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Management of Acute Pancreatitis

Authors:
Pasquale Cianci at Università degli studi di Foggia
Pasquale Cianci
Giaracuni G
Giaracuni G
Giaracuni G
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Fernanda Vovola at Università degli studi di Foggia
Fernanda Vovola
Nicola Tartaglia at Università degli studi di Foggia
Nicola Tartaglia
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9:A
:
:F
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B
07*./+++H/+*61
24
H*H*A00
' 0+-,
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.1
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  !
004(&<
?::
BGA
Dir Bil
(0.02 – 0.30
mg/dL)
<2 mg/dl
Dir Bil
(0.02 – 0.30
mg/dL)
2 -5 mg/dl
AST/ALT X3 g-GT (7-38 u/L)
>200 u/L
61.2% 38.8% 29.4% 63.4%
Serum Calcium
(8.4 – 10.5
mg/dL)
>10.5 mg/dL
Trygliceridaemia
(40-170 mg/dL)
>170 mg/dL
Cholecystic
lithiasis/slugde
CBD size (US)
(8mm)
Undefined
etiology
16% 43% 84% 41.3% 6.8%
  !
  !
::C&# '  !!'
D
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A ++
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/ J0+5 6*./+34251
2 0+H7+5 *4.73,+51
, :7+5 



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!F5 !53
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?

.#1.51
 7375.*H*-1
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& -3*45.7H,*1 //3/5.2H*-1
$B ,0345.04H,*1 6/3/5.*0H*-1
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-+7+
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=
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
3%777+-,,-
-
•-
•+-
•+-
#%# ! $ 
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4
5
%(--%%
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3
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L7+
&++0,+
(!
=:029::3
#:A
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#(?
:/27.6/3/51A
,?
@:C(!
60H
,7
-/
*4
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-+7+00++77+0
#%# ! $ $

:004(
&
*I:
&H&64K*0
.*,3251
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:
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D::
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:

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#%# ! $ $

:004(
&
/I:
D:
004(&A9
0,:./1*2*
.7-A42519:(&?
'#&H
Direct bilirubin (range 0,1 – 0,3 mg/dL) 0.17 mg/dL
Gamma-GT (range 31-64 iU/L) 52 iU/L
AST (range 22-57 iU/L) 25 iU/L
ALT (range 25-64 iU/L) 31 iU/L
Lipasemia (range 120-221 iU/L) 165 iU/L
Pancreatic amylasemia (range 34-72 iU/L) 47 iU/L
Alkaline phosphatase (range 67-220 iU/L) 115 iU/L
CBD size (range 5-8 mm, Abdominal US) 7 mm
Detection of CBD stones (Abdominal US) -
#%# ! $ $

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5;5(@:C8
::C&+0)++<2:2F76
@+8;16544?8<7+-2-
,-(!
Direct bilirubin (range 0,1 – 0,3 mg/dL) 0.21 mg/dL
Gamma-GT (range 31-64 iU/L) 48 iU/L
AST (range 22-57 iU/L) 24 iU/L
ALT (range 25-64 iU/L) 29 iU/L
Lipasemia (range 120-221 iU/L) 171 iU/L
Pancreatic amylasemia (range 34-72
iU/L)
42 iU/L
Alkaline phosphatase (range 67-220
iU/L)
105 iU/L
CBD size (range 5-8 mm, Abdominal US) 5 mm
Detection of CBD stones (Abdominal US) -
#%# ! $ $
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
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:+3616+461;
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Home monitoring vs hospitalization for mild acute pancreatitis. A pilot randomized controlled clinical trials
Article
Full-text available
  • May 2023
Introduction: Acute pancreatitis is a high-incidence benign disease. In 2009, it was the second highest cause of total hospital stays, the largest contributor to aggregate costs (approximately US$ 7000.00 per hospitalization), and the fifth leading cause of in-hospital deaths in the United States. Although almost 80% of acute pancreatitis cases are mild (usually requiring short-term hospitalization and without further complications), severe cases can be quite challenging.Classifications, scores, and radiological criteria have been developed to predict disease severity and outcome accurately; however, in-hospital care remains of widespread use, regardless of disease severity. A recent Turkish study reported that mild acute pancreatitis can be effectively and safely managed with home monitoring. Although the optimal timing for oral refeeding remains controversial and could cast some doubt on the feasibility of home monitoring, some guidelines already advocate for starting it within 24 hours.The present clinical trial aims to assess whether home monitoring is effective, safe and non-inferior to hospitalization for managing mild acute pancreatitis. Methods: This will be a multicenter open-label randomized (1:1) controlled clinical trial to assess the efficacy and safety of home monitoring compared to in-hospital care for mild acute pancreatitis. All patients coming to the emergency department with suspected acute pancreatitis will be screened for enrollment. The main variable will be treatment failure (Yes/No) within the first 7 days after randomization. Discussion: Acute pancreatitis implies a high economic burden in healthcare systems worldwide. Recent evidence suggests that mild disease can be safely and effectively treated with home monitoring. This approach may produce considerable cost savings and positively impact patients' quality of life. We expect the results to show that home monitoring is effective and not inferior to hospitalization for managing mild acute pancreatitis and that the economic costs are lower, kickstarting similar trials throughout the world, optimizing the use of limited healthcare budgets, and improving patients' quality of life.
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Acute pancreatitis
Article
  • May 2022
Acute pancreatitis is nowadays one of the most common diseases among gastroenterology disorders, being gallstones and alcohol the main etiologies. Diagnostic criteria and indications of different imaging techniques are well defined, so that abdominal ultrasound is useful for etiological diagnosis whereas computarized tomography is better for risk stratification and local complications assessment. Goal directed fludtherapy, early starting of oral feeding and pain management are the mainstay of early treatment in acute pancreatitis. Antibiotics are useful when infected necrosis or extra pancreatic infections are documented or suspected but no as prophylaxis in sterile necrotizing pancreatitis. Minimally invasive approaches have emerged in the last decade for walled off necrosis management, improving complication rates, quality of life and length of hospital stay when compared with open surgery.
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Pancreatitis aguda
Article
  • Mar 2022
  • MED CLIN-BARCELONA
Resumen La pancreatitis aguda continúa siendo una de las patologías más relevantes en los servicios de aparato digestivo, destacando la litiasis y el alcohol como las causas principales. Presenta unos criterios diagnósticos bien establecidos y unas indicaciones específicas para la realización de pruebas de imagen, considerando de gran utilidad la ecografía abdominal en el estudio etiológico y la tomografía computarizada abdominal para la estratificación del riesgo y estudio de complicaciones locales. Una fluidoterapia basada en metas, el uso precoz de la nutrición por vía oral y una adecuada analgesia constituyen los pilares básicos del manejo inicial. La antibioterapia está indicada en casos de necrosis infectada o infecciones extrapancreáticas pero no ha demostrado beneficio como profilaxis en pancreatitis aguda necrotizante. En la última década se han desarrollado abordajes mínimamente invasivos que han cambiado radicalmente el tratamiento de las necrosis encapsuladas mejorando la tasa de complicaciones, estancia hospitalaria y calidad de vida de los pacientes.
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Immediate Oral Refeeding in Patients With Mild and Moderate Acute Pancreatitis: A Multicenter, Randomized Controlled Trial (PADI trial)
Article
Full-text available
  • Nov 2020
Objective: To establish the optimal time to start oral refeeding in mild and moderate acute pancreatitis (AP) to reduce hospital length-of-stay (LOS) and complications. Summary background data: Oral diet is essential in mild and moderate AP. The greatest benefits are obtained if refeeding starts early; however, the definition of "early" remains controversial. Methods: This multicenter, randomized, controlled trial (NCT03829085) included patients with a diagnosis of mild or moderate AP admitted consecutively to 4 hospitals from 2017 to 2019. Patients were randomized into 2 treatment groups: immediate oral refeeding (IORF) and conventional oral refeeding (CORF). The IORF group (low-fat-solid diet initiated immediately after hospital admission) was compared to CORF group (progressive oral diet was restarted when clinical and laboratory parameters had improved) in terms of LOS (primary endpoint), pain relapse, diet intolerance, complications, and, hospital costs. Results: One hundred-thirty-three patients were included for randomization. The mean LOS for the IORF and CORF groups was 3.4 (SD ± 1.7) and 8.8 (SD ± 7.9) days, respectively (P < 0.001). In the CORF group alone, pain relapse rate was 16%. There were fewer complications (8% vs 26%) and health costs were twice as low, with a savings of 1325.7&OV0556;/patient in the IORF than CORF group. Conclusions: IORF is safe and feasible in mild and moderate AP, resulting in significantly shorter LOS and cost savings, without causing adverse effects or complications.
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Pancreatitis aguda
Article
  • May 2020
Resumen La pancreatitis aguda (PA) es una enfermedad frecuente que puede asociarse a una considerable morbilidad (15-20% de los casos) y es potencialmente mortal (2%). Las causas más frecuentes de PA son la litiasis biliar y el consumo de alcohol. El diagnóstico se basa en la presencia de dos de tres hallazgos: dolor abdominal típico, elevación de enzimas pancreáticas en sangre, prueba de imagen compatible con PA. La clasificación de la gravedad de la PA se basa en la presencia de complicaciones locales y/o sistémicas asociadas a la misma. El manejo se basa en medidas de soporte vital, monitorización del paciente durante los primeros días de ingreso, alivio del dolor y tratamiento de las complicaciones.
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Fluid resuscitation in acute pancreatitis
Article
Full-text available
  • Dec 2014
  • WORLD J GASTROENTERO
Acute pancreatitis remains a clinical challenge, despite an exponential increase in our knowledge of its complex pathophysiological changes. Early fluid therapy is the cornerstone of treatment and is universally recommended; however, there is a lack of consensus regarding the type, rate, amount and end points of fluid replacement. Further confusion is added with the newer studies reporting better results with controlled fluid therapy. This review focuses on the pathophysiology of fluid depletion in acute pancreatitis, as well as the rationale for fluid replacement, the type, optimal amount, rate of infusion and monitoring of such patients. The basic goal of fluid epletion should be to prevent or minimize the systemic response to inflammatory markers. For this review, various studies and reviews were critically evaluated, along with authors' recommendations, for predicted severe or severe pancreatitis based on the available evidence.
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Defining a Therapeutic Program for Recurrent Acute Pancreatitis Patients with Unknown Etiology
Article
Full-text available
  • Jan 2014
To define a therapeutic program for mild-moderate acute pancreatitis (AP), often recurrent, which at the end of the diagnostic process remains of undefined etiology. In the period 2011-2012, we observed 64 cases of AP: 52 mild-moderate, 12 severe; biliary 39, biliary in alcoholic chronic pancreatitis 5, unexplained recurrent 20. The clinical and instrumental evaluation of the 20 cases of unexplained AP showed 6 patients with biliary sludge, 4 microlithiasis, 4 sphincter of Oddi dysfunction, and 6 cases that remained undefined. Among 20 patients with recurrent, unexplained AP at initial etiological assessment, we performed 10 video laparo cholecystectomies (VLCs), 2 open cholecystectomies and 4 endoscopic retrograde cholangiopancreatography/endoscopic sphincterotomies (ERCP/ES) in patients who had undergone previous cholecystectomy; 4 patients refused surgery. Among these 20 patients, 6 had AP that remained unexplained after second-level imaging investigations. For these patients, 4 VLCs and 2 ERCP/ES were performed. Follow-up after six months was negative for further recurrence. The recurrence of unexplained acute pancreatitis could be treated with empirical cholecystectomy and/or ERCP/ES in cases of previous cholecystectomy.
