Abdominal pain suggestive of pancreatitis

Amylase or lipase > 3X normal

Characteristic findings on CT or MRI (or US)- Noncontrast CT sufficient- Contrast enhanced CT not required

but consider to confirm diagnosis- Ultrasonography

Diagnosis of Acute Pancreatitis

Diagnosis Requires 2 of 3 Criteria

1 Banks Gut, 2013. 62(1):102-11; 2Tenner Am J Gastro 2013. 108(9):1400-15; 3 IAP/APA Guideline Pancreatology 2013;13(4 Suppl 2):e1-e15

Definition of Onset of Acute Pancreatitis

• Onset of abdominal pain

• Not time of admission or presentation to ED

UNDER-DIAGNOSIS

Sensitivity of amylase1

• 32% in patients with alcoholic pancreatitis2

- Hypertriglyceridemia interferes w/assay• 95-98% by others3-7

Delayed, postmortem diagnoses8

• Glascow (1974-84): 126 deaths of 975 cases• 1st diagnosis at autopsy in 42% (53 of 126 deaths)• Etiologies: unknown (40%) gallstone (24%)

post-op (19%) alcohol (15%)• Characteristics: 13% presented with abdominal pain

9% had amylase measurement

Under-Diagnoses of Acute Pancreatitis

1Sternby Mayo Clin Proc 1996; 2Spechler Dig Dis Sci 1983; 3Satz Z Gastroenterol 1990; 4Lankisch Klin Wochenschr 1990; 5Lott Clin Chem 1991; 6Potts Surg Clin North Am 1988; 7Steinberg Ann Intern Med 1985; 8Wilson Int J Pancreatol 1988

PageDiagnosisSection1.1.1 Diagnosis & Risk Factors

TabEtiology / Risk Factors

ETIOLOGY

Remove this

Alcohol30-45%

Biliary30-45%

Idiopathic

Other

Etiology of Acute PancreatitisERCP-iatrogenicDrugsInfectiousHyperlipidemiaHypercalcemiaDuctal ObstructionTraumaPost-OperativeToxic (mushroom)VascularMisc (e.g. cancer, celiac)

Chronic pancreatitisMicrolithiasisGenetic- - - - - - - - - - - - - - - - - (Autoimmune)(Sphincter of Oddi Dysfxn)(Pancreas Divisum)

True Idiopathic < 10%

History smoking, alcohol, FH, trauma, hx gallstones, ERCP, medications, diabetes, hemo-dialysis, viral illness, prior attacks, chronic pancreatitis, *obesity, *age, *comorbidities,

Evaluation• LFTs, Calcium, Triglycerides (if no stones, alcohol)• Transabdominal US• Other: celiac 4 • Imaging to exclude tumor if age > 40 yrs• Referral to expert for idiopathic pancreatitis• Genetics: Age<30, FH, idiopathic (recurrent)

Etiologic Evaluation

1 Banks Gut, 2013. 62(1):102-11; 2Tenner Am J Gastro 2013. 108(9):1400-15; 3IAP/APA Guideline Pancreatology 2013;13(4 Suppl 2):e1-e15; 4 DiMagno Cur Opin Gastroenterol 2013. 29(5):531-6

5 Variables Help Distinguish Gallstone From Alcoholic Pancreatitis

GallstoneAlcohol

25

2 3-50

75

0-1

100

50

No. Positive Factors

% o

f Pat

ient

s

5 Predictive Variables• Age > 50 yrs• Female• AST >100 U/L• Alk Phos >300 IU/L• Amylase >4000 IU/L

1 Dougherty Surg Gyn Obstet 1988;166:491-66; 2 Carter Am J Surg 1988;155:10-17; 3 Wang Pancreas 1988;3:153-58.

Objective Parameters for DiagnosingGallstone Pancreatitis

Diagnostic Variables• Stones or sludge detected in gallbladder or CBD

• Elevated liver chemistries2

- transaminases have highest PPV

• Suggestive: dilated CBD

1 Banks Am J Gastroenterol 2006;101(10):2379-2400; 2 Tenner Am J Gastroenterol 1994;89(10):1863-1866;3 Johnson Pancreatology 2010;10(1)27-32.

SPECIFIC RISK FACTORS

- Obesity

- Alcohol

- Smoking

Obesity: Meta-analysis of 739 pts from 5 studies1

Risk associations - severe AP- complications- increased mortality

Alcohol: >2 drinks/day increases risk of necrosis2

OR 2.27 (95% CI 1.2-4.3)Risk independent of etiology of pancreatitis

Alcohol: Repeat counseling reduces attacks of RAP3

RAP = 21% (single) vs 8% (repeated) P=0.042Message: Biannual RVs to discuss sobriety

Risk Factors for Acute PancreatitisObesity and Alcohol

1Martinez 2006 Pancreatol; 2Papachristou 2006 Am J Gastro; 3Pelli 2008 Scand J Gastroenterol

How much chronic alcohol ingestion can cause alcoholic chronic pancreatitis?

4 - 5 drinks/d for 16 to 35 yrs has greatest risk<2 drinks/d may not increase riskCofactors important (AP in 3% of alcoholics) – smoking

Questions regarding bingingCan binge drinking by persons with alcoholic chronic pancreatitis induce an attack of “acute pancreatitis?”

Does binge drinking induce an attack of acute pancreatitis in persons without an alcohol history, no history of previous attacks, no chronic pancreatitis, and no other etiology for pancreatitis?

Risk Factors for Acute Pancreatitis“Drunkard’s Pancreas”1 - How much alcohol is too much?2-3

1Friedreich 1878 Diseases of the pancreas; 2Phillip 2011 CGH; 3DiMagno 2011 CGH

Association: CP: known since at least 18421-2

AP: case control3-4 and retrospect cohort5

Prospective cohort study 6Independent RF: 1st attack AP [OR 2.27 (1.5-3.1)]Total exposure correlates with overall risk

Population - Copenhagen City Heart Study (n=17,905)7

Record linkage with Danish National RegistryTotal pancreatitis: smokers HR 2.6 (1.1-6.2)Acute pancreatitis: ex-smokers HR 2.3 (1.3-4.1)

Multicenter, prospective cohort study (NAPS2)8

Independent RF: RAP & CP…but not 1st attack AP

Message: Smoking cessation…but risk may persist1Claessen 1842 2Andriulli 2010 Pancreas 3Talamini 1996 Pancreas 4Morton 2004 AJG 5Blomgren 2002 Eur J Clin Pharmacol; 6Lindqvist 2008 Pancreatol; 7Tolstrup 2009 Arch Int Med; 8Yadav 2009 Arch Int Med

Cigarette Smoking and Acute Pancreatitis

Meta-analysis: 3 case control & 2 cohort (n= 1836 pts) 1Variable RR95% CICurrent smoking 1.74 1.39-2.17Former smoking 1.32 1.03-1.71

Meta-analysis: 6 case control & 6 cohort (n= 3690 pts) 2Variable RR95% CIEver smoking 1.54 1.31-1.80Current smoking 1.71 1.37-2.14Former smoking 1.21 1.02-1.43

Dose response: ↑ risk 40%/10 cigs (95% CI, 30–51%)

Etiology: alcohol, idiopathic, drug; not gallstonepossibly protective for post-ERCP AP 2-3

1Yuharal Pancreas 2014;43: 1201–1207; 2Sun et al 2015 Pancreatology; 3DiMagno et al Pancreas 2013;42:996-1003

Cigarette Smoking & Acute PancreatitisSystematic Reviews & Meta-Analyses

PageDiagnosisSection1.1.1 Diagnosis & Risk Factors

TabEpidemiology

EPIDEMIOLOGY

Peery Gastroenterol 2012;143(5):1179-1187

National Inpatient Sample Database 2009Acute Pancreatitis: #1 GI reason for Hospitalization

Primary dx #Discharges% change Mortalityfrom 2000

Acute pancreatitis 274,119 +30 1.0%Cholelithiasis226,216 -140.4%Diverticulitis 219,133 +41 0.6%Acute appendicitis 207,345 +22 0.04%-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

GI hemorrhage 140,497 +22 3.5%CLD & viral hepatitis 136,752 +14 6.0%Functional Bowel dz130,744 +26 0.9%IBD 100,687 +37 0.4%Chronic pancreatitis 19,724 -230.4%

National Inpatient Sample Database 2009Increasing Discharges with Primary dx of Acute Pancreatitis

Increasing incidence - parallel increase in alcohol & gallstone AP

Explanations: increased incidence, better diagnostic tests

Brown 2008 JOP

Onset Predominantly 6th decade

Incidence Increasing in 10 non-UK countriesPrimarily alcoholic, less so gallstone

Etiology Gallstones 10.8-56%Idiopathic 8-44%Alcohol 3-66%

Mortality• Pop mortality rates: stable• Case fatality rates: decline 5-20% to 5%• Cumulative deaths: 65% (<14d) 80% (<30d)• Effect of aging: <40 years <5%

>80 years 30-40%Yadav and Lowenfels 2006 Pancreas

Epidemiology Outside USAReview 12 longitudinal studies: UK, non-UK, iceland

Incidence: Increase of 32% (age-standardized)Inc: biliary 52% > IP 18% > alcohol 12%

Etiology:Idiopathic 37%Biliary 33%

Alcohol 20%Mortality:

Case fatality rates: same (<6%), age #1 RFRisk remained 9-12 mos post-d/c

Etiology: AlcoholHome fatalities: 1/3 deaths, 75% alcoholic

Concern: Inpatient cholecystectomy in only 43% GS APFrey 2006 Pancreas

Epidemiology Within USACalifornia cohort of hospitalized pts 1994-2001

PagePredict & Define Disease SeveritySectionPredict Disease Severity: Scoring Systems

TabSIRS

SIRS - Simple- Allows repetitive assessment

Pulse >90/min

Rectal temp <36º C or >38º C

WBC <4,000 or >12,000 per mm3

RR >20/min or PCO2 <32 mm Hg

SIRSSystemic Inflammatory Response Syndrome

Score of >2 predicts severe disease

SIRS Score >2 During Initial 24 HoursIdentifies Those At Risk for Severe Disease & Death

Absence of SIRS >2 (on admission)• Up to 100% NPV for mortality, 3 but no guarantee• 98-100% NPV for severe acute pancreatitis 1

Mortality increases with higher SIRS score 1-3

SIRS Score (0-4)1 2 3 4

Mortality (%) 0%3%7%13%

1Singh CGH 2009;7:1247-51; 2Mofidi Br J Surg 2006;93:738-44; 3Buter Br J Surg 2002;89:298-302;

Persistent >2 SIRS (>48 hs)Associates with Increased Mortality

Mortality>2 SIRS % 2,4 Sensitivity1-3 Specificity1-3

Admission 7% ~100% 31%> 48h 25% 77-89% 79-86%

Assessment of persistent SIRS links • Prognosis• Patient characteristics• Response to therapy – emphasis on reassessment

1Singh CGH 2009;7:1247-51; 2Mofidi Br J Surg 2006;93:738-44; 3Buter Br J Surg 2002;89:298-302; 4Mole HPB (Oxford) 2009;11:166-70

PagePredict & Define Disease SeveritySectionPredict Disease Severity: Scoring Systems

TabGlasgow-Imrie

GLASGOW-IMRIE SCORE - Equal or superior to other predictors- Predictive early and at 48 hours

patient Age >55 yearsBUN >45 mg/dlGlucose >180 mg/dl Albumin <3.2 mg/dl Calcium <8 mg/dl LDH >600 IU/L

labs

WBC >15,000/ml blood gas PaO2 <60 mm HG

Glasgow Criteria or Imrie ScoreScore of >3 predicts severe acute pancreatitis

1Blamey Gut 1984;25:1340-6;

PagePredict & Define Disease SeveritySectionPredict Disease Severity: Scoring Systems

TabEvidence

Glasgow Criteria >3 During Initial 24 HsAppears Modestly More Predictive of Persistent OF vs Eight Scoring Systems & Two *Single Variables

1 Mounzer Gastroenterology 2012;142:1476-1482 – Validation Cohort of 397 patients (Boston)

Score Sensitivity Specificity PPV NPV AUCGlasgow 0.65 0.82 0.22 0.97 0.74*BUN 0.65 0.81 0.21 0.97 0.73APACHE-II 0.97 0.44 0.14 0.99 0.71*Creatinine 0.77 0.63 0.14 0.97 0.70BISAP 0.62 0.76 0.20 0.96 0.69JSS 0.42 0.89 0.23 0.95 0.66HAPS 0.73 0.58 0.12 0.97 0.66SIRS 0.69 0.58 0.11 0.96 0.64POP 0.46 0.81 0.16 0.95 0.64Ranson 0.46 0.80 0.16 0.95 0.64Panc-3 0.62 0.52 0.11 0.94 0.57

PagePredict & Define Disease Severity

SectionPredict Disease Severity: Scoring SystemsTab3-D Assmnt

Host Risk FactorsAge >55 y Ranson and Glasgow-Imrie Scoring systems 1-2

>50-80 y1-13 Increasing systemic complicationsIncreasing mortality 28% age >60 y 12

30-40% age >80 y 10,13

BMI >30 meta-analysis 14 and systematic review 15-16 Comorbidity not predictive 5-7

Prognostic tools e.g. SIRS 17-19 Others 20-22

Monitoring response to therapyPersistent SIRS 17-19 BUN 23 and Cr 24

1Ranson Am J Gastro 1974;61:443–51; 2Blamey Gut 1984;25:1340–6; 3Yadav Pancreas 2006;33:323-30; 4Frey Pancreas 2006;33:336-44; 5Gardner Pancreatology 2008;8:265–270; 6Uomo Ital J Gastroenterol Hepatol 1998;30:616-21; 7Fan Br J Surg 1988;75:463–466; 8Lankisch Pancreas 1996;13:344–349; 9Ong Br J Surg 1979;66:398-403; 10Trapnell Br Med J 1975;2:179-83; 11Imrie Br J Surg 1974;61:539-44; 12Corfield Gut 1985;26:724-9; 13Eland Scand J Gastroenterol 2000;35(10):1110-16; 14Martinez Pancreatology 2006;6:206-9; 15Wang Pancreatology 2011;11:92-8; 16Premkumar Pancreatology 2015;15:25-33;17Buter Br J Surg 2002;89:298-302; 18Singh CGH 2009;7:1247-51; 19Mofidi Br J Surg 2006;93:738-44; 20Papachristou AJG 2010;105:435-41.; 21Mounzer Gastroenterology 2012;142:1476-82; 22DiMagno AJG 2014;109:306-15; 23Wu Arch Intern Med 2011;171:669-76; 24Muddana AJG 2010;104(1):164-70

IAP/APA: “3-Dimensional Assessment”of Pancreatitis Severity & OutcomesGRADE-2B

PagePredict & Define Disease SeveritySectionDefine Disease Severity

TabOverview

Severe pancreatitis is defined by having 1 or both• Persistent organ failure (>48 hrs)

2012 Revised Atlanta Classification 1

• Infected pancreatic necrosis2012 Determinant Based Classification 2

Severe pancreatitis is predicted by 1-4

• Transient organ failure (<48 hrs)• Systemic inflammatory response syndrome (SIRS)• 3 dimensional assessment 4

Host RFs (age/BMI); Prognostic tools; Response to Rx

Defining and Predicting Severity & Outcome

1Banks Gut 2013;62(1):102-11; 2Dellinger Ann Surg 2012;256:875-80;3Tenner Am J Gastro 2013. 108(9):1400-15; 4 IAP/APA Guideline Pancreatology 2013;13(4 Suppl 2):e1-e15

Weeks 1-2 persistent organ failure (>48 h)Inflammatory response to tissue injuryNot necessarily related to extent of necrosis

Weeks 2-6 complication of infected necrosis

Timing and Cause of DeathDiffer at Each Stage of Pancreatitis

Banks Gut 2013;62(1):102-11

PagePredict & Define Disease Severity

SectionDefine Disease SeverityTabOrgan Failure

Defining Organ Failure – Marshall Score

PARAMETER SCORE0 1 2 3 4

PaO2 / FIO2 >400 400-301 300-201 200-101 <101

Creatinine (mg/ml) <1.4 1.4-1.8 1.9-3.6 3.7-4.9 >4.9

SBP (mm Hg) >90 <90Fluid

responsive

<90Not fluid

responsive

<90, pH<7.3

<90, pH<7.2

<48 hs Score >2 for >1 organ predicts severe disease >48 hs Score >2 for >1 organ defines severe disease

Marshall Crit Care Med 1995;23:1638-52; Banks Gut 2013;62(1):102-11

Clinical Significance of Organ FailureType of Organ Failure MortalityNone 2.5%

0% due to pancreatitis

On admission Transient 1.7%Persistent 36%

After admission Transient 0%(but <7 days) Persistent 26.7%

Single vs multisystem organ failure 3% vs 47%

Day of (any) death 38% at <1 wk; 62% at >1 wk

1Johnson Gut 2004;53:1340-4.; 2Banks AJG 2006;101:2379-400

Death 1-9% overall 1-2

20-25% in severe acute pancreatitis (AP) 3

Timing 6death Median days between onset AP & death = 6

Median days between onset OF & death = 3

MOF Key determinant of death 410-15% overall, 5 typically lung then renal OF 6

Analysis of 1024 cases of fatal AP 5

All had OF (defined by 8 organ systems)1 OF n=384 37%2 OF n=242 24%Multi- OF n=398 39%

Timing & Cause of DeathRole of Organ Failure (OF) & Multi-OF (MOF)

1Peery Gastroenterol 2012;143(5):1179-1187; 2Goldacre BMJ 2004;328:1466-9; 3Johnson Gut 2004;53:1340-4;4Buter Br J Surg 2002;89:298-302; 5Mitchell Lancet 2003;361:1447-55; 6Mole HPB 2009;11:166-70;

63%

PagePredict & Define Disease SeveritySectionDefine Disease Severity

TabInfected Necrosis

Meta-analysis of 14 studies and 1478 patients • OF defined by each study; IPN = positive culture

MortalityComplication N (%) Subgroup OverallOF 600 41% 30% (179) 12%IPN31421% 32% (102) 7%

• Interactions among complications and mortalityOF IPNMortality No Yes11%YesNo 22%YesYes43%

Death Influenced by Organ Failure (OF)and Infected Pancreatic Necrosis (IPN)

Petrov Gastroenterology 2010;139:813-20

Early stage Failure to Walled offNecrosis Improve Necrosis

Nutritional supportStep-up approach Intervention onlywhen symptomatic

Seek alternate sources Percutaneous Direct endoscopicof infectiondrainage necrosectomy

No role for Delay major Local expertiseprophylactic Abx interventions necrosectomy

Multi-disciplinaryapproach

Key Points: Management of Necrotizing Pancreatitis and its Complications

Persistent sepsis / deterioration- Despite max supportive care- No alternative infection

Gas in collection on CE-CT

Gram stain or culture +

Three Criteria Raise Concern for Infected Pancreatic Necrosis

1Banks Gut 2013; 2Tenner AJG 2013; 3Pancreatol 2013

Banks Gut 2013

Arrows: Border of acute necrotic collections Arrowheads: Gas bubbles

Step 1: Antibiotics & percutaneous drainage• Upsize catheters as needed• Daily irrigation

Step 2: video assisted retroperitoneal debridement (VARD)

• Minimally invasive surgery for failure to respond within 72 hours

• PANTER trial: 35% in step-up arm did not require further debridement

Step-Up Approach to Infected Necrosis

Percutaneous Endoscopic SurgeryDrainage Debridement

First line Access dependent Minimally invasiveBridge or definitive Technical expertise Salvage/Rescue

Interventions for Walled-Off Necrosis (WON)

