Acute pancreatitis. Intensive Care Training Program Radboud University Medical Centre Nijmegen

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1 Acute pancreatitis Intensive Care Training Program Radboud University Medical Centre Nijmegen

2 Diagnosis Abdominal pain consistent with pancreatitis Serum lipase or amylase at least 3 times the upper limit Characteristic findings on abdominal contrast enhanced CT (rarely MRI/US) Two of three features are necessary Gut 2013;62:

3 Acute pancreatitis ± 90% ± 10% Interstitial oedