple organ failure (MOF) was 0.55 (95% CI 0.37 to
0.81),
for systemic infection was 0.39 (95% CI 0.23 to 0.65),
for operative interventions was 0.44 (95% CI 0.29 to 0.67),
for local septic complications was 0.74 (95% CI 0.40 to
1.35), and
for other local complications was 0.70 (95% CI 0.43 to
1.13).

Mean length of hospital stay was reduced by

2.37 days in EN vs TPN groups (95% CI 7.18

to 2.44).
Furthermore, a subgroup analysis for EN vs
TPN in patients with severe acute pancreatitis
showed a RR for death of 0.18 (95% CI 0.06 to
0.58) and a RR for MOF of 0.46 (95% CI 0.16
to 1.29).

Authors' conclusions:
In patients with acute pancreatitis, enteral

nutrition significantly reduced mortality,

multiple organ failure, systemic infections,
and the need for operative interventions
compared to those who received TPN.
In addition, there was a trend towards a
reduction in length of hospital stay.
These data suggest that EN should be
considered the standard of care for patients
with acute pancreatitis requiring nutritional
support.

Nutrition Support in Acute Pancreatitis: A

Systematic Review of the Literature

Stephen A. McClave, Wei-Kuo Chang, Rupinder Dhaliwal, Daren K. Heyland,

JPEN J Parenter Enteral Nutr MARCH-APRIL 2006 vol. 30 no. 2 143-156 doi: 10.1177/0148607106030002143

Patients with acute severe pancreatitis should

begin EN early because such therapy modulates

the stress response, promotes more rapid
resolution of the disease process, and results in
better outcome.
In this sense, EN is the preferred route and has
eclipsed PN as the new gold standard of
nutrition therapy. When PN is used, it should be
initiated after 5 days.
Individual variability allows for a wide range of
tolerance to EN, even in severe pancreatitis

Nutrition in AP: NG or NJ?

CONTEXT: Nasogastric tube feeding is safe

Nasogastric tube feeding in predicted severe acute pancreatitis. A systematic review of the literature to determine safety and tolerance.
Petrov MS, Correia MI, Windsor JA. JOP. 2008 Jul 10;9(4):440-8.

and well tolerated in most critically ill

patients. However, its safety and tolerance in
the setting of severe acute pancreatitis is
debatable.
OBJECTIVE: to review all available studies on
nasogastric feeding in patients with severe
acute pancreatitis to determine the safety and
tolerance of this approach. A further aim was
to perform a meta-analysis of the available
randomized
controlled
trials
regarding
nasogastric versus nasojejunal feeding.

RESULTS:
A total of four studies on nasogastric tube feeding

in 92 patients with predicted severe acute

pancreatitis were identified.
Documented infected pancreatic necrosis
developed in 11 patients (16.9%) and multiple
organ failure in 10 (15.4%) out of 65 patients with
available data.
Overall, there were 15 deaths (16.3%).
An exacerbation of pain after initiation of feeding
occurred in 3 (4.3%) out of 69 patients with
available data.
Full tolerance was achieved in 73 (79.3%) patients

CONCLUSION:
Nasogastric feeding appears safe and

well tolerated in patients with predicted

severe acute pancreatitis.
An adequately powered randomized trial on
nasogastric versus nasojejunal feeding is
required to support this approach as routine
clinical management.

Nasogastric or nasointestinal feeding in severe acute

pancreatitis.
Piciucchi M, Merola E, Marignani M, Signoretti M, Valente R, Cocomello L, Baccini F, Panzuto F, Capurso G, Delle Fave G.
World J Gastroenterol. 2010 Aug 7;16(29):3692-6.