• RCT n=88 patients• Suspected or confirmed pancreatic necrosis• Composite endpoint: new onset organ failure

perforation, bleeding or death• 40% step-up vs 69% open necrosectomy (p=0.006)

van Santvoort NEJM 2010;362:1491-502

Multi-center RCT Netherlands• N=22 patients• Endoscopic vs surgical necrosectomy (VARD)

following percutaneous drainage• Endoscopic necrosectomy: reduced IL-6 and

composite clinical outcomes

Multi-center US and German cohorts• US series, n=104 with 95% success• German series, n=93 with 84% success• Complications: bleeding, cyst cavity rupture,

mortality 1-7%

Evidence for Direct Endoscopic Drainage

Bakker JAMA 2012; Gardner GIE 2011; Seifert Gut 2009

SEVERITY CLASSIFICATIONSAND DEATH

REMOVE THIS

PagePredict & Define Disease SeveritySectionDefine Disease Severity

TabClassification Systems

2012 Revised Atlanta Criteria (RAC) 1- 3 Grades- Development: Web-based iterative process

2012 Determinants Based Classification (DBC) 2- 4 Grades- Development: Based on meta-analysis

Differences but generally comparable and complementary for predicting outcomes 3-7

ICU admission Hospital stay RAC MortalityICU length of stay Need for intervention DBC

Two New Severity Classification SystemsAre Comparable and Complementary

1Banks Gut 2013;62(1):102-11; 2Dellinger Ann Surg 2012;256:875-80; 3Thandassery Pancreas 2013;42:392-6; 4Jin Hepatobiliary Pancreat Dis Int 2014;13:323-7; 5Acevedo-Piedra Clin Gastroenterol Hepatol 2014;12:311-6; 6Nawaz Am J Gastroenterol 2013;108:1911-7; 7Windsor Pancreatology 2015;15:101-104

Mild No organ failureNo local or systemic complications

Moderate >1 Transient organ failure (<48 hs)Local or systemic complication

(e.g. acute peripancreatic fluid collection [APFC])

Exacerbation of a chronic illness(e.g. COPD, CAD)

Severe >1 Persistent organ failure (>48 hs)

2012 Revised Atlanta CriteriaDefinitions of Severity of Acute Pancreatitis

Banks Gut 2013;62(1):102-11

2012 Determinants Based ClassificationDefinitions of Severity of Acute Pancreatitis

Mild No organ failure or pancreatic necrosis

Moderate Sterile (peri)pancreatic necrosisAnd / Or

>1 Transient organ failure (<48 hs)

Severe Infected (peri)pancreatic necrosisAnd / or

>1 Persistent organ failure (>48 hs)

Critical Infected (peri)pancreatic necrosisAnd

>1 Persistent organ failure (>48 hs)Dellinger Ann Surg 2012:256:875-80

PageTherapySectionGoal Directed Fluid Therapy (FT)TabFT Algorithm

IV FLUID THERAPY (FT)

REMOVE THIS

1. Use crystalloid FT (Lactated Ringers) 2-4 GRADE-1B

2. Infuse (5-10 ml/kg/h) until hemodynamically stable 2, 4-9 GRADE-2B

Goals : HR <120, MAP 65-85, Urine output >50 ml/hCaution: Patients age >55, preexisting organ failure

3. Begin continuous FT 3 ml/kg/h 4, 8, 10

4. Adjust FT Q 6 hours by BUN checkpoint 2-4, 11-15

Checkpoint: Is BUN <20 mg/dl or BUN falling?If Yes: Change maintenance fluids to 1.5 ml/kg/hIf No: Reinfuse (5-10 ml/kg/h), THEN infuse 3

ml/kg/h

ALL PATIENTS: GOAL-DIRECTED FLUID THERAPY (FT)Emphasis on Initial 12 Hour FT Window (Adapted from 1)

1DiMagno AJG 2014;109:306-15; 2IAP/APA Guideline Pancreatology 2013;13:e1-e15; 3Tenner AJG 2013;108:1400-15; 4Wu CGH 2011;9:710–717; 5Rivers NEJM 2001;345:1368-77; 6Gardner CGH 2008;6:1070-6; 7DiMagno F1000 Med Rep 2009;1:59; 8Whitcomb NEJM 2006,354:2142-50; 9Mao Chin Med J 2009;122:169-73 10Wall Pancreas 2011;40:547-50 (2009 Gastro abstract); 11 Wu Gut 2008;57:1698–703 12 Wu Gastro 2009;137:129-35; 13Ranson Surg Gynecol Obstet 1974;139:69–81; 14Blamey Gut 1984;25:1340–6; 15Ueda Surgery 2007;141:51–8

Goal-Directed Fluid Therapy Applies to Patients with Predicted Severe and Mild Pancreatitis

Avoids overlooking and undertreating patients, particularly those with severe acute pancreatitis (AP) due to:

• Imperfection of risk stratification tools

• Potential evolution of mild to severe AP

PageTherapySectionGoal Directed Fluid Therapy (FT)TabFT Guidelines

• Initial FT type LR 1-2 (data limited 3) GRADE-1B

Initial FT rate 2013 ACG Guideline 1

250-500 cc/h: 6-12 L/24h more if unstable(Goal-directed)1B reduce BUN

Initial FT rate 2013 IAP/APA Guideline2

5-10 ml/kg/h ~8-17 L/24h typically 2.5-4.0 L Goal-directed1B >1 goal directed parametersGRADE-2B

1 Noninvasive HR <120 MAP 65-85 mmHgHct 35-44%U/O >0.5-1 ml/kg/h

2 Invasive stroke volumeintrathoracic blood vol determination

Goal-Directed Fluid Therapy (FT) in APACG and IAP/APA Guidelines 1-2

1Tenner AJG 2013;108:1400-15; 2IAP/APA Guideline Pancreatology 2013;13:e1-e15; 3Wu CGH 2011;9:710-717

PageTherapySectionGoal Directed Fluid Therapy (FT)TabFT Evidence

FT mitigates the hypovolemic shock that commonly accompanies acute pancreatitis, improving pancreatic microvascular perfusion and thereby improving patient outcomes

Historical View of Fluid Therapy (FT)for Shock in Acute Pancreatitis

1Elliott AMA Arch Surg. 1957;75:573-579; 2Elliott Gastroenterology. 1955;28:563-587; 3Klar Br J Surg 1990;77:1205-1210; 4DiMagno AJP-GI Liv Physiol 2004;287:G80-G87; 5Cuthbertson Br J Surg 2006;93:518-530; 6Gardner CGH 2008;6:1070-1076; DiMagno F1000 Med Rep. 2009;1:59.

