Pancreatitis in the Critical Care Setting

Classification System ◽

Pancreatic Necrosis ◽

The United States ◽

Complex Spectrum ◽

Early Management ◽

Key Words Acute Pancreatitis

Pancreatitis is a complex spectrum of disease including chronic pancreatitis, acute pancreatitis, and manifestations of severe acute pancreatitis such as sterile and infected necrotizing pancreatitis. Acute pancreatitis is the leading cause of hospitalization for gastrointestinal disorders in the United States. Pancreatitis is a dynamic condition, and severity may change and evolve during the course of the disease. Although most patients with acute pancreatitis have mild disease, 10 to 15% will run a fulminant course, leading to severe acute pancreatitis, pancreatic necrosis, and multisystem organ injury. The mortality for severe acute pancreatitis is 15 to 30%; however, the overall mortality for all patients with acute pancreatitis is less than 5%. Early management of acute pancreatitis includes fluid resuscitation, pain control, and enteral nutrition. There are no specific directed therapies proven to be effective for the early treatment of acute necrotizing pancreatitis; therapy is entirely supportive. Chronic pancreatitis is a challenging disease often marked by chronic pain. Surgical intervention may help improve quality of life and relieve pain in selected patients. International consensus guidelines provide definitions and classifications to aid clinicians with diagnosis and management of pancreatitis. This review covers advances related to pancreatitis, including literature pertaining to the step-up approach for necrotizing pancreatitis first published in 2010, discussion of the revised Atlanta Classification System for severity of acute pancreatitis published in 2013, review of the current spectrum of microbial pathogens implicated in infected necrotizing pancreatitis, and the international draft consensus proposal for a new mechanistic definition for chronic pancreatitis published in 2016. Key words: acute pancreatitis, antibiotic prophylaxis, Atlanta Classification System, biliary pancreatitis, chronic pancreatitis, necrosectomy, pancreatic necrosis, pancreatitis, step-up approach, video-assisted retroperitoneal drainage (VARD)

Pancreatitis

10.2310/7ccsp.8321 ◽

2017 ◽

Author(s):

Lisa M. Kodadek ◽

Pamela A. Lipsett

Keyword(s):

Acute Pancreatitis ◽

Chronic Pancreatitis ◽

Classification System ◽

Pancreatic Necrosis ◽

The United States ◽

Complex Spectrum ◽

Early Management ◽

Key Words Acute Pancreatitis

Serum D-dimer is a Predictor of Severity and Outcome of Acute Pancreatitis

BIRDEM Medical Journal ◽

10.3329/birdem.v9i1.39723 ◽

2019 ◽

Vol 9 (1) ◽

pp. 44-54

Author(s):

Abdullah Al Mamun ◽

Indrajit Kumar Datta ◽

Md Anisur Rahman ◽

Md Nazmul Hoque

Keyword(s):