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A comparison of the Ranson, Glasgow, and APACHE II scoring systems to a multiple organ system scorein predicting patient outcome in pancreatitis
Article
  • Feb 2005
  • AM J SURG
Background: Systems for evaluating acute pancreatitis are useful in hospitalized. patients. Traditional systems of evaluation are well established but might be outdated. We propose a Multiple Organ System Score (MOSS) containing data that are more consistently collected and which are accurate in predicting patient outcome. Methods: A retrospective chart review of 49 patients was completed. We determined if the physician obtained all of the variables necessary to calculate Ranson, Glasgow, or APACHE II scores, if these scores were predictive of patient outcome in the form of length of hospital stay (LOS), and if new, more frequently evaluated variables could be used. Results: None of the: patients could be assigned complete scores. According to Spearman rank correlation, both Glasgow and MOSS showed correlation with patient outcome when APACHE II and Ranson did not. Conclusions: Although larger studies should be performed, the MOSS is useful in predicting outcomes of patients with acute pancreatitis.
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Urinary trypsinogen activation peptide is more accurate than hematocrit in determining severity in patients with acute pancreatitis. A prospective study
Article
  • Aug 2002
OBJECTIVE:The management of patients with acute pancreatitis is complicated by the inability to distinguish mild from severe disease during the early stages. It has been previously shown that urinary trypsinogen activation peptide (TAP) and hematocrit (Hct) may serve as early predictors of severity in patients with acute pancreatitis. To establish which marker is more accurate in the determination of severity in patients with acute pancreatitis, a prospective study was performed.METHODS:A consecutive series of patients admitted with pain consistent with acute pancreatitis and an amylase of three times the upper limit of normal were included. The admission and 24-h Hct was obtained. A urine sample was obtained within 12 h of admission. Urinary TAP was determined using a modified solid phase ELISA. Severity was defined by the Atlanta Symposium, as the presence of organ failure and/or pancreatic necrosis.RESULTS:Fifty-eight consecutive patients with acute pancreatitis participated. There were 33 men and 25 women with a mean age of 60 ± 19. Thirty-nine patients had mild disease; 19 had severe disease. Urinary TAP was elevated in 26 patients. All patients with severe pancreatitis were correctly identified as having severe disease by an elevated urinary TAP (sensitivity 100%, specificity 77%). The admission Hct was higher than 47 in only three patients, all with mild disease. Of the patients with a rise in Hct, eight had mild disease, and only one had severe disease. Using a Hct of 44 as a cutoff did not affect the accuracy. There was no association between a rise in Hct and failure of Hct to decrease in the determination of severity.CONCLUSIONS:In comparison to admission Hct, urinary TAP was more accurate in determining severity in patients with acute pancreatitis by Atlanta, APACHE II, and Ranson criteria. We conclude that urinary TAP is a more accurate predictor of severity in patients with acute pancreatitis compared with Hct. Urinary TAP should be used to determine severity in patients early in the course of acute pancreatitis.
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Diagnostic Relevance of Procalcitonin, IL-6, and sICAM-1 in the Prediction of Infected Necrosis in Acute Pancreatitis
Article
  • Apr 2012
  • Int J Gastrointest Canc
Background: Infected pancreatic necrosis (IPN) is an absolute indication for surgical intervention, therefore an early and accurate laboratory diagnosis is necessary to confirm the infection. The aim of the study was to analyze the clinical value of procalcitonin (PCT) for the prediction of infected necrosis, in comparison with interleukin-6 (IL-6) and sICAM 1. Patients and methods: A total of 30 patients were investigated; 10 patients with sterile pancreatic necrosis (SPN), 10 with IPN, and 10 with sepsis of different origin. The concentrations of PCT in the patients' sera were measured by immunoluminometric assay (BRAHMS Diagnostica, Berlin, Germany, PCT Lumitest), the IL-6 concentrations by bioassay, applying the B-9 cell line, and the sICAM-1 levels by enzyme-linked immunosorbent assay (ELISA) (R&D). PCT was determined in cell lysates by ECL Western blot. Results: PCT was found in relatively high concentrations (8.5 +/- 4.8 ng/mL) only in patients with infected pancreatic necrosis, and in patients with sepsis of different origin ( 15 +/- 5.4 ng/mL). Positive values (> 1 ng/mL) preceded positive bacterial results from either blood or surgical samples. None of the serum samples of patients with SPN exhibited PCT concentrations higher than 1.2 ng/mL. In contrast, IL-6 and sICAM-1 were overproduced in both types (infected and sterile) of pancreatic necrosis, and their levels remained elevated for several days even after surgical elimination of the infected focus (widespread necrosectomy and continuous lavage). Sensitivity, specificity, and positive predictive values for discriminating IPN from SPN was 90, 100, and 100% for PCT (p < 0.0001); 100, 20, and 55% for IL-6 (p 0.474 n.s.) and 90, 10, and 50% for sICAM-1 (p 1.000 n.s.). Immunoblotting revealed no PCT in patients' leukocytes, or in human endothelial cell lines. Conclusion: Elevated serum IL-6 and sICAM-1 levels are characteristic in systemic inflammatory response syndrome (SIRS) of either infectious or noninfectious origin. In contrast, the PCT level is an accurate, readily available parameter that allows the discrimination of IPN, and is a helpful marker facilitating a decision concerning surgical intervention.
