Acute PancreatitisAcute PancreatitisManagement ConferenceManagement Conference

LTC J. David Horwhat, MDLTC J. David Horwhat, MD

Assistant Chief, GIAssistant Chief, GI

WRAMCWRAMC

Acute Pancreatitis

DemographicsDemographics• IncidenceIncidence

• 17 per 100,00017 per 100,000

• MortalityMortality• 2-3% overall mortality from acute pancreatitis2-3% overall mortality from acute pancreatitis

• Tertiary centers report rates of 5-15%, high of Tertiary centers report rates of 5-15%, high of 30%30%

• Skew towards series with more severe pancreatitisSkew towards series with more severe pancreatitis• Interstitial pancreatitis (1%)Interstitial pancreatitis (1%)• Necrotizing pancreatitis/organ failure (30%) Necrotizing pancreatitis/organ failure (30%)

• Physician office visitsPhysician office visits• 911,000 per year911,000 per year

• HospitalizationsHospitalizations• 230,000 in 2002 230,000 in 2002

• DeathsDeaths• 2500 per year2500 per year

Acute Pancreatitis

More DemographicsMore Demographics

• The median age at onset depends The median age at onset depends on the etiology on the etiology • AIDS-related - 31 yearsAIDS-related - 31 years• Vasculitis-related - 36 yearsVasculitis-related - 36 years• Alcohol-related - 39 yearsAlcohol-related - 39 years• Drug-induced etiology - 42 yearsDrug-induced etiology - 42 years• ERCP-related - 58 yearsERCP-related - 58 years• Trauma-related - 66 years Trauma-related - 66 years • Biliary tract–related - 69 yearsBiliary tract–related - 69 years

Acute Pancreatitis

Acute Pancreatitis

Terminology of Acute Terminology of Acute PancreatitisPancreatitis

• Acute interstitial Acute interstitial pancreatitis (~80%)pancreatitis (~80%)

• Necrotizing Necrotizing pancreatitis (~20%)pancreatitis (~20%)• Sterile necrosisSterile necrosis• Infected necrosisInfected necrosis

• Pancreatic fluid Pancreatic fluid collectioncollection• SterileSterile• InfectedInfected

• Pancreatic Pancreatic pseudocystpseudocyst• SterileSterile• InfectedInfected

• Pancreatic abscessPancreatic abscess• Collection of pus with Collection of pus with

little or no pancreatic little or no pancreatic necrosisnecrosis

• Terms no longer Terms no longer usedused• Hemorrhagic Hemorrhagic

pancreatitispancreatitis• PhlegmonPhlegmon

Acute Pancreatitis

Clinical PresentationClinical Presentation• Pain (95%)Pain (95%)

• Acute onset Acute onset • Mid-abdominal or mid-epigastric Mid-abdominal or mid-epigastric • Radiates to the back (50%)Radiates to the back (50%)

• Peak intensity in 30 minutesPeak intensity in 30 minutes• Lasts for several hoursLasts for several hours

• Nausea and vomiting (80%)Nausea and vomiting (80%)

• Abdominal distension (75%)Abdominal distension (75%)

• Abdominal guarding and tenderness (50%)Abdominal guarding and tenderness (50%)

• Restlessness and agitationRestlessness and agitation

Acute Pancreatitis

Laboratory DiagnosisLaboratory Diagnosis• Increased amylase Increased amylase and/orand/or lipase lipase

• >3 times ULN>3 times ULN• <3 ULN does not rule out diagnosis in right clinical <3 ULN does not rule out diagnosis in right clinical

contextcontext

• Amylase levels rise w/in 2 to 12h of sxsAmylase levels rise w/in 2 to 12h of sxs• Peak w/in first 48h Peak w/in first 48h • Remain elevated 3-5d before return to baselineRemain elevated 3-5d before return to baseline • ↑ ↑ TGs interferes with assay (false negative)TGs interferes with assay (false negative)

• Lipase much more specificLipase much more specific• Causes for < 3x elevationCauses for < 3x elevation