2013 Systematic Review: Weak Evidence for Fluid Therapy (FT) in Pancreatitis

• Evidence for recommending rates and type of FT ‘‘remains paltry and of poor quality’’

• Inconclusive whether higher rates of FT prevent or contribute to clinical outcomes

• reverse causation bias 2

• Limitations of FT are that it beginso after initiation of clinical acute pancreatitiso when the ‘‘therapeutic window’’ for FT is closing

1Haydock et al Fluid therapy in acute pancreatitis: anybody’s guess. Ann Surg. 2013;257:182-188; 2 de Madaria Pancreatology 2014;4:433-35

Sepsis – Extrapolation to Acute Pancreatitis?Fluid Therapy (FT) Window in First 6-12 hs

Sepsis Model1 - 1st 6 hs CriticalGoal-directed boluses (initially 1000 ml/h)Impact questioned by recent studies 8-9

Acute Pancreatitis (AP)Standardized FT protocol lacking2-3

Patients with severe AP- Frequently require >5 L during initial 24 hs4

Better outcomes with early FT3, 5

- First 6-12 hs may be critical 5 - Use early goal-directed FT6-7 GRADE-1B

1Rivers NEJM 2001;345:1368-77; 2DiMagno F1000 Med Rep 2009;1:59; 3Gardner CGH 2008;6:1070-6; 4Forsmark Gastro 2007;132:2022-44; 5Wall Pancreas 2011;40:547-50 (2009 Gastro abstract); 6Wu CGH 2011;9:710-17; 7Wu Gastro 2009;137:129-35; 8Mouncey NEJM 2015;372:1301-11; 9Angus Intens Care Med 2015; 41:1549-60.

TherapeuticWindow!

TherapeuticWindow??

Death stratified by admit BUN & predicted by• Admit BUN cutoff of 22mg/dl (75th %tile)

• Serial BUN increase or decrease

Admission and Serial BUN Predicts DeathPotential Gauge of (In)adequacy of Fluid Therapy

Wu Gastroenterology 2009;137:129-35

0 to 5 5 to 10 >10

24 hour increase in BUN mg/dL0 to 5 5 to 10 > 10

Dea

th (%

)

Dea

th (%

)

0

5

10

15

20

25 Admit BUN <22 mg/dLAdmit BUN >22 mg/dL

0

5

10

15

20

25

24 hour decrease in BUN mg/dL

Admit BUN <22 mg/dLAdmit BUN >22 mg/dL

2 RCTs from China3-4 report a higher frequency of complications with more aggressive FT

• Faster FT infusion rates (10-15 ml/kg/h vs 5-10 ml/kg/h) increases rates of respiratory failure, abdominal compartment syndrome, sepsis and mortality 3

• Rapid hemodilution within 48 h (Hct <35% vs Hct >35%) increases rates of sepsis and mortality 4

Current Guideline Recommendations Avoid Overly Aggressive Fluid Therapy (FT)1-2

1Tenner AJG 2013;108:1400-15; 2IAP/APA Guideline Pancreatology 2013;13:e1-e15;3Mao Chin Med J 2009;122:169-73; 4Mao Chin Med J 2010;123:1639-44;

Promising Data for IV Fluid Therapy (FT) In Pancreatitis

FT improves survival• Dogs 9%vs 50% 4 • Mice 31% vs 67% 5

Does not• Prevent AP 4-5

• Maintain pancreatic perfusion afteronset of microcirculatory damage,which occurs within 8h of AP onset 2

Survival Benefit of Early Fluid Therapy (FT)Given Before/During Induction of Experimental AP1-6

1Klar Br J Surg 1990;77:1205-1210; 2Cuthbertson Br J Surg 2006;93:518-530; 3Gardner CGH 2008;6:1070-76; 4Horton Surgery 1988;103:538-546; 5Niederau Gastroenterology 1988;95:1648-1657; 6Knol J Surg Res 1987;43:387-92

Surv

ival

(%)

H20ad lib

0

100

0

40

80

4 6 8ml s.c crystalloid / day

60

20

P<0.05

P<0.01

67%

37%

64%

Survival in Mice at 168 hrs

54%

31%

Two cohort studies 1-2

• Greater periprocedural FT- Independent predictor of less severe PEP- Associates with shorter hospital LOS

One small RCT (n=64 pts) 3

• Aggressive vs standard FT: Less frequent PEP• Cautionary editorial (sample size, methodology) 4

A prospective validation study has begun (USA)

1DiMagno Pancreas 2014;43:642-647; 2Sagi J Gastroenterol Hepatol 2014;29:1316-20;3Buxbaum CGH 2014;12(2): 303-7; ; 4Elmunzer CGH 2014;12:308-10;

Clinical Illustration of FT Window in APEvidence from Post-ERCP Pancreatitis (PEP)

Experimental pancreatitis (comparison to crystalloid)• Greater survival with hypertonic saline4 and colloids

(Albumin;5-6 HMW dextrans;7-14 FFP;15 Purified bovine hgb16-17)

Clinical pancreatitis – few studies 18-20

• Less SIRS Lactated ringers (LR) vs Normal saline 18

• Less abd HTN Hydroxyethyl starch vs LR 19

Critical care/sepsis – Fluid type confers no benefit• No benefit Colloid vs Crystalloid 21

• No benefit Albumin vs Crystalloid 22-24 • Harm (AKI)Hydroxyethyl starch vs Crystalloid 25-26

Optimal Fluid Type, Particularly Use of Colloid, is Controversial in Pancreatitis1-3 and Sepsis

1Klar Br J Surg 1990;77:1205-1210; 2Cuthbertson Br J Surg 2006;93:518-530; 3Gardner CGH 2008;6:1070-1076; 4Shields Br J Surg 2000;87:1336-1340; 5Elliot AMA Arch Surg 1957;75:573-579; 6Elliot Gastroenterol 1955;28:563-587; 7Anderson JAMA1965;192:398-400; 8Donaldson Surgery;1978;84:313-321; 9Donaldson Ann Surg 1979;190:728-731; 10Klar Ann Surg 1990;211:346-353; 11Schmidt Am J Surg 1993;165:40-44; 12Schmidt Intensive Care Med 1996;22:1207-1213; 14Goodhead Surg Gynecol Obstet 1969;129:331-340; 14Knol J Surg Res 1983;35:73-82; 15Leese Int J Pancreatol 1999;3:437-447; 16Strate Pancreas 2005;30:254Y259; 17Strate Ann Surg 2003;238:765-771; 18Wu CGH 2011;9:710-717; 19Du Pancreas 2011;40:1220-1225; 20Leese Ann R Coll Surg Engl 1991;73:207-214; 21Perel Cochrane Database Syst Rev 2013 Feb 28;2; 22Finfer NEJM 2004;350:2247-2256; 23Roberts Cochrane Database Syst Rev. 2011 Oct 5;(10); 24Caironi NEJM 2014;370(15):1412-21; 25Perner NEJM 2012;367:124-134; 26Mutter Cochrane Database Syst Rev 2013 Jul 23;7;

Results of a full cycle QI project

Illustration of a goal-directed FT algorithm

1DiMagno AJG 2014;109:306-15

PageTherapySectionGoal Directed Fluid Therapy (FT)TabFT Complications

IV Fluid Therapy (FT) Complications

- Abdominal Hypertension

- Abdominal Compartment Syndrome

IA pressure (IAP) measured by transbladder technique• IAH IAP >12 mm HG• ACS IAP >20 mm HG and new OF

Etiology• Inflammation of the pancreas• Overly aggressive fluid therapy• Large peripancreatic collections

Treatments• Noninvasive: analgesia, neuromuscular blockade, body

position, GI decompression, neostigmine, fluid balance• Minimally invasive: percutaneous catheter drainage• Invasive: decompressive laparotomy

Abdominal Compartment Syndrome (ACS) & Intra-Abdominal (IA) Hypertension (IAH) in Pancreatitis

1Kirkpatrick Intens Care Med 2013;39:1190-1206

Retrospective 2-center study (Brigham & Alicante Univ)

Variable P Multiple linear regressionYounger age <0.05

Alcohol etiology <0.001Elevated Hct <0.001Elevated glucose<0.05SIRS <0.01

Median fluid sequestration (FS) = 3.2 L Increasing FS associated: longer LOS POF

fluid collections necrosisCausation unclear: most variables associate with SAP

Variables Associated with Fluid Sequestration (FS) During 1st 48 hrs of AP Care

De Madaria Clin Gastroenterol Hepatol 2014;12:997-1002

Systematic Review of 7 Studies of Abdominal Compartment Syndrome (ACS) in Acute Pancreatitis

1van Brunschot Pancreas 2014;43:665-74

ACS in 103 (38% of 271) -> intervention in 87 (84% of 103)

First intervention in 87 with invasive intervention• Percutaneous catheter drainage 11 (13%)

• Subsequent surgical decompression 8 (73%)• Surgical decompression 76 (87%)

- Median IAP (mm Hg) fell from 33 to 18

Outcomes ACS No ACSOverall mortality 49% (50/103) 11% (19/168)Mean hospital stay76 daysMean ICU stay 23 days

TREATMENT – MEDICAL

REMOVE THIS

PageTherapySectionNutrition, Analgesia & Preventing ComplicationsTabNutrition Guidelines

NUTRITIONAL SUPPORT

REMOVE THIS

Mild disease• Begin oral feeding when nausea, vomiting and

abdominal pain improvingGRADE-2B

• Low fat as diet as safe as clear liquids

Severe disease• Begin oral feeding when hunger returns (~8 days) 3 • Enteral feeding by 72 hrs - reduces infectious complications 1B

• NG vs NJ delivery comparably effective & safeGRADE-2A

• Polymeric or elemental formulationsGRADE-2B

• Avoid parenteral nutrition if possibleGRADE-2C

Nutritional Support in Acute PancreatitisACG and IAP/APA Pancreatitis Guidelines 1-2

1Tenner AJG 2013;108:1400-15; 2IAP/APA Guideline Pancreatology 2013;13:e1-e15; 3 Zhao, Nutrition 2015, 31:171-5

PageTherapySectionNutrition, Analgesia & Preventing ComplicationsTabNutrition Evidence

Systematic Reviews 1-2 and Guidelines 3-7

Begin EN early for severe APLess costly than PNReduces infection:- gut barrier - glycemic control 8

Pooled Data From Meta-analyses 9-11

EN superior to PN in predicted SAPOutcome OR (pooled) RefInfectious complications 0.24-0.48 9-11

Organ failure (>2 organs)0.33 10-11

Mortality 0.25-0.32 9-11

Greatest Benefit: EN started within 48 h 11

Enteral (EN) vs Parenteral (PN) Nutrition

1McClave JPEN 2006;30:143-56; 2Al-Omran Cochrane Database Syst Rev 2010:CD002837; 3Meijer Clin Nutr 2006;25:275-84; 4Banks AJG 2006;101:2379-400; 5Nathans Crit Care Med 2004;32:2524-36; 6Tenner 2013;108:1400-15; 7IAP/APA Guideline Pancreatology 2013;13:e1-e15; 8Petrov Clin Nutr 2007;26:514-23; 9Petrov Arch Surg 2008;143:1111-7; 10Cao Ann Nutr Metab 2008;53:268-275; 11 Petrov Br J Nutr 2009;101:787-93;

19-Center Dutch RCT (N=208 with predicted SAP)• Early EN within 24 hs of randomization • On-demand oral diet 72 hs after admission (tolerated=69%)

or EN if oral diet not tolerated

Outcome % P Composite endpoint 30 vs 27 0.76

Major infection 25 vs 26 0.87Death w/in 6 months 11 vs 7 0.33

Limitations2-3 Only 1/3 had actual SAP40% of feeding tubes dislodgedParallel treatments uncontrolled (e.g. fluids)

Early Enteral Nutrition (EN) is Not Superior to On-Demand Feeding in Pancreatitis

1Bakker NEJM 2014;37(21):1983-93; 2Petrov NEJM 2015;372:684-5; 3Moran NEJM 2015;372:684-5

Systematic review, Meta-Analysis of 15 RCTs3 Treatment arms: ENPN NN (no nutrition)

Meta-AnalysesIndirect-Adjusted Random EffectsEN vs NN PN vs NN EN vs PN(1 RCT, n=27) (3 RCT, n=113) (11 RCT, n=453)

Mortality RR (95% CI) 0.22 (0.07-0.7) 0.35 (0.13-0.97)0.6 (0.32-1.14) P=0.01 P=0.04 P=0.12

Infection RR (95% CI) 0.56 (0.07-4.3) 1.36 (0.18-10.4)0.41 (0.30-0.57) P=0.58P=0.77 P<0.00001

Petrov Aliment Pharmacol Ther 2008;28:704-712

Enteral (EN) & Parenteral Nutrition (PN)Reduce Mortality in Acute Pancreatitis

PageTherapySectionNutrition, Analgesia & Preventing ComplicationsTabAnalgesia

ANALGESIA

REMOVE THIS

Verify: Diagnosis, treatment history, MAPS, drug test

Options: Those without contraindications (above)