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Minimal Access Retroperitoneal Pancreatic Necrosectomy Improvement in Morbidity and Mortality With a Less Invasive Approach
Article
  • May 2010
  • ANN SURG
Comparison of minimal access retroperitoneal pancreatic necrosectomy (MARPN) versus open necrosectomy in the treatment of infected or nonresolving pancreatic necrosis. Infected pancreatic necrosis may lead to progressive organ failure and death. Minimal access techniques have been developed in an attempt to reduce the high mortality of open necrosectomy. This was a retrospective analysis on a prospective data base comprising 189 consecutive patients undergoing MARPN or open necrosectomy (August 1997 to September 2008). Outcome measures included total and postoperative ICU and hospital stays, organ dysfunction, complications and mortality using an intention to treat analysis. Overall 137 patients underwent MARPN versus open necrosectomy in 52. Median (range) age of the patients was 57.5 (18-85) years; 118 (62%) were male. A total of 131 (69%) patients were tertiary referrals, with a median time to transfer from index hospital of 19 (2-76) days. Etiology was gallstones or alcohol in 129 cases (68%); 98 of 168 (58%) patients had a positive culture at the first procedure. Of the 137 patients, 34 (31%) had postoperative organ failure in the MARPN group, and 39 of 52 (56%) in the open group (P<0.0001); 59/137 (43%) versus 40/52 (77%), respectively, required postoperative ICU support (P<0.0001). Of the 137 patients 75 (55%) had complications in the MARPN group and 42 of 52 (81%) in the open group (P=0.001). There were 26 (19%) deaths in the MARPN group and 20 (38%) following open procedure (P=0.009). Age (P<0.0001), preoperative multiorgan failure (P<0.0001), and surgical procedure (MARPN, P=0.016) were independent predictors of mortality. This study has shown significant benefits for a minimal access approach including fewer complications and deaths compared with open necrosectomy.
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The Harmless Acute Pancreatitis Score: A Clinical Algorithm for Rapid Initial Stratification of Nonsevere Disease
Article
  • Feb 2009
Only severe acute pancreatitis requires treatment, according to the principles of intensive care medicine in an intensive care or intermediate care unit. The aim of the study was to define and evaluate a simple clinical algorithm for rapid initial identification of patients with a first attack of acute pancreatitis who do not require intensive care. This prospective study included 394 patients who were admitted to the Municipal Clinic of Lüneburg, Germany, between 1987 and 2003. From a number of parameters of disease severity on admission, 3 parameters that showed the strongest prediction of a nonsevere course (no rebound tenderness and/or guarding, normal hematocrit level, and normal serum creatinine level) were combined to form the harmless acute pancreatitis score (HAPS). The score then was validated in a German multicenter study including 452 patients between 2004 and 2006. In both the initial and the validation set, the HAPS correlated with a nonsevere course of the disease (P < .0001). The score correctly identified a harmless course in 200 (98%) of 204 patients. The HAPS enables identification, within approximately 30 minutes after admission, of patients with acute pancreatitis whose disease will run a mild course. The high level of accuracy of this test (98%) will allow physicians to identify patients quickly who do not require intensive care, and potentially those who will not require inpatient treatment at all. Thus, the HAPS may save substantial hospital costs.
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