AIM:
To assess the rate of spontaneous tube migration and to
compare the effects of naso-gastric and naso-intestinal (NI)
(beyond the ligament of Treitz) feeding in severe acute
pancreatitis (SAP).
CONCLUSION:
Spontaneous distal tube migration is successful in 40% of
SAP patients, with higher CT severity index predicting
intragastric retention;
In such cases EN by NG tubes seems to provide a pragmatic

alternative opportunity with similar outcomes

Nutritional strategies in severe acute pancreatitis: A

systematic review of the evidence.
Ahmad Al Samaraee, Iain J.D. McCallum, Peter E. Coyne, Keith Seymour
The Surgeon; Volume 8, Issue 2 , Pages 105-110, April 2010

Evidence supports nasojejunal enteral nutrition (NJ-EN) over parenteral

nutrition (PN) reducing infectious morbidity and showing a trend towards

reduced organ failure although there is no detectable difference in mortality.
NJ-EN is safe when started immediately (level 3 evidence). NJ-EN is often
impractical and naso-gastric (NG) feeding seems to be equivalent in terms of
safety and outcomes whilst being more practical (level 2 evidence).
Regarding feed supplementation, probiotic feed supplementation is not beneficial
(level 1 evidence) the and may cause harm with excess mortality (level 2
evidence).
No evidence exists to confirm benefit of the addition of prokinetics in severe
acute pancreatitis (SAP) although their use is proven in other critically ill
patients.
Level 2 evidence does not currently support the use of combination immunonutrition though further work on individual agents may provide differing results.
Level 2 evidence does not support intravenous supplementation of anti-oxidants
and has demonstrated that these too may cause harm

Timing of NG
feedingtube feeding versus nil
Early nasogastric
per os in mild to moderate acute
pancreatitis: A randomized controlled trial.
Petrov MS, McIlroy K, Grayson L, Phillips AR, Windsor JA. Clin Nutr. 2012 Dec 31. pii: S0261-5614(12)00284-1. doi:
10.1016/j.clnu.2012.12.011

BACKGROUND & AIMS:

Nasojejunal tube feeding is a standard of care in
patients with predicted severe acute pancreatitis (AP)
and several recent trials suggested that nasogastric
tube feeding (NGT) is as safe and efficient as
nasojejunal tube feeding in these patients. The aim
was to investigate whether NGT presents any benefit
to patients with mild to moderate AP.

Early NGT feeding in acute

pancreatitis...contd
METHODS:
The study design was a randomized controlled trial. The patients
in the intervention group received NGT within 24 h of hospital
admission. The patients in the control group were on nil per os
(NPO). The severity of acute pancreatitis was determined
according to the new international multidisciplinary classification.
CONCLUSIONS:
NGT commenced within 24 h of hospital admission is well
tolerated in patients with mild to moderate acute
pancreatitis.
Further, when compared with NPO, it significantly reduces
the intensity and duration of abdominal pain, need for
opiates, and risk of oral food intolerance, but not overall
hospital stay

Acute Pancreatitis
Issues:
Intervention in form of ERCP

Timing and need for

ERCP
Objectives:
To systematically review evidence from randomized
controlled trials (RCTs) assessing the clinical
effectiveness and safety of the early routine ERCP
strategy compared to the early conservative
management with or without selective use of ERCP
strategy, based on all important, clinically relevant
and standardized outcomes including mortality, local
and systemic complications as defined by the Atlanta
Classification (Bradley 1993) and by authors of the
primary study, and ERCPrelated complications in
unselected patients with acute gallstone pancreatitis

Selection criteria:
RCTs

comparing the early routine ERCP

strategy versus the early conservative
management with or without selective use of
ERCP strategy in patients with suspected
acute gallstone pancreatitis.
Included studies in which the population with
acute gallstone pancreatitis was a subgroup
within a larger group of patients.
Only included studies involving only a
selected subgroup of patients with acute
gallstone
pancreatitis
(actual
severe
pancreatitis) in subgroup analyses.

Main results:
Five RCTs comprising 644 participants were included in the

main analyses.
Two additional RCTs, comprising only patients with actual
severe acute gallstone pancreatitis, were included only in
subgroup analyses.
In unselected patients with acute gallstone pancreatitis,
there were no statistically significant differences between
the two strategies in mortality (RR 0.74, 95% CI 0.18 to
3.03), local and systemic complications as defined by the
Atlanta Classification (RR 0.86, 95% CI 0.52 to 1.43; and
RR 0.59, 95% CI 0.31 to 1.11 respectively) and by authors
of the primary study (RR 0.80, 95% CI 0.51 to 1.26; and RR
0.76, 95% CI 0.53 to 1.09 respectively).