1. Ketorolac

2. Oral opioids

3. PCA (if parenteral therapy is needed)

• Morphine preferred•

• Appropriate dose based on prior opioid exposure

• See PCA order sets: opioid naïveopioid tolerantopioid highly tolerant patients

Pain Management

Recommendations of Dr. Daniel Berland July 16, 2010

PageTherapySectionNutrition, Analgesia & Preventing ComplicationsTabPrevent Complications

PREVENT COMPLICATIONS- Persistent organ failure

- Mortality

- Infections

- Deep venous thromboses

Are Complications and Death Preventable?Answer: IAP/APA Acute Pancreatitis Working Group (2012)

Responses to Early Fluid † Enteral Treatment Therapy 1 Nutrition 2,3

SIRS * yes unclear 4,5

Organ failure * yes yesPancreatic necrosis no noInfections yes yesMortality * yes yes

† Data for enteral nutrition is compared to parenteral nutrition

1Gardner CGH Pancreatology 2008;8:265-70; 2Al-Omran Cochrane Database Syst Rev 2010:CD002837; 3Petrov Arch Surg 2008;143:1111-7; 4Petrov Br J Nutr 2009;101:787-93; 5Bakker Pancreatology 2014;14:340-6; 6Bakker NEJM 2014;371:1983-93;

Antibiotics1-6

• Indicated Proven infection, sepsis 1,2

• Not indicated Prophylaxis for sterile necrosis 3-7

RCT (114 pts) with necrotizing or clinically severe AP 3Cipro/flagyl vs placebo -> no impact on infected necrosis or mortality

RCT (32 centers, 100 pts) with necrotizing AP 4Meropenam vs placebo -> no impact on infected necrosis or mortality

2010 Cochrane meta-analysis -> prophylactic Abx no benefit 5

Prevent infection 8 UTI from catheters, line infection, HAPProphylaxis 8-9 Pulmonary & skin hygiene

Elevate head of bed 30 degreesDVT prophylaxis

PICC line IVF, blood draws, (antibiotics)

Preventing Infections & DVTs

1Nathens Crit Car Med 2004; 2Dellinger Crit Care Med 2013; 3 Isenmann Gastroenterology 2004; 4 Dellinger Ann Surg 2007; 5 Villatoro Cochrane Meta-analysis 2010; 6Tenner Am J Gastro 2013. 108(9):1400-15; 7 IAP/APA Guideline Pancreatology 2013;13(4 Suppl 2):e1-e15; 8 Wu Gastroenterology 2008; 9 Wu Gastroenterology 2013;

ICU EVALUATION

- Severe disease

- Severe comorbidities

- REMOVE THIS

PageICU-EvalSectionICU EvaluationTabGuidelines

Assessment for admission to ICU in patients at high risk for deterioration

• Persistent SIRS (Predicted severe disease)

• Inadequate response to IV fluid resuscitation

- Unclear intravascular volume status

• Elderly and obese

• Comorbidities

IAP/APA Guideline Pancreatology 2013;13(4 Suppl 2):e1-e15

Guidelines for ICU EvaluationIAP/APA 2013 1

Variable Definitions• Pulse <40 or >150 bpm• SBP <80 mmHg• MAP <60 mmHg• DBP >120 mmHg• RR >35 breaths/min• Serum sodium <110 or >170 mmol/l• Serum potassium <2.0 or >7.0 mmol/l• PaO2 <50 mmHg• pH <7.1 or >7.7• Serum glucose >800 mg/dl• Serum calcium >15 mg/dl • Anuria• Coma• Severe acute pancreatitis persistent organ failure

Guidelines for ICU EvaluationSociety of Critical Care Medicine (SCCM) 1-2

1Crit Care med 1999;27:633-8; 2IAP/APA Guideline Pancreatology 2013;13(4 Suppl 2):e1-e15

PageICU-EvalSectionICU EvaluationTabHigh Risk Groups

Individualize Care of High-Risk Groups

High Risk Conditions

Renal failure - GFR < 40 ml/minHeart failure - NYHA II, recent MIRespiratory - COPD, pneumoniaLiver failurePregnancyOther conditionsTransfers to U of M

Cautious approach to avoid over resuscitation• ? ICU• ? Intravascular monitoring

PageICU-EvalSectionICU EvaluationTabLow ICU Use

• Strong evidence is lacking 2-3

• Limited ICU availability (hospital congestion) 2

• High resource utilization 2

• Resources not controlled by the practitioner 4

Multiple Factors Contribute to Infrequent ICU Admissions for Acute Pancreatitis

1DiMagno Am J Gastro 2014; 2Nathans Crit Care Med, 2004;32(12):2524-36; 3Dube Royal College of Surgeons of Edinburgh, 2001;46(5):292-6; 4Foitzik Pancreatology, 2007;7(1):80-5

TREATMENTOF

BILIARY PANCREATITIS

- Early ERCP criteria

- Cholecystectomy

- REMOVE THIS

PageTherapySectionERCP & Cholecystectomy

TabERCP

ERCP Indications For Gallstone Pancreatitis

Probably indicated: Severe AP with biliary obstruction• Optimal timing unknown (24-72 hours)

1Neoptolemos Lancet 1988; 2Fan NEJM 1993; 3Folsch NEJM 1997; 4Runzi Gastro 1999; 5IAP guidelines (Uhl) 2002; 6NIH Consensus 2002; 7Banks AJG 2006; 8Forsmark Gastro 2007; 9Nathens Crit Care Med 2004; 10Petrov Ann Surg 2008; 11Moretti Dig Liver Dis 2008; 10Banks Gut 2013; 11Tenner AJG 2013; 12Pancreatol 2013; 13Kiriyama J Hepatobiliary Pancreat Sci 2013

2013 Tokyo Guideline13

SuspectedFever or chillsInflammation (e.g. wbc)Abnormal LFTsJaundice

Definite (above plus)Biliary dilationEtiology on imaging

(stone)

Need1

Need1

Indicated: Cholangitis -> ERCP within 24 hrs

Charcot’s triad

• RUQ pain• Jaundice• Fever

Reynolds pentad (above plus)• Hypotension• Confusion

Cholecystectomy for Gallstone AP

Mild pancreatitis – during index admission 2-7 Study of 220 pts w/mild-mod dz (<3 Ranson’s) – w/in 2-3 d 8

- ↓ ed hosp stay (4 vs 7) with similar complications (no deaths)

Necrosis or peripancreatic fluid collections• Delay until collections resolve or persist beyond 6 weeks• Possible infection risk for early CCY (7 vs 47%) 9

Post-Cholecystectomy• Risk of AP same as the general population 10

1Elfstrom 1978 Acta Chir Scand; 2Uhl 1999 Surg Endosc ; 3IAP guidelines 2002; 4McAlister 2007 Cochrane Database of Syst Rev; 5Tenner AJG 2013; 6IAP/APA Guideline Pancreatology 2013; 7Van Baal 2012 Ann Surg; 8Rosing 2007 J Am Coll Surg; 9Nealon 2004 Ann Surg; 10Moreau 1988 Mayo Clinic Proc