Acute Pancreatitis ◽

General Hospital ◽

Severe Disease ◽

Early Management ◽

Mild Disease ◽

The Mean ◽

The Difference ◽

D Dimer

Background: Acute pancreatitis (AP) is characterized by a spectrum of symptoms, ranging from a local inflammatory process to the more severe form (acute necrotizing pancreatitis) which is associated with a systemic inflammatory response. The overall mortality rate of AP is between 5% and 15%, reaching 30 % in severe acute pancreatitis (SAP). Early optimized care may improve prognosis in patients with the most severe forms but it remains a challenge to identify these poor prognosis cases specially in the first 48 hours. The objective of our study is to evaluate the efficacy of serum D-dimer in the prediction of severity and outcome of acute pancreatitis. Methods: This prospective and observational study was conducted in the Department of Gastrointestinal, Hepatobiliary and Pancreatic Disorders (GHPD), BIRDEM General Hospital, Dhaka, Bangladesh from January, 2016 to September, 2017. Patients with acute pancreatitis admitted to Department of GHPD of BIRDEM General Hospital, Dhaka, were included in this study. Purposive type of non probability sampling technique was applied to enroll the patients. A predesigned structured questionnaire was used for recording the necessary information. Patients admitted with abdominal pain and fulfilling the diagnostic criteria of acute pancreatitis by clinical history, physical examination, biochemical tests and different imaging modalities and patients aged more than 18 years were included in this study. The patients were followed up on day 1, day 3 of admission and on the day before discharge. Results: Total 87 patients with acute pancreatitis, who fulfilled the inclusion criteria, were included in this study. This study found that 53(61.0%) had mild acute pancreatitis, 27(31.0%) patients had moderately severe acute pancreatitis and 7(8.0%) patients had severe acute pancreatitis. The mean serum D-dimer at day 1 of patients with mild disease was 2.31± 1.82(mean±SD) μg/ml, in patients with moderately severe disease was 4.67± 2.02(mean±SD) μg/ml and in severe acute pancreatitis it was 10.11±3.11 (mean±SD) μg/ml. The difference among the groups were statistically significant (p<0.001). The mean serum D-dimer at day 3 of patients with mild disease was 0.8±0.51 (mean±SD) μg/ml, in patients with moderately severe disease was 1.86±2.22 (mean± SD) μg/ml and in severe acute pancreatitis it was 3.62±1.9 (mean±SD) μg/ml. The difference among the groups were statistically significant (p<0.001). Thus serum D-dimer could predict disease severity early in the course of disease successfully. In the present study 55(63.2%) patients did not develop any kind of complications and serum D-dimer level at day 1 and day 3 were 2.4±1.73 and 0.81±0.49 respectively. On the other hand 32 (36.8%) patients developed complications and serum D-dimer level at day 1 and day 3 were 5.86±3.5 and 2.31±2.3 respectively. The difference among the groups were statistically significant (p<0.001).That reveals serum D-dimer is a predictor of outcome of acute pancreatitis. Sensitivity, specificity and accuracy was 77.8%, 76.5% and 77.0% respectively at day 1 (cut off value e”3.3 μg/ml) and it was 73.5%, 77.4% and 75.9% respectively at day 3 (cut off value e”1.05 μg/ml) in prediction outcome of AP. Conclusion: The difference of serum D-dimer levels between mild, moderately severe and severe acute pancreatitis was statistically significant and it was also higher in patients who developed complications following acute pancreatitis than those without complications. This simple, feasible and reproducible marker can be used in clinical practice to improve the early management of acute pancreatitis. Birdem Med J 2019; 9(1): 44-54

Revista Brasileira de Ginecologia e Obstetrícia / RBGO Gynecology and Obstetrics ◽

Familial Chylomicronemia Syndrome-Induced Acute Necrotizing Pancreatitis during Pregnancy

10.1055/s-0040-1722173 ◽

2021 ◽

Vol 43 (03) ◽

pp. 220-224

Author(s):

Julia Cristina Coronado Arroyo ◽

Marcio José Concepción Zavaleta ◽

Eilhart Jorge García Villasante ◽

Mikaela Kcomt Lam ◽

Luis Alberto Concepción Urteaga ◽

...

Keyword(s):

Acute Pancreatitis ◽

Pancreatic Necrosis ◽

Clinical Course ◽

Rare Condition ◽

Severe Hypertriglyceridemia ◽

Fetal Complications ◽

Acute Necrotizing ◽

History Of ◽

Important Objective

AbstractAcute pancreatitis is a rare condition in pregnancy, associated with a high mortality rate. Hypertriglyceridemia represents its second most common cause. We present the case of a 38-year-old woman in the 24th week of gestation with a history of hypertriglyceridemia and recurrent episodes of pancreatitis. She was admitted to our hospital with acute pancreatitis due to severe hypertriglyceridemia. She was stabilized and treated with fibrates. Despite her favorable clinical course, she developed a second episode of acute pancreatitis complicated by multi-organ dysfunction and pancreatic necrosis, requiring a necrosectomy. The pregnancy was ended by cesarean section, after which three plasmapheresis sessions were performed. She is currently asymptomatic with stable triglyceride levels. Acute pancreatitis due to hypertriglyceridemia represents a diagnostic and therapeutic challenge in pregnant women, associated with serious maternal and fetal complications. When primary hypertriglyceridemia is suspected, such as familial chylomicronemia syndrome, the most important objective is preventing the onset of pancreatitis.