Among

trials that included patients with

cholangitis, the early routine ERCP strategy
significantly reduced mortality (RR 0.20, 95%
CI 0.06 to 0.68), local and systemic
complications as defined by the Atlanta
Classification (RR 0.45, 95% CI 0.20 to 0.99;
and RR 0.37, 95% CI 0.18 to 0.78 respectively)
and by authors of the primary study (RR 0.50,
95% CI 0.29 to 0.87; and RR 0.41, 95% CI 0.21
to 0.82 respectively).

Among trials that included patients with biliary

obstruction, the early routine ERCP strategy was

associated with a significant reduction in local
complications as defined by authors of the primary
study (RR 0.54, 95% CI 0.32 to 0.91), and a non
significant trend towards reduction of local and
systemic complications as defined by the Atlanta
Classification (RR 0.53, 95% CI 0.26 to 1.07; and RR
0.56, 95% CI 0.30 to 1.02 respectively) and systemic
complications as defined by authors of the primary
study (RR 0.59, 95% CI 0.35 to 1.01). ERCP
complications were infrequent

Authors' conclusions:
In patients with acute gallstone pancreatitis,

there is no evidence that early routine ERCP

significantly affects mortality, and local or
systemic
complications
of
pancreatitis,
regardless of predicted severity.
Our results, however, provide support for
current recommendations that early ERCP
should be considered in patients with co
existing cholangitis or biliary obstruction

Emergency ERCP in AP
In persistent and severe biliary pancreatitis,

when an obstructing gallstone lodged at the

ampulla of Vater

Acute Pancreatitis
Issue:
Surgery/Removal of
necrosis

sterile or infected

Any role of early

Surgery?
Except in the unusual situation of fulminating acute

pancreatitis with organ failure and a rapidly progressive

downhill course soon after admission to the hospital,
most patients should not undergo operation during the
first week of their illness.
When clinical deterioration is rapid and surgery is
undertaken during the first week, these patients have a
high mortality rate.
The outcome is better when surgery is postponed at
least until the second week or later, when the margins
of the pancreatic necrosis have become better defined,
and the acute inflammation has subsided somewhat.

Acute Pancreatitis
Issue: Surgery:
Background facts
More than 80% of deaths amongst patients
with acute pancreatitis are caused by infected
necrosis
Aggressive surgical treatment
required in
such cases
Patients with infected necrosis require
emergent surgery.

Common Organisms
Enteric Gram Negative organisms like E.coli
Gram positive organisms
Anaerobes
Fungal Infection is a late event usually

following prolonged antibiotic therapy

Daziel D J. Doolas A. Pancreatic abscess and pancreatic necrosis: current concepts and
controversies. Problems in General Surgery, vol 7 (3) pp 415-27. 1990

Diagnosis of infected
necrosis
Most reliably by CT or ultrasound-guided fine

needle aspiration (FNA) with Gram staining and

culture of the aspirate. The material should be
sent for bacterial and fungal culture.
Some patients with infection have only a low
grade fever and a WBC <15,000. Thus,
threshold must be low.
In a minority of patients, gas bubbles are
evident on the CT study in the area of the
pancreas. If this is found, FNA is unnecessary.

Surgical indications in acute

pancreatitis.

Haas B, Nathens AB. Curr Opin Crit Care. 2010 Apr;16(2):153-8. doi:

10.1097/MCC.0b013e328336ae88.)

Infected pancreatic necrosis remains the primary indication for

surgery in patients with acute pancreatitis.

Up to a quarter of patients with acute pancreatitis develop early
bacteremia and pneumonia, and assessment of patients for
surgery should include a thorough search for nonpancreatic
sources of infection.
Retroperitoneal, percutaneous and endoscopic approaches to
pancreatic debridement can be used with success in
appropriately selected critically ill patients.
All minimally invasive approaches to necrosectomy are
evolving, and there is currently insufficient evidence to
advocate one approach over another.
Management of patients with acute pancreatitis at high-volume
centers appears to be associated with a survival benefit.

Role of open necrosectomy in the

current management of Acute
Necrotizing Pancreatitis: A Review
Article

K. Vasiliadis, C. Papavasiliou, A.Al Nimer, N. Lamprou, C. Makridis. ISRN Surg. 2013;2013:579435. doi:
10.1155/2013/579435. Epub 2013 Jan 28

Contraindications for open necrosectomy [14, 17].