PageTherapySectionERCP & Cholecystectomy

TabCholecystectomy

Cholecystectomy for Mild Gallstone APRisks of Wait-and-See Approach

No Cholecystectomy during index admission• Overall risk of recurrent AP ranges 29-63% 3

• At 6 wks 25% risk of recurrent AP, cholecystitis, or cholangitis 1,4

• Additional 25% may have biliary colic without pancreatitis 1,4

• 78% increased mortality for wait-and-see approach (Cochrane) 4

2012 Systematic Review 7

• At 6 wks 18% readmission for recurrent biliary events

ERCP and sphincterotomy w/o Cholecystectomy 7-8

• Decreased rate of AP but not other biliary events

1Elfstrom 1978 Acta Chir Scand; 2Uhl 1999 Surg Endosc ; 3IAP guidelines 2002; 4McAlister 2007 Cochrane Database of Syst Rev; 5Rosing 2007 J Am Coll Surg; 6Moreau 1988 Mayo Clinic Proc; 7Van Baal 2012 Ann Surg; 8Bakker 2011 Br J Surg;

DISCHARGE PLANNINGAND

READMISSION

- Discharge Criteria

- Cholecystectomy

- Remove this

PageDischarge & Readmission

SectionDischarge Planning & Reducing Risk of Readmission

TabReasons for Readmission

Retrospective cohort of discharges (Brigham, 2005-2007)• 30-day re-admission 19% (47/248)• Similar to 10-30% in high risk groups (elderly, CHF, asthma)

Exclusions: chronic pancreatitis, death, hospice, no documented f/u

Reasons for early readmission % nAcute pancreatitis (AP) 28% 13/47Symptoms of AP (abd pain, n/v, diarrhea) 19% 9/47Complications - of AP (e.g. pseudocyst) 17% 8/47 - of therapy for AP (e.g. catheter infection) 15% 7/47 - of index hospitalization (e.g. nosocomial infection) 9% 4/47Common etiologic factor (GS, etoh) 9% 4/47Exacerbation of comorbidity 4% 2/47

Whitlock 2010 Am J Gastro

Discharge Planning/Readmission Rate

Multivariate analysis of risk factors for early readmission

Variable OR95% CI* GI symptoms (n/v, diarrhea) 44.2 4.1-472.1Less than solid diet at d/c 23.8 4.8-118.2Alcohol use after d/c (>= 1 drink/d) 10.1 1.2-82.6NS: *pain (p=0.07), abdominal drains and/or antibiotics at hospital dischargeNS Factors in univariable analysis: severity, comorbidities, OSH transfers

Message Address readmission criteria prior to discharge

3 Variables Predict Early Unplanned Readmission After Hospital Discharge For Pancreatitis

Whitlock 2010 Am J Gastro

Alcohol 1-3Gallstone 2-4 Post-ERCP prophylaxis

Repeated counseling Early cholecystectomy MPD stenting 2, 5

6-month intervals Mild/uncomplicated High-risk

Rectal NSAID 2, 6-8

High-risk

Prevention of (Re)Admission For Pancreatitis

1Nordback Gastroenterology 2009; 136:848-55; 2Tenner AJG 2013;108:1400-15; 3IAP/APA Guideline Pancreatology 2013;13:e1-e15; 4 Van Baal Ann Surg 2012;255:860e6; 5 Andriulli Digestion 2007;75:156–63; 6Sotoudehmanesh AJG 2007;102:978–83; 7Elmunzer Gut 2008;57:1262–7; 8Elmunzer NEJM 2012;366:1414–22

PageDischarge & Readmission

SectionDischarge Planning & Reducing Risk of Readmission

TabCholecystectomy

RecommendationsTiming of Cholecystectomy for Gallstone APMild pancreatitis – during index admission 2-7

Study of 220 pts w/mild-mod dz (<3 Ranson’s) – w/in 2-3 d 9

- ↓ ed hosp stay (4 vs 7) with similar complications (no deaths)

Necrosis or peripancreatic fluid collections - delayed• Delay until collections resolve or persist beyond 6 weeks• Possible infection risk for early CCY (7 vs 47%) 10

Post-Cholecystectomy• Risk of AP same as the general population 11

1Elfstrom 1978 Acta Chir Scand; 2Uhl 1999 Surg Endosc ; 3IAP guidelines 2002; 4McAlister 2007 Cochrane Database of Syst Rev; 5Tenner AJG 2013; 6IAP/APA Guideline Pancreatology 2013; 7Tenner AJG 2013; 8Van Baal 2012 Ann Surg; 9Rosing 2007 J Am Coll Surg; 10Nealon 2004 Ann Surg; 11Moreau 1988 Mayo Clinic Proc

Evidence Supports Cholecystectomy During Index Admission for Mild Gallstone AP

Significant Complications without Cholecystectomy• Overall risk of recurrent AP ranges 29-63% 3

• At 6 wks 25% risk of recurrent AP, cholecystitis, or cholangitis 1,4

• Additional 25% may have biliary colic without pancreatitis 1,4

• 78% increased mortality for wait-and-see approach (Cochrane) 4

2012 Systematic Review 7

• At 6 wks 18% readmission for recurrent biliary events

ERCP and sphincterotomy w/o Cholecystectomy 7-8

• Decreased rate of AP but not other biliary events

1Elfstrom 1978 Acta Chir Scand; 2Uhl 1999 Surg Endosc ; 3IAP guidelines 2002; 4McAlister 2007 Cochrane Database of Syst Rev; 5Rosing 2007 J Am Coll Surg; 6Moreau 1988 Mayo Clinic Proc; 7Van Baal 2012 Ann Surg; 8Bakker 2011 Br J Surg;

MANAGINGPANCREATIC COLLECTIONS

Is this going to go under Therapy?

Interstitial edematous pancreatitis

Necrotizing pancreatitis

APFC (acute peripancreatic fluid collection)

Pancreatic pseudocyst

ANC (acute necrotic collection)

WON (walled-off necrosis)

DEFINITIONSSix Pancreatic Morphologic Descriptors

Banks Gut 2013

Complications of Pseudocyst• Severe pain• Obstruction (CBD, duodenum)• Dissection• Bleeding• Infection• Leakage (ascites, pleural effusion)• Rupture

Pseudocysts & InterventionIndications• Size > 5 cm• Duration > 6 weeks• Severe pain• Rapid expansion• ComplicationsTechniques• Surgical• Percutaneous• Endoscopic

Banks Gut 2013