• Perforated ulcer, mesenteric ischemia, CRF (CrCl < 20 Perforated ulcer, mesenteric ischemia, CRF (CrCl < 20 ml/min)ml/min)

• Height of elevation does Height of elevation does notnot correlate with severity correlate with severity• No utility in following daily levels after the No utility in following daily levels after the

diagnosisdiagnosis

Acute Pancreatitis

Lab studiesLab studies

• Other causes for Other causes for amylaseamylase• SBOSBO• mesenteric ischemiamesenteric ischemia• tubo-ovarian diseasetubo-ovarian disease• renal insufficiencyrenal insufficiency• macroamylasemiamacroamylasemia• brain injury/brain traumabrain injury/brain trauma

• LTFsLTFs• ALT > 3x ULN = 95% ALT > 3x ULN = 95%

PPV for biliary PPV for biliary etiologyetiology

• CalciumCalcium Ca as a causeCa as a cause Ca as a Ca as a

complicationcomplication• saponification of saponification of

fats in fats in retroperitoneumretroperitoneum

• TGTG• Can be falsely low Can be falsely low

during an attackduring an attack

Acute Pancreatitis

Differential DiagnosisDifferential Diagnosis

• Mesenteric ischemiaMesenteric ischemia

• Perforated peptic ulcerPerforated peptic ulcer

• Intestinal obstructionIntestinal obstruction

• Biliary colicBiliary colic

• Inferior wall MIInferior wall MI

• Ectopic pregnancyEctopic pregnancy

Acute Pancreatitis

CausesCauses

OBSTRUCTIONOBSTRUCTION -GB Stones: 30 to 75% *ALT > 3x ULN = 95% PPV -Tumors

TOXINSTOXINS --EtOHEtOH: ~30%: ~30% -Scorpion bites-Scorpion bitesTityus trinitatisTityus trinitatis & &T. serrulatusT. serrulatus -Insecticides-Insecticides METABOLICMETABOLIC

-- TG ~ 4% TG ~ 4% -> 1000 mg/dl-> 1000 mg/dl - - PTH < 0.5% PTH < 0.5%

TRAUMATRAUMA-Surgery-Surgery-Post-ERCP-Post-ERCP-MVAs etc-MVAs etc..

INFECTIONINFECTION-Viral-Viral -HIV/EBV/Coxsackie/Mumps-HIV/EBV/Coxsackie/Mumps -CMV/Varicella/Hep A&C-CMV/Varicella/Hep A&C

-Parasitic-Parasitic -Ascariasis, clonorchiasis-Ascariasis, clonorchiasis

-Bacterial-Bacterial -Mycoplasma, -Mycoplasma, C. jejuni, C. jejuni, TBTB -MAI, Leptospirosis, Legionella-MAI, Leptospirosis, Legionella

DrugsDrugs-Imuran-Imuran-Estrogens-Estrogens-TCN-TCN-Flagyl-Flagyl-Thiazides-Thiazides

-Lasix-Lasix-DDI-DDI-Sulfa drugs-Sulfa drugs-Depakote-Depakote-Pentamidine-PentamidineVASCULARVASCULAR

-Ischemia-Ischemia-Embolic-Embolic-Vasculitis-Vasculitis

MISCMISC-Hereditary-Hereditary-Cystic Fibrosis-Cystic Fibrosis--IdiopathicIdiopathic: 10 to 30%: 10 to 30% - 70% microlithiasis- 70% microlithiasis-P. divisumP. divisum-Annular pancreasAnnular pancreas-SODSOD-Crohn’s Dz-Crohn’s Dz-Post Perf DU-Post Perf DU

80%80%

Acute Pancreatitis

Management Management questionsquestions

• When should patients admitted with AP be monitored in an ICU or step-down unit?

• When do I order a CT scan?• Should patients with SAP receive prophylactic

abx? • What is the optimal mode and timing of

nutritional support for the patient with SAP? • Under what circumstances should patients

with gallstone pancreatitis undergo interventions to clear the bile duct?

• What are the indications for surgery in AP; optimal timing for intervention, and roles for less invasive approaches including percutaneous drainage and laparoscopy?

Acute Pancreatitis

Tityus trinitatusTityus trinitatus

Tityus serrulatus

Acute Pancreatitis

When Do I Transfer to the When Do I Transfer to the Unit ?Unit ?

• Severe pancreatitisSevere pancreatitis• Multi-organ failureMulti-organ failure

• PulmonaryPulmonary• RenalRenal

• Consider it if you are placing Consider it if you are placing the patient on antibiotics the patient on antibiotics and/or ordering a CT to and/or ordering a CT to evaluate non-improvementevaluate non-improvement

Acute Pancreatitis

Determining severityDetermining severity• Clinical criteriaClinical criteria

• early development/persistence of organ early development/persistence of organ dysfnxdysfnx

• Ranson criteriaRanson criteria• Atlanta criteriaAtlanta criteria• POP scorePOP score

• Clinical assessmentClinical assessment• frequent VS, fluid status/UOP, pulse oximetryfrequent VS, fluid status/UOP, pulse oximetry

• Radiographic criteriaRadiographic criteria• CT severity indexCT severity index

• necrosis may not be evident until 48-72hnecrosis may not be evident until 48-72h

Acute Pancreatitis

Ranson CriteriaRanson Criteria• AdmissionAdmission

• Age > 55 yearsAge > 55 years• White blood cells > 16,000/mmWhite blood cells > 16,000/mm33 • Glucose > 200 mg/dLGlucose > 200 mg/dL• LDH > 350 IU/LLDH > 350 IU/L• AST > 250 U/LAST > 250 U/L

• During Initial 48 Hours During Initial 48 Hours • Hct decrease of > 10 mg/dLHct decrease of > 10 mg/dL• BUN increase of > 5 mg/dLBUN increase of > 5 mg/dL• Base deficit > 4 mEq/LBase deficit > 4 mEq/L• Fluid sequestration > 6 LFluid sequestration > 6 L• Ca++ < 8 mg/dLCa++ < 8 mg/dL• Pa OPa O22 < 60 mm Hg < 60 mm Hg

•Directly related to Directly related to fluid resuscitationfluid resuscitation

•Independent Independent predictors of predictors of mortalitymortality

** Caveat **** Caveat **

Valid at 48h after onset of symptoms and not at any other time during Valid at 48h after onset of symptoms and not at any other time during the diseasethe disease

Acute Pancreatitis

MORTALITY MORTALITY ††

MORBIDITY MORBIDITY **

Ranson et al. Radiology, 1990;174:331Ranson et al. Radiology, 1990;174:331

†† Sn 73%, Sp Sn 73%, Sp 77%77%

* * > 7 d in ICU> 7 d in ICU

Acute Pancreatitis

Pancreatitis Outcome Pancreatitis Outcome Prediction (POP) ScorePrediction (POP) Score

-Data collected within 24hr of ICU admissionData collected within 24hr of ICU admission

-2,462 patients from 159 ICUs in the UK2,462 patients from 159 ICUs in the UK

-Logistic regression model with area under the ROC curve of Logistic regression model with area under the ROC curve of 0.8380.838

(needs prospective validation)(needs prospective validation)

Acute Pancreatitis

Pancreatitis Outcome Pancreatitis Outcome Prediction ScorePrediction Score

Acute Pancreatitis

TAP? CRP? Hct?TAP? CRP? Hct?

• Trypsinogen Trypsinogen activation peptideactivation peptide

• CRPCRP• Latency of 24-48hrLatency of 24-48hr

not useful for EARLY not useful for EARLY determinationdetermination

• HematocritHematocrit• Admission Hct ≥50%Admission Hct ≥50%

• significant predictor of significant predictor of severe pancreatitis, severe pancreatitis, necrosis, LOS, need for ICUnecrosis, LOS, need for ICU