Pancreatic and/or peripancreatic necrosis without evidence of infection or

clinical deterioration
Early operation (within 1 week from onset of acute pancreatitis)

Role of Open...

(Vasiliadis contd)

Indications
and
timing
necrosectomy [14, 17].

for

open

The operation should be undertaken as late as possible, when

necroses have been ceased, viable and nonviable tissues are

well demarcated, and infected necrotic tissues are walled off.
Pancreatic and/or peripancreatic necrosis complicated by
documented infection (guided FNA culture or extraluminal
retroperitoneal gas)
Sterile necrosis:(a) Progressive clinical deterioration despite
maximal
medical
treatment(b)
Fulminant
acute
pancreatitis
Massive hemorrhage or hollow viscus perforation

Surgery in Acute Pancreatitis: Indications

other than Infected Necrosis.
1. When the patient's condition deteriorates,

often with the failure of one or more organ

systems even in sterile necrosis
2. To
drain
a
pancreatic
abscess,
if
percutaneous drainage does not produce the
desired result.

Cholecystectomy in Gall Stone

Pancreatitis

Timing of cholecystectomy after mild biliary

pancreatitis: a systematic review.

van Baal MC, Besselink MG, Bakker OJ, van Santvoort HC, Schaapherder AF, Nieuwenhuijs VB, Gooszen HG, van Ramshorst B, Boerma D
; Dutch Pancreatitis Study Group. Ann Surg. 2012 May;255(5):860-6. doi: 10.1097/SLA.0b013e3182507646.

Interval cholecystectomy (40 days) after mild

biliary pancreatitis is associated with a high risk of

readmission for recurrent biliary events, especially
recurrent biliary pancreatitis. Cholecystectomy
during index admission for mild biliary pancreatitis
appears safe, but selection bias could not be
excluded.

Timing of cholecystectomy after mild biliary pancreatitis.

Bakker OJ, van Santvoort HC, Hagenaars JC, Besselink MG, Bollen TL, Gooszen HG, Schaapherder AF;
Dutch Pancreatitis Study Group . Br J Surg. 2011 Oct;98(10):1446-54. doi: 10.1002/bjs.7587. Epub 2011 Jun 27

Between

2004 and 2007, patients with acute

pancreatitis were registered prospectively in 15 Dutch
hospitals. Patients with mild biliary pancreatitis were
candidates for cholecystectomy. Recurrent biliary
events requiring admission before and after
cholecystectomy,
and
after
endoscopic
sphincterotomy (ES), were evaluated.
CONCLUSION: A delay in cholecystectomy after mild
biliary pancreatitis carries a substantial risk of
recurrent biliary events. ES reduces the risk of
recurrent pancreatitis but not of other biliary events
.

Cholecystectomy in Gall Stone

Pancreatitis
In

mild
gallstone-associated
acute
pancreatitis, cholecystectomy should be
performed as soon as the patient has
recovered and ideally during the same
hospital admission.
In
severe
gallstone-associated
acute
pancreatitis, cholecystectomy should be
delayed until there is sufficient resolution of
the inflammatory response and clinical
recovery.

Summary: Surgery in
Acute Pancreatitis
Bchler MW, Gloor B, Mller CA et al. Acute necrotizing pancreatitis: treatment strategy according to the status of
infection. Ann Surg 2000;232:619626. | Article | PubMed | ISI | ChemPort |
Lytras D, Manes K, Triantopoulou C et al. Persistent early organ failure: defining the high-risk group of patients with
severe acute pancreatitis? Pancreas 2008;36:249254. | Article | PubMed
Le Me J, Paye F, Sauvanet A et al. Incidence and reversibility of organ failure in the course of sterile or infected
necrotizing pancreatitis. Arch Surg 2001;136:13861390. | Article | PubMed

Summary
Mild acute pancreatitis is not an indication

for pancreatic surgery.

Infected pancreatic necrosis in patients

with clinical signs and symptoms of sepsis

is an indication for intervention including
surgery and radiological drainage.

Summary
Patients with sterile pancreatic necrosis should be managed

conservatively and only undergo intervention in selected cases.

