Management and Complications of Acute

PancreatitisSimrat Kaur

MANAGEMENT

In most patients (85-90%) with mild acute pancreatitis, the disease is self-limited and subsides spontaneously, usually within 3-7 days.

However, a conservative (non-invasive) approach is indicated(1) analgesics for pain, (2) IV fluids and colloids to maintain normal intravascular volume, and (3) no oral alimentation.

A brief period of fasting may be sensible mainly in patients who are nauseated or in pain.

SEVERE ATTACK

Markers of severity within 24 hours are-SIRS, Hct>44%,BUN>22mg%

Admit the patient to ICU, Give Analgesic drugs and Aggressive fluid rehydration.

Oxygen masks may be applied and Invasive monitoring of vital signs, central venous pressure, urine output and blood gases should be carried out.

Frequent monitoring of haematological and biochemical parameters

Nasogastric drainage, it is not essential but may be of value in patients with vomiting.

Antibiotic prophylaxis can be considered (imipenem, cefuroxime). The overall rate of infected necrosis is 20%.

CT scan(contrast enhanced) essential if organ failure, clinical deterioration or signs of sepsis develop. Its severity can be judged by Balthazar scoring system.

ERCP within 36-72 hours for severe gallstone pancreatitis or signs of cholangitis.

Supportive therapy for organ failure if it develops (inotropes, ventilatory support, haemofiltration, etc.)

If nutritional support is required, consider enteral (nasogastric) feeding instead of TPN.

SYSTEMIC COMPLICATIONS

(More common in the first week)

Cardiovascular Shock

Arrhythmias Pulmonary

ARDSRenal failure

Haematological DIC

Metabolic - Hypocalcaemia Hyperglycaemia Hyperlipidaemia

Gastrointestinal Ileus

NeurologicalVisual disturbances Confusion, irritability Encephalopathy

Miscellaneous Subcutaneous fat necrosis Arthralgia

LOCAL COMPLICATIONS

Usually develops after the first week.

A CT scan should be performed where clinical resolution does not take place and signs of of sepsis develop.

These complications carry a significant burden of mortality.

1. ACUTE FLUID COLLECTION

It occurs early in the course of disease, the fluid is sterile and no intervention is needed unless it causes symptoms or pressure effects in which case it can be percutaneously aspirated under USO or CT.

2. Sterile/Infected Pancreatic necrosis

Pancreatic necrosis is a Diffuse or focal area of non-viable parenchyma in the pancreas and can be identified by an absence of contrast enhancement on CT.

These are sterile to begin with, but can become subsequently infected, probably due to translocation of gut bacteria. Infected necrosis is associated with a mortality rate of up to 50%.

If the pancreatic fluid aspirate is purulent, percutaneous drainage of the infected fluid should be carried out. The tube drain inserted should have the widest bore possible.

Pancreatic Necrosectomy

If the area involved is the head of pancreas midline laprotomy should be carried out. The duodenocolic and gastrocolic ligaments should be divided and the lesser sac opened. Thorough debridement of the dead tissue around the pancreas should be carried out.

If the body and tail of the gland are primarily involved, a retroperitoneal approach though a left flank incision may be more appropriate.

Laproscopy- A rigid laparoscope is inserted into the peripancreatic area through a retroperitoneal approach, and vigorous irrigation and suction is combined with a gradual nibbling away of the necrotic debris.

3) Pancreatic Abscess

This is a circumscribed collection of pus, and may be an acute fluid collection or a pseudocyst that has become infected. Percutaneous drainage with the widest possible drains should be done

4) Pancreatic Ascites and Effusion

Pancreatic Ascites is a chronic, generalised, peritoneal, enzyme-rich effusion usually associated with pancreatic duct disruption. Paracentesis will reveal turbid fluid with a high amylase level.

Pancreatic effusion is an encapsulated collection of fluid in the pleural cavity. Concomitant pancreatic ascites may be present, or there may be a communication with an intra-abdominal collection.

5) Haemmorhage

Bleeding may occur into the gut, into the retroperitoneum or into the peritoneal cavity. Possible causes include bleeding into a pseudocyst cavity, or diffuse bleeding from a large raw surface.

6) Portal or Splenic vein thrombosis

7) PseudocystA pseudocyst is a extra pancreatic collection of amylase-

rich fluid enclosed in a wall of fibrous or granulation tissue.

Disruption of Pancreatic ductal system is common, however the course may vary from spontaneous healing to tense ascites.

Cause – 90% pancreatitis 10% trauma

They are often single but, occasionally, patients will develop multiple pseudocysts.

A pseudocyst is usually identified on ultrasound or a CT scan. It is important to differentiate a pseudocyst from an acute fluid collection or an abscess and a cystic neoplasm.

Distinguishing a pseudocyst from a cystic neoplasm

History

Appearance on CT and ultrasound

FNA of fluid, preferably under EUS guidance and Cytology typically reveals inflammatory cells in pseudocyst fluid.

CEA (high level in mucinous tumours .400ng/ml)Amylase (level usually high in pseudocysts, but occasionally in tumours)

ComplicationsProcess Outcomes

Infection AbscessSystemic sepsis

Rupture(prime cause of death) into the gut

into the peritoneum

GI bleeding

peritonitis

Enlargement Pressure effects

Obstructive jaundice from biliary compression Bowel obstruction

Erosion into a vessel Haemorrhage into the cyst Haemoperitoneum ( A triad of findings-inc size of mass, localized bruise over mass and a sudden dec in Hb and Hematocrit without external blood loss)

ManagementPseudocysts that are thick-walled or large (over 6 cm in

diameter), have lasted for a long time (over 12 weeks) are less likely to resolve spontaneously.

1. Percutaneous drainage to the exterior under radiological guidance should be avoided. It carries a very high likelihood of recurrence.

2. Endoscopic drainage usually involves puncture of the cyst through the stomach or duodenal wall under EUS guidance, and placement of a tube drain with one end in the cyst cavity and the other end in the gastric lumen.

3. Surgical drainage involves internally draining the cyst into the gastric or jejunal lumen. Pseudocysts that have developed complications are best managed surgically.

Local Complications

Acute fluid collection

Sterile/Infected pancreatic necrosis

Pancreatic Abscess

Pancreatic ascites or effusion

Portal/ splenic vein thrombosis

Pseudocyst