Clinical profile of patients with pancreatitis

International Surgery Journal ◽

10.18203/2349-2902.isj20164702 ◽

2017 ◽

Vol 4 (2) ◽

pp. 534

Author(s):

MD. Shakeel ◽

Syed Shahid Irfan

Keyword(s):

Acute Pancreatitis ◽

Chronic Pancreatitis ◽

Dietary Habits ◽

Cross Sectional Study ◽

Cross Sectional ◽

Common Diagnosis ◽

History Of ◽

In The Beginning ◽

Alcoholic Liver Diseases

Background: Pancreatitis is an inflammatory process leading to abdominal pain, progressive destruction of the exocrine tissue and in some patients a loss of endocrine tissue as well. However owing to the tremendous reserve of pancreatic function, insufficiency may be at subclinical at least in the beginning of the disease.Methods: A cross sectional study was conducted which included the patients admitted with pancreatitis. For all the patients, meticulous records will be maintained regarding clinical features, family history of pancreatitis, alcohol intake, dietary habits, and stigmata of alcoholic liver diseases and by performing various investigations. 200 cases admitted, diagnosed to have pancreatitis.Results: The most common diagnosis was acute pancreatitis (48%) followed by chronic pancreatitis (12%), acute pancreatitis and pseudocyst (12%), acute on chronic pancreatitis (12%), necrotizing pancreatitis (8%) and acute pancreatitis with others (8%).Conclusions: Overall acute pancreatitis constituted 76%, chronic pancreatitis 12% and acute on chronic pancreatitis 12%.

Severe acute pancreatitis- it's diagnosis and management- A study of 20 cases

Community Based Medical Journal ◽

10.3329/cbmj.v8i2.55768 ◽

2019 ◽

Vol 8 (2) ◽

pp. 17-29

Author(s):

Mohammad Monir Hossain ◽

S M Shakwat Hossain ◽

Delowar Hossain

Keyword(s):

Acute Pancreatitis ◽

Conservative Treatment ◽

Pancreatic Necrosis ◽

Military Hospital ◽

Fatty Tissue ◽

Ct Findings ◽

Contrast Enhanced Ct ◽

Management Protocol ◽

Life Threatening

Background: Severe acute pancreatitis is defined as pancreatitis in which there is persistent organ failure that does not resolve within 48 hours. Severe acute Pancreatitis is characterized by pancreatic necrosis, a severe systemic inflammatory response and often multiorgan failure. Severe acute pancreatitis is a serious and life threatening disease. Mortality varies from 20 to 50 percent. Objective: The objectives of this study are to develop our knowledge about presentation and diagnosis of severe acute pancreatitis, and to develop a standard management protocol to rescue that patient suffering from severe acute pancreatitis. Methods: This observational study was carried out in Combined Military Hospital (CMH) Dhaka, during the period of August 2014 - Feb 2015. A total 20 patients of severe acute pancreatitis were studied prospectively, evaluated and managed. Results: In this study, out of 20 patients 12(60%) male and 08(40%) female. Male: Female = 3:2. The youngest patient of this series was 03 years and oldest was of 55 years. First categorization of severity of acute pancreatitis was done on the basis of Ranson score. Those patients whose score is 3 or more are categorized as severe. After categorization subsequent management was planned on the basis of laboratory and CT findings. Out of 20 patients all have raised WBC, serum Calcium level decrease in 16 patients, LDH raised in 16 patients, PaO2 decrease in 14 patients, Base deficitincreased in 12 patients, and blood urea nitrate raised in 14 patients. Contrast enhanced CT scan done in all patients and 12 patients were found with reduced enhancement in pancreas, peripancreatic edema and stranding of fatty tissue and remaining 8 patients have fluid collected in peri- and retro pancreatic space. Total 12 patients were given conservative treatment. Remaining 8 patients were operated whose CT findings were reduced enhancement in pancreas and these patients were suspected for infective pancreatic necrosis. In this study 3 patients were expired. Out of these three patients, 2 patients underwent operative intervention and 1 patient was given conservative treatment. Conclusion: Severe acute pancreatitis is a life threatening condition. Its serious regional and systemic involvement causes multiple organ or system failure. Early diagnosis and effective treatment can significantly reduce the mortality and morbidity. CBMJ 2019 July: Vol. 08 No. 02 P: 17-29

Management of Splenic Abscess after Splenic Arterial Embolization in Severe Acute Pancreatitis: A 5-Year Single-Center Experience

Gastroenterology Research and Practice ◽

10.1155/2019/6069179 ◽

2019 ◽

Vol 2019 ◽

pp. 1-5

Author(s):

Gang Li ◽

Lin Gao ◽

Jing Zhou ◽

Bo Ye ◽

Jingzhu Zhang ◽

...