Minimally invasive approach to necrosectomy is expected to
play a significant role in a selected group of patients
Surgical and other forms of interventional management should
favor
an
organ-preserving
approach,
which
involves
debridement or necrosectomy combined with a postoperative
management concept that maximizes postoperative evacuation
of retroperitoneal debris and exudate.
Cholecystectomy should be performed to avoid recurrence of
gallstone-associated acute pancreatitis.
ES is alternative to cholecystectomy but there is a theoretical
risk of introducing infection into sterile pancreatic necrosis.

Thanks
Dr Arth Shah Dr Manoj K Ghoda

Acute Pancreatitis
Revisited

SAP
SAP is defined by the Atlanta classification as

an

AP

with

local

and/or

systemic

complications[

Bradley EL 3rd. A clinically based classification system for acute

pancreatitis. Summary of the International Symposium on Acute Pancreatitis, Atlanta, Ga, September 11
through 13, 1992. Arch Surg. 1993;128:586590.]

Some

patients
develop
pancreatitisassociated organ failure during the early
phase of the SAP [Stanten R, Frey CF. Comprehensive management of acute
necrotizing pancreatitis and pancreatic abscess. Arch Surg. 1990;125:12691274; discussion 12741275.].

Severe Acute Pancreatitis

Clinical features and

Diagnosis

and

Its Interpretation

Diagnosis of Severity
C reactive Protein:
Together with both amylase and lipase,
often provides a precise picture of the
clinical situation (Del Prete M et al.)
C-reactive protein (cut-off of 150 mg/L) is a
useful indicator of necrosis with a
sensitivity and specificity of 80%
It is required to be measured more than 48 h
after the onset of symptoms [Dervenis C, Johnson CD, Bassi C,
Bradley E, Imrie CW, McMahon MJ, Modlin I. Diagnosis, objective assessment of severity, and
management of acute pancreatitis. Santorini consensus conference. Int J Pancreatol. 1999;25:195
210. ].

Diagnosis of Severity
Urinary

trypsinogen activation
peptide (TAP),
Serum and urinary trypsinogen
[Hirano T, Manabe T. A possible mechanism for gallstone pancreatitis: repeated short-term pancreaticobiliary
duct obstruction with exocrine stimulation in rats. Proc Soc Exp Biol Med. 1993;202:246252., Lempinen M,
Stenman UH, Finne P, Puolakkainen P, Haapiainen R, Kemppainen E. Trypsinogen-2 and trypsinogen activation
peptide (TAP) in urine of patients with acute pancreatitis. J Surg Res. 2003;111:267273. ]

But these are less widely available.

Diagnosis of Severity
Urinary

trypsinogen-2
is
comparable
diagnostic accuracy, and provides greater
(99%) negative predictive value.
The novel serum markers procalcitonin and
interleukin 6 allow earlier prediction (12 to 24
hours after admission) of severity. [Papachristou GI,
Papachristou DJ, Avula H, Slivka A, Whitcomb DC. Obesity increases the severity of acute pancreatitis:
performance of APACHE-O score and correlation with the inflammatory response. Pancreatology.
2006;6:279285.],

Serum

interleukins-6
and
-8
and
polymorphonuclear elastase at 24 h after
admission. [Rau BM. Predicting severity of acute pancreatitis. Curr Gastroenterol Rep.
2007;9:107115. ].

Other tests
61-80 % of patients show

leukocytosis with shift to the left.

54-82 % lymphopenia is noted.
Anemia
S. Bil, Urea, SGOT,LDH, Sugar,
Calcium, and ABG abnormal
Daily urine examination is helpful. In
urine
the
proteinuria,
a
microhematuria, and casts may be

Sequential organ failure assessment score (SOFA) .

SOFA: Sequential organ failure assessment,

Score
Organ system
involved
1

Cardiovascular

No hypotension

Respiratory
PaO2/FiO2
> 400
(mmHg)
Renal creatinine
< 100
(mol/L)
Neurological
glasgow coma 15
score
Haematological
platelet count > 150
( 109/L)
Hepatic bilirubin
< 20
(mol/L)

World J Gastroenterol. 2009 June 28; 15(24): 29452959. Published online 2009 June 28. doi: 10.3748/wjg.15.2945.