• LR 7.5 for severe APLR 7.5 for severe AP

Acute Pancreatitis

Famous people who have Famous people who have had pancreatitishad pancreatitis

• Alexander the GreatAlexander the Great

• Ludwig von BeethovenLudwig von Beethoven

• Dizzie GillespieDizzie Gillespie

• Maximilian SchellMaximilian Schell

• Matthew PerryMatthew Perry

• John AshcroftJohn Ashcroft

Acute Pancreatitis

Acute Pancreatitis

Acute PancreatitisAcute Pancreatitis

INTERSTITIALINTERSTITIAL(Edematous)(Edematous)

80%80%

NECROTIZINGNECROTIZING

20%20%

INFECTEDINFECTED NECROSISNECROSIS

70%70%

INFLAMMATORY INFLAMMATORY MASSMASS

STERILE NECROSISSTERILE NECROSIS

30%30%

HEALINGHEALING

CHRONIC CHRONIC PSEUDOCYSTPSEUDOCYST

PANCREATICPANCREATICABSCESSABSCESS

Acute Pancreatitis

Severe PancreatitisSevere PancreatitisAtlanta criteriaAtlanta criteria

• Organ FailureOrgan Failure• i.e. systolic blood pressure <90 mm Hg, PaOi.e. systolic blood pressure <90 mm Hg, PaO22 <60 mm Hg, <60 mm Hg,

serum creatinine >2 mg/dL, >500 mL/24 h GI bleeding serum creatinine >2 mg/dL, >500 mL/24 h GI bleeding OROR

• Local ComplicationsLocal Complications• NecrosisNecrosis• AbscessAbscess• Pseudocyst Pseudocyst OROR

• Unfavorable Early Prognostic Signs Unfavorable Early Prognostic Signs 3 Ranson's signs 3 Ranson's signs

OROR

8 APACHE-II points8 APACHE-II points

Acute Pancreatitis

Organ FailureOrgan Failure• CardiovascularCardiovascular

• HypotensionHypotension• Septic physiologySeptic physiology

HR, CO and HR, CO and SVR SVR

• RespiratoryRespiratory• HypoxemiaHypoxemia• Pleural effusionsPleural effusions

• Renal Renal • ATNATN• OliguriaOliguria

• HematologicHematologic• DICDIC• ThrombocytosisThrombocytosis

• HepaticHepatic• EncephalopathyEncephalopathy T bili (3 mg/dl)T bili (3 mg/dl) AST/ALT 2X nlAST/ALT 2X nl

• GIGI• Stress ulcerStress ulcer• Acalculous Acalculous

cholecystitischolecystitis

Acute Pancreatitis

When Do I Order A When Do I Order A CT?CT?

• If the patient has…..If the patient has…..• Signs of severe acute pancreatitisSigns of severe acute pancreatitis• No signs of clinical improvement after several daysNo signs of clinical improvement after several days• Diagnostic dilemmaDiagnostic dilemma• Infection suspectedInfection suspected

• T > 101T > 101oo F F• Positive blood culturesPositive blood cultures

• What kind of CT?What kind of CT?• Dynamic with rapid bolus IV contrastDynamic with rapid bolus IV contrast

• What are you looking for?What are you looking for?• Necrosis:Necrosis: Lack of enhancement with contrastLack of enhancement with contrast• Fluid CollectionsFluid Collections• Alternate diagnosisAlternate diagnosis

Acute Pancreatitis

CT FindingsCT Findings

• PancreasPancreas• Pancreatic enlargementPancreatic enlargement• Decreased density due to edemaDecreased density due to edema• Intrapancreatic fluid collectionsIntrapancreatic fluid collections• Blurring of gland margins due to inflammationBlurring of gland margins due to inflammation

• PeripancreaticPeripancreatic• Fluid collections and stranding densitiesFluid collections and stranding densities• Thickening of retroperitoneal fat Thickening of retroperitoneal fat

* It may take up to 72h for inflammatory changes to become * It may take up to 72h for inflammatory changes to become apparent on CT * apparent on CT *

Acute Pancreatitis

CT FindingsCT Findings

Tail Indistinct

Intraperitoneal fluid

PANCPANC

LIVERLIVER

Acute Pancreatitis

CT FindingsCT FindingsSevere PancreatitisSevere Pancreatitis

Peripancreatic edemaand inflammation

UnenhancingNecrosis

PANCPANCLIVERLIVER

GBGB

Acute Pancreatitis

Normal Pancreas

Acute Pancreatitis

POINTSPOINTS

GradeGrade of Acute Pancreatitis A = Normal pancreas 0B = Pancreatic enlargement 1C = Pancreatic/peripancreatic

inflammation 2D = Single peripancreatic fluid collection 3E = Multiple fluid collections 4

Grade E = 50% chance of developing an infection Grade E = 50% chance of developing an infection and 15% chance of deathand 15% chance of death

DegreeDegree of Necrosis No necrosis 0Necrosis of one third of pancreas 2Necrosis of one half of pancreas 4Necrosis of more than one half 6 CT Severity Index = Grade + Degree of necrosis

Acute Pancreatitis

MORTALITYMORTALITY

MORBIDITY*MORBIDITY*

* > 7 days * > 7 days in the ICUin the ICU

CT Severity CT Severity IndexIndex = Grade of = Grade of Panc. + Degree Panc. + Degree

of Necrosisof Necrosis

per Balthazarper Balthazar

Acute Pancreatitis

Cullen’s signCullen’s sign

Acute Pancreatitis

ManagementManagementMild-ModerateMild-Moderate

• NPO with IVF (crystalloid)NPO with IVF (crystalloid)• Colloid (blood if Hct <25, albumin if serum alb <2)Colloid (blood if Hct <25, albumin if serum alb <2)

• Closely follow I/Os, UOPClosely follow I/Os, UOP• UOP 0.5cc/kg body wt per hr in absence of renal UOP 0.5cc/kg body wt per hr in absence of renal

failurefailure• Generous narcoticsGenerous narcotics

• PCAPCA• MSO4 OK MSO4 OK

• no evidence in humans of worsening Ac Panc d/t sphincter no evidence in humans of worsening Ac Panc d/t sphincter of Oddiof Oddi

• Scheduled not PRNScheduled not PRN• NGT decompression NGT decompression

• if frequent emesis or evidence of ileus on plain filmsif frequent emesis or evidence of ileus on plain films• Start clear liquids when pain/anorexia resolveStart clear liquids when pain/anorexia resolve• DO NOT follow amylase and lipase levelsDO NOT follow amylase and lipase levels

Acute Pancreatitis

When Do I Start When Do I Start Antibiotics?Antibiotics?

• Acute pancreatitis is c/b infection ~ 10%Acute pancreatitis is c/b infection ~ 10%• 30-50% of those with necrosis get infection30-50% of those with necrosis get infection

• Prophylactic antibioticsProphylactic antibiotics• ControversialControversial

• No benefit in mild EtOH pancreatitisNo benefit in mild EtOH pancreatitis• Imipenem or meropenem in necrotizing pancreatitisImipenem or meropenem in necrotizing pancreatitis• Selective gut decontamination may be beneficialSelective gut decontamination may be beneficial• Abx do not appear to promote fungal infectionAbx do not appear to promote fungal infection

• General recommendations for use:General recommendations for use:• Biliary pancreatitis with signs of cholangitisBiliary pancreatitis with signs of cholangitis• > 30% necrosis on CT scan> 30% necrosis on CT scan

Acute Pancreatitis

Antibiotics - EBMAntibiotics - EBM

Antibiotic therapy for prophylaxis against Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute infection of pancreatic necrosis in acute

pancreatitis.pancreatitis.Cochrane Database of Systematic Reviews. 3, 2005Cochrane Database of Systematic Reviews. 3, 2005

Despite variations in drug agent, case mix, Despite variations in drug agent, case mix, duration of treatment and methodological duration of treatment and methodological quality (especially the lack of double blinded quality (especially the lack of double blinded studies), there was studies), there was strong evidencestrong evidence that that intravenous antibiotic prophylacticintravenous antibiotic prophylactic therapy for therapy for 10 to 14 days10 to 14 days decreaseddecreased the the risk of super-risk of super-infectioninfection of necrotic tissueof necrotic tissue and and mortalitymortality in in patients with severe acute pancreatitis with patients with severe acute pancreatitis with proven pancreatic necrosis at CTproven pancreatic necrosis at CT