Keyword(s):

Acute Pancreatitis ◽

Minimally Invasive ◽

Splenic Artery ◽

Pancreatic Necrosis ◽

Splenic Abscess ◽

Arterial Embolization ◽

Massive Bleeding ◽

Massive Hemorrhage ◽

Single Center Experience

Objective. To describe the management and prognosis of splenic abscess after splenic arterial embolization in severe acute pancreatitis (SAP) patients.Methods. This is a retrospective observational study. From August 2012 to August 2017, SAP patients with infected pancreatic necrosis (IPN) who underwent splenic arterial embolization after massive hemorrhage of the splenic artery were screened and those who developed splenic abscess were included for analysis. The demographic characteristics, etiology, treatment of splenic abscess, and clinical outcomes of these cases were collected and analyzed.Results. A total of 18 patients with splenic abscess formed after splenic arterial embolization were included for data analysis. The median age of the 18 patients was 46 years. The etiologies included biliary AP, hypertriglyceridemic AP (HTG-AP), and other causes. Ten patients underwent minimally invasive percutaneous drainage only for splenic abscess while the other eight patients received splenectomy. One patient died due to uncontrolled infection and another patient died due to massive bleeding, and the remaining sixteen patients survived.Conclusion. The incidence of splenic abscess was high in patients requiring splenic arterial embolization due to massive bleeding. Our data showed that most splenic abscess could be successfully managed with minimally invasive interventions, and traditional splenectomy should serve as a backup treatment.

The burden of acute pancreatitis and early experience of step-up approach for acute necrotizing pancreatitis at Military Hospital

Journal of Society of Surgeons of Nepal ◽

10.3126/jssn.v22i2.28723 ◽

2019 ◽

Vol 22 (2) ◽

pp. 11-17

Author(s):

Sushil Bahadur Rawal ◽

Uttam Laudari ◽

Basanta Khatiwada ◽

Anup Thapa ◽

Manoj Kumar Jha ◽

...

Keyword(s):

Acute Pancreatitis ◽

Early Experience ◽

Acute Necrotizing Pancreatitis ◽

Military Hospital ◽

Army Hospital ◽

Acute Necrotizing ◽

Hospital Resources ◽

Open Necrosectomy

Introduction: Twenty-five percent of acute pancreatitis develops severe acute pancreatitis (SAP). SAP patients have prolonged hospitalization and require a substantial amount of manpower and hospital resources. The aim of this study was to give an insight into the burden of acute pancreatitis at a tertiary level military hospital and to share the experience of managing pancreatic necrosis with the application of the step-up approach. Methods: A prospective descriptive study of consecutive patients was conducted at Shree Birendra Army Hospital from 2017 June to 2017 November. Patients with a diagnosis of acute pancreatitis admitted were stratified according to severity as per Revised Atlanta classification 2012. Patients with acute necrotizing pancreatitis were enrolled for the step-up approach. Patient’s demography, baseline investigations, radiology, prognostic scoring scales and type of intervention were analyzed. The burden of severe acute pancreatitis at our center and the early experience of the step-up approach at our centre within the study period were studied. Results: Out of 35 five patients with acute pancreatitis, 7 (20%) subsequently developed severe acute pancreatitis. Among them, five patients subsequently developed necrotizing pancreatitis who were managed according to the step-up approach. Out of them, three patients subsequently underwent operative intervention in the form of minimally invasive procedures like percutaneous drain placement, laparoscopic necrosectomy, video-assisted retroperitoneal debridement, and open necrosectomy. Conclusion: Acute pancreatitis is a common presentation at our centre. The step-up approach in the management of acute necrotizing pancreatitis is a safe and feasible approach.