MAP < 70
mmHg

Dopamine or
dobutamine
(any dose)

Dopamine > 5
g/kg per min
or adrenaline
(epinephrine) <
0.1 g/kg per
min or
noradrenaline
(norepinephrine
) < 0.1 g/kg
per min

Dopamine < 0.1

g/kg per min
or > 15 g/kg
per min or
adrenaline >
0.1 g/kg per
min or
noradrenaline >
0.1 g/kg per
min

400-300

300-200

200-1001

1001

100-200

200-350

350-500

> 500

14-13

12-10

9-7

150-100

100-50

20-50

20

20-60

60-120

120-240

> 240

Modified multiple organ dysfunction score

Organ

system involved Score 1 2 3 4 5

Cardiovascular PAHR (beats/min) 10 10-15 30-15 20-30
> 30 Respiratory PaO2/FiO2 (mmHg) > 300 300-225 150225 75-150 < 75 Renal creatinine (mol/L) < 100 100200 200-350 350-500 > 500 Neurological glasgow coma
score 15 14-13 12-10 9-7 6 Hematological platelet
count ( 109/L) > 120 80-120 50-80 20-50 20 Hepatic
bilirubin (mol/L) < 20 20-60 60-120 120-240 > 240
PAHR: Pressure-adjusted heart rate [heart rate (right
atrial pressure/mean arterial pressure]; FiO 2: Fraction of
inspired oxygen.

World J Gastroenterol. 2009 June 28; 15(24): 29452959.

Published online 2009 June 28. doi: 10.3748/wjg.15.2945.

 Since the mortality in the presence of pancreatic necrosis

increases from 1% to 10%-23%, the importance of early

detection of pancreatic necrosis is not to be overlooked
[Balthazar EJ. Acute pancreatitis: assessment of severity with clinical and CT evaluation.
Radiology. 2002;223:603613. ].

Contrast-enhanced CT has been considered the gold

standard for the diagnosis of pancreatic necrosis [Ranson JH,

Balthazar E, Caccavale R, Cooper M. Computed tomography and the prediction of pancreatic abscess
in acute pancreatitis. Ann Surg. 1985;201:656665. Simchuk EJ, Traverso LW, Nukui Y, Kozarek RA.
Computed tomography severity index is a predictor of outcomes for severe pancreatitis. Am J Surg.
2000;179:352355. ].

Therefore, immediate assessment should include clinical

evaluation particularly of any cardiovascular, respiratory and

renal compromise, BMI, chest X-ray and different acute
diseases scores.
The presence of any single and/or multiple organ failure has
been increasingly recognized as an important variable for
predicting mortality from AP.
The most common organ dysfunction scores used for
critically ill patients are the Multiple Organ Dysfunction Score
(MODS) and the Sequential Organ Failure Assessment (SOFA)
[Vincent JL, de Mendona A, Cantraine F, Moreno R, Takala J, Suter PM, Sprung CL, Colardyn F, Blecher S. Use of
the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: results of a
multicenter, prospective study. Working group on "sepsis-related problems" of the European Society of Intensive
Care Medicine. Crit Care Med. 1998;26:1793800. Marshall JC, Cook DJ, Christou NV, Bernard GR, Sprung CL,
Sibbald WJ. Multiple organ dysfunction score: a reliable descriptor of a complex clinical outcome. Crit Care Med.
1995;23:16381652.] (Tables 3 and 4).

Although these scoring systems can help the

physician in a first assessment of the patient,

the most important distinction in terms of
prediction of severity is the presence of
severe manifestations of the disease such as
evidence of SIRS and presence of organ
failure.

Mofidi, in a recent retrospective study of 259

patients admitted with AP, showed that the

mortality rate was significantly higher in
patients who developed or had persistent SIRS
at 48 h after admission (25.4%) than in
patients who had transient SIRS (8%) or no
SIRS in the first 48 h (0.7%)[
Mofidi R, Duff MD, Wigmore SJ, Madhavan KK,

Garden OJ, Parks RW. Association between early systemic inflammatory response, severity of multiorgan dysfunction and death in
acute pancreatitis. Br J Surg. 2006;93:738744. .