Acute Pancreatitis

Acute Pancreatitis

A final word on A final word on antibioticsantibiotics

• Do not use empirically early in Do not use empirically early in mild pancreatitismild pancreatitis

• Fever earlyFever early in the disease in the disease process is process is almost universally almost universally secondary tosecondary to the the inflammatory inflammatory responseresponse and NOT an and NOT an infectious processinfectious process

Acute Pancreatitis

When can he eat ?When can he eat ?Nutritional issues in APNutritional issues in AP

• TPN vs. enteral feedingTPN vs. enteral feeding• Not Not TPN per meta-analysis but …*TPN per meta-analysis but …*• NJ not NG NJ not NG

• Early initiation of enteral Early initiation of enteral nutrition in severe APnutrition in severe AP

• tube feed if anticipate NPO > 1 weektube feed if anticipate NPO > 1 week• may be unnecessary for mild APmay be unnecessary for mild AP

• Reduce microbial translocationReduce microbial translocation• Enhance gut mucosal blood flowEnhance gut mucosal blood flow• Promote gut mucosal surface immunityPromote gut mucosal surface immunity

Reduce Reduce incidence of incidence of

infected infected necrosisnecrosis

* 6 older studies, relationship b/w glycemic control and infectious risk may * 6 older studies, relationship b/w glycemic control and infectious risk may confound vs. TPNconfound vs. TPN

Acute Pancreatitis

NutritionNutrition• Mild pancreatitisMild pancreatitis

• Calories from IVF Calories from IVF (D5W) are (D5W) are sufficientsufficient

• No benefit from No benefit from additional additional nutritional nutritional supportsupport

• Oral intake Oral intake advancing to low advancing to low fat diet once fat diet once pain/anorexia pain/anorexia resolve resolve

• Moderate/SevereModerate/Severe• Begin nutritional Begin nutritional

support as early support as early as possibleas possible• NJ tube preferredNJ tube preferred

• TPN only if :TPN only if :• Can’t maintain Can’t maintain

adequate jejunal adequate jejunal accessaccess

• Unable to meet Unable to meet caloric demands caloric demands enterallyenterally

Acute Pancreatitis

Acute Pancreatitis

When Do I Consult When Do I Consult GI ?GI ?

• Evidence of biliary pancreatitisEvidence of biliary pancreatitis• Elevated LFTs + pancreatitisElevated LFTs + pancreatitis

• No matter what the US showsNo matter what the US shows

• Severe pancreatitisSevere pancreatitis• Recurrent unexplained pancreatitisRecurrent unexplained pancreatitis• Rule out infected necrosisRule out infected necrosis

• EUS FNA sampling of fluid collectionsEUS FNA sampling of fluid collections

• Endoscopic treatment of Endoscopic treatment of necrosis/abscessnecrosis/abscess

Acute Pancreatitis

Biliary pancreatitisBiliary pancreatitis

• Q: When should I suspect it ?Q: When should I suspect it ?• A: AlwaysA: Always

• Q: How do I evaluate for it ?Q: How do I evaluate for it ?• A: (E)US and LFTsA: (E)US and LFTs

• Q: When is ERCP indicated ?Q: When is ERCP indicated ?• A: 3 studies looked at emergency A: 3 studies looked at emergency

(within 24-72h) ERC (within 24-72h) ERC with ESwith ES vs vs standard therapy in biliary APstandard therapy in biliary AP

Acute Pancreatitis

FanFan

NeoptolemusNeoptolemus

FölschFölsch

Meta-Meta-analysisanalysis

•Emergency Emergency ERCERC (with ES & stone (with ES & stone extraction when stones extraction when stones present)present)

•benefits benefits severe AP but severe AP but not mildnot mild

Acute Pancreatitis

Management of Management of Pancreatic Pancreatic

ComplicationsComplications

• Acute fluid collectionsAcute fluid collections• Occur early, seen not feltOccur early, seen not felt• No defined wall No defined wall usually resolve usually resolve

spontaneouslyspontaneously• NONO routine percutaneous or operative drainage routine percutaneous or operative drainage

• may infect otherwise sterile tissuemay infect otherwise sterile tissue

• Infected pancreatic necrosisInfected pancreatic necrosis• Pancreatic abscessPancreatic abscess• PseudocystsPseudocysts

Acute Pancreatitis

Grey-Turner’s signGrey-Turner’s sign

Acute Pancreatitis

Management of Management of Pancreatic Pancreatic

ComplicationsComplications• Infected necrosisInfected necrosis

• Organisms on gram Organisms on gram stain after aspiratestain after aspirate

• Surgical drainageSurgical drainage• Trans-gastric Trans-gastric

drainagedrainage• Try to delay Try to delay

necrosectomy 2-3wk necrosectomy 2-3wk for demarcation of for demarcation of necrosisnecrosis

• Pancreatic Pancreatic abscessabscess• CT or EUS CT or EUS

guided drainageguided drainage• Walled collection Walled collection

of pusof pus• Similar to Similar to

management of management of pseudocystpseudocyst

Acute Pancreatitis

Acute Pancreatitis

PseudocystsPseudocysts

• Collection of pancreatic fluid Collection of pancreatic fluid enclosed by enclosed by non-epithelialized non-epithelialized wall of granulation tissuewall of granulation tissue

• Complicates 5-10% cases of APComplicates 5-10% cases of AP• ~ 4 weeks after insult~ 4 weeks after insult• 25-50% resolve spontaneously25-50% resolve spontaneously

Acute Pancreatitis

Complications of Complications of PseudocystPseudocyst

• Infection - 14%Infection - 14%• Rupture - 6.8%Rupture - 6.8%• Hemorrhage - 6.5% Hemorrhage - 6.5% • Common bile duct obstruction - Common bile duct obstruction -

6.3%6.3%• GI obstruction - 2.6%GI obstruction - 2.6%

Acute Pancreatitis

Pseudocyst Pseudocyst ManagementManagement

• Old thoughtOld thought• Pseudocysts > 5 cm that have Pseudocysts > 5 cm that have

been present > 6 weeks must be been present > 6 weeks must be draineddrained

• Current practiceCurrent practice• Asymptomatic pseudocystsAsymptomatic pseudocysts, ,

regardless of size, regardless of size, do not require do not require treatmenttreatment

Acute Pancreatitis

Pseudocyst Drainage Pseudocyst Drainage TechniquesTechniques

• EndoscopicEndoscopic• SurgicalSurgical• RadiologicRadiologic

LiverLiver

PCPC

PCPC

StomStom

Acute Pancreatitis

Endoscopic Pseudocyst Endoscopic Pseudocyst ManagementManagement

• Pseudocyst Pseudocyst classificationclassification• CommunicatingCommunicating• Non-communicatingNon-communicating

Acute Pancreatitis

Endoscopic Pseudocyst Endoscopic Pseudocyst ManagementManagement

Acute Pancreatitis

PercutaneousPercutaneousPseudocystPseudocystDrainageDrainage

Open Open CystgastrostoCystgastrosto

mymy

Acute Pancreatitis

Laparoscopic Cyst Laparoscopic Cyst GastrostomyGastrostomy

Acute Pancreatitis

Closing PointsClosing Points

• 4 out of 5 patients have mild 4 out of 5 patients have mild uneventful pancreatitisuneventful pancreatitis

• If the patient is not getting If the patient is not getting considerably better in 36-48 hrs, start considerably better in 36-48 hrs, start thinking about that “5th patient”thinking about that “5th patient”

• A CT is that 5th patient’s friendA CT is that 5th patient’s friend• If you are thinking about antibiotics, If you are thinking about antibiotics,

you should be thinking about a CT and you should be thinking about a CT and a few consultsa few consults

• The pancreas is mean organ….respect The pancreas is mean organ….respect itit

Acute Pancreatitis

Questions?Questions?