Surgery in the Treatment of Acute Pancreatitis — Open Pancreatic Necrosectomy

Scandinavian Journal of Surgery ◽

10.1177/145749690509400209 ◽

2005 ◽

Vol 94 (2) ◽

pp. 130-134 ◽

Cited By ~ 47

Author(s):

J. Werner ◽

W. Hartwig ◽

T. Hackert ◽

M. W. Büchler

Keyword(s):

Acute Pancreatitis ◽

Late Phase ◽

Surgical Techniques ◽

Interventional Therapy ◽

Minimal Invasive ◽

Infected Necrosis ◽

Early Management ◽

Pancreatic Infection ◽

The Past

Management of acute necrotizing pancreatitis has changed significantly over the past years. Early management is non-surgically and solely supportive. Today, more patients survive the early phase of severe pancreatitis due to improvements of intensive-care-medicine. Pancreatic infection is the major risk factor with regard to morbidity and mortality in the late phase of severe acute pancreatitis. Whereas early surgery and surgery for sterile necrosis can only be recommended in selected cases, pancreatic infection is a well accepted indication for surgical treatment. Surgery should ideally be postponed until four weeks after the onset of symptoms as necrosis is well demarcated at that time. Four surgical techniques can be performed with comparable results regarding mortality: necrosectomy combined with (1) open packing, (2) planned staged relaparotomies with repeated lavage, (3) closed continuous lavage of the retroperitoneum, and (4) closed packing. However, closed continuous lavage of the retroperitoneum, and closed packing seem to be associated with a lower morbidity compared to the other two approaches. Advances in radiologic imaging, new developments of interventional radiology and other minimal access interventions have revolutionized the management of many surgical conditions over the past decades. However, minimal invasive surgery and interventional therapy for infected necrosis should be limited to specific indications in patients who are critically ill and otherwise unfit for conventional surgery. Open surgical debridement is the “gold standard” for treatment of infected pancreatic and peripancreatic necrosis.

Continuous regional arterial infusion versus intravenous administration of the protease inhibitor nafamostat mesilate for predicted severe acute pancreatitis: a multicenter, randomized, open-label, phase 2 trial

Journal of Gastroenterology ◽

10.1007/s00535-019-01644-z ◽

2019 ◽

Vol 55 (3) ◽

pp. 342-352 ◽

Cited By ~ 11

Author(s):

Morihisa Hirota ◽

Tooru Shimosegawa ◽

Katsuya Kitamura ◽

Kazunori Takeda ◽

Yoshifumi Takeyama ◽

...

Keyword(s):

Acute Pancreatitis ◽

Protease Inhibitor ◽

Continuous Regional Arterial Infusion

Analgesic Effect ◽

Pancreatic Necrosis ◽

Controlled Trial ◽

Nafamostat Mesilate ◽

Open Label ◽

Arterial Infusion ◽

Abstract Background Continuous regional arterial infusion (CRAI) of protease inhibitor nafamostat mesilate (NM) is used in the context of predicted severe acute pancreatitis (SAP) to prevent the development of pancreatic necrosis. Although this therapy is well known in Japan, its efficacy and safety remain unclear. Methods This investigator-initiated and -driven, multicenter, open-label, randomized, controlled trial (UMIN000020868) enrolled 39 patients with predicted SAP and low enhancement of the pancreatic parenchyma on computed tomography (CT). Twenty patients were assigned to the CRAI group, while 19 served as controls and were administered NM at the same dose intravenously (IV group). The primary endpoint was the development of pancreatic necrosis as determined by CT on Day 14, judged by blinded central review. Results There was no difference between the CRAI and IV groups regarding the percentages of participants who developed pancreatic necrosis (more than 1/3 of the pancreas: 25.0%, range 8.7–49.1% vs. 15.8%, range 3.4–39.6%, respectively, P = 0.694; more than 2/3 of the pancreas: 20%, range 5.7–43.7% vs. 5.3%, range 0.1–26.0%, respectively, P = 0.341). The early analgesic effect was evaluated based on 24-h cumulative fentanyl consumption and additional administration by intravenous patient-controlled analgesia. The results showed that the CRAI group used significantly less analgesic. There were two adverse events related to CRAI, namely bleeding and splenic infarction. Conclusions CRAI with NM did not inhibit the development of pancreatic necrosis although early analgesic effect of CRAI was superior to that of IV. Less-invasive IV therapy can be considered a viable alternative to CRAI therapy.

Severe Acute Pancreatitis and Necrotizing Pancreatitis

Critical Care Clinics ◽

10.1016/j.ccc.2015.12.006 ◽

2016 ◽

Vol 32 (2) ◽

pp. 279-290 ◽

Cited By ~ 29

Author(s):

Rahul Maheshwari ◽

Ram M. Subramanian

Keyword(s):

Acute Pancreatitis ◽

Necrotizing Pancreatitis