Ransons Criteria
At admission
> 55 years
WCC > 16000 cells/mm3
blood glucose > 200 mg/dL)
serum AST > 250 IU/L
serum LDH > 350 IU/L

Acute pancreatitis graded with CT and CT severity index

table
Grade CT finding Points Necrosis Severity index
Percentage Additional points A Normal pancreas 0 0
0 0 B Pancreatic enlargement 1 0 0 1 C Pancreatic
inflammation and/or peripancreatic fat 2 < 30 2 4 D
Single peripancreatic fluid collection 3 30-50 4 7 E Two
or more fluid collections and/or retroperitoneal air 4 >
50 6 10
World J Gastroenterol. 2009 June 28; 15(24): 29452959.
Published online 2009 June 28. doi:
10.3748/wjg.15.2945.

Although CT is useful in detecting pancreatic necrosis, it is not able to

detect a super-infection of necrosis in the later stage of the disease unless

gas bubbles are seen within the necrotic area[Uhl W, Roggo A, Kirschstein
T, Anghelacopoulos SE, Gloor B, Mller CA, Malfertheiner P, Bchler MW.
Influence of contrast-enhanced computed tomography on course and
outcome in patients with acute pancreatitis. Pancreas. 2002;24:191
197. ].
Patients with persisting organ failure, or in whom new organ failure
develops, and in those with persisting pain and signs of sepsis, will require
evaluation by dynamic contrast enhanced CT. CT evidence of necrosis
correlates well with the risk of other local and systemic complications.
Since pancreatic necrosis commonly remains stable in appearance, a
follow-up CT scan at 3 to 4 wk is not normally considered[Vitellas KM,
Paulson EK, Enns RA, Keogan MT, Pappas TN. Pancreatitis complicated by
gland necrosis: evolution of findings on contrast-enhanced CT. J Comput
Assist Tomogr. 1999;23:898905. ].

Ransons Criteria
At 48 hours
Calcium < 8.0 mg/dL)
Hematocrit fall > 10%
Oxygen (hypoxemia PO2 < 60 mmHg)
BUN increased by 5 or more mg/dL) after
IV fluid hydration
Base deficit (negative base excess) > 4
mEq/L
Sequestration of fluids > 6 L

APACHE II score
Hemorrhagic peritoneal fluid
Obesity
Indicators of organ failure
Hypotension (SBP <90 mm HG) or

tachycardia > 130 beat/min

PO2 <60 mmHg
Oliguria (<50 mL/h) or increasing BUN and
creatinine
Calcium <8.0mg/dL or
Albumin <3.2.g/dL)

APACHE II score
Apache score of 8 Organ failure

Substantial pancreatic necrosis (at least

30% glandular necrosis according to
contrast-enhanced CT)
Interpretation If the score 3, severe
pancreatitis likely. If the score < 3,
severe pancreatitis is unlikely, Or
Score 0 to 2: 2% mortality Score 3 to 4:
15% mortality Score 5 to 6: 40%
mortality Score 7 to 8: 100% mortality

Diagnosis
Abdominal ultrasound:
Very popular and useful
High positive predictive value >95%
Moderate to high negative predictive
value, 85=90%

Diagnosis
Computerized tomography (CT) scan.
Positive predictive value, negative predictive
value, sensitivity and specificity as good as
USG
More useful for peripancreatic lesion and
Necrosis.

Diagnosis
Endoscopic ultrasound (EUS):
Excellent Mode
Comparable or superior to both CT and USG
Additional advantage of accurately visualizing
Lower CBD.
Useful for outlining the treatment

Diagnosis
MRCP / MRI
Comparable to CT
Use of Gadolinium may increase sensitivity
and specificity
No contrast related renal problems
Additional advantage of visualizing Biliary tree

Diagnosis
ERCP:
ERCP is usually used only in the presence of gallstones.
The benefits of ERCP with sphincterotomy (ES) has been studied in 3 randomized trials[Neoptolemos JP, CarrLocke DL, London NJ, Bailey IA, James D, Fossard DP. Controlled trial of urgent endoscopic retrograde
cholangiopancreatography and endoscopic sphincterotomy versus conservative treatment for acute
pancreatitis due to gallstones. Lancet. 1988;2:979983] and 2 meta-analyses[Petrov MS, van Santvoort HC,
Besselink MG, van der Heijden GJ, van Erpecum KJ, Gooszen HG. Early endoscopic retrograde
cholangiopancreatography versus conservative management in acute biliary pancreatitis without cholangitis:
a meta-analysis of randomized trials. Ann Surg. 2008;247:250257.]. Patients with predicted mild acute
biliary pancreatitis (ABP) in the absence of cholangitis have not shown benefits from an early ERCP.
The decision on management of patients with predicted severe ABP is still debatable. The most recent United
Kingdom guidelines recommend that urgent therapeutic ERCP should be performed within 72 h of admission
in all patients with predicted severe ABP, whether or not cholangitis is present[UK guidelines for the
management of acute pancreatitis. Gut. 2005;54 Suppl 3:iii1iii9.].
However, a recent meta-analysis by Petrov et al[Petrov MS, van Santvoort HC, Besselink MG, van der Heijden
GJ, van Erpecum KJ, Gooszen HG. Early endoscopic retrograde cholangiopancreatography versus
conservative management in acute biliary pancreatitis without cholangitis: a meta-analysis of randomized
trials. Ann Surg. 2008;247:250257. ] demonstrated that early ERCP with or without ES had no beneficial
effect in patients with predicted mild or severe ABP without cholangitis. The conclusion of this study was
partially supported by the 2007 guidelines of the American Gastroenterology Association which stated that
early ERCP in patient with severe ABP without signs of acute cholangitis is still not uniformly accepted in the
literature[Forsmark CE, Baillie J. AGA Institute technical review on acute pancreatitis. Gastroenterology.
2007;132:20222044. ].

Diagnosis of Various Forms of disease

The acute interstitial pancreatitis is characterized

by rapidity, a relative short duration of disease.

Clinical features usually disappear during 3-7,
and acute pathological changes by 10-14 days.
In most mild cases at an early stage, few of
abnormal signs of disease are observed.
Pain and vomiting are and quickly pass under
the influence of conservative treatment,
The systemic involvement is minimal and
metabolic abnormalities are very few.

Acute necrotizing pancreatitis

Clinical implications of necrosis last for more

than 3 4 weeks, and pathological changes

may last from 1- 5 months.
Anemia, moderate to severe abdominal pain
and repeated vomiting are usually present.
The patient may go in to shock.
Vigorous
resuscitative
measures
are
mandatory in these cases.

Aseptic

reactive process involve not only a gland and a

retroperitoneal fat, but also surrounding organs.
The most important objective sign is palpated in region glands the
infiltrate arising for 5-7th day and later from the beginning of an
attack.
This conglomerate is not very painful, has no accurate borders and
becomes more expressed at a premise under a back of the patient of
a pillow or the platen.
The condition of the patient more often moderately severe, becomes
perceptible the appetite depression, moderately expressed pallor of
integuments, is frequent - a paresis GASTROINTESTINAL TRACT.
Temperature, as a rule, afebrile, the leukocytosis with neutrophilic
alteration is moderately expressed. Indicators of an ESR, the S-jet
protein, a fibrinogen are raised.

Clinical Classifications
Depending on a phase of development of

pathological process it is possible to delineate 4

forms of an acute pancreatitis:
acute interstitial, corresponding to an edema phase
acute necrotic, expressing a phase of formation of a
necrosis
infiltrative-necrotizing
it is purulent-necrotizing, corresponding to a phase
of fusion and a sequestration of the necrotic locuses.

Pancreas, liver, and kidney functions (including levels of pancreatic enzymes amylase and lipase)

Signs of infections

Blood cell counts indicating signs of anemia

Pregnancy test

Blood sugar, electrolyte levels (an imbalance suggests dehydration) and calcium level
Results of the blood tests may be inconclusive if the pancreas is still making digestive enzymes and

insulin.
Diagnostic imaging tests are usually needed to look for complications of pancreatitis, including
gallstones.
Diagnostic imaging tests may include the following:
X-ray films may be ordered to look for complications of pancreatitis as well as for other causes of
discomfort.

Chinese herbal medicine in AP

Authors' conclusions: Some Chinese

medicinal herbs may work in acute

pancreatitis. However, because the trials were
of low quality, the evidence is too weak to
recommend any single herb. Rigorously
designed, randomized, doubleblind, placebo
controlled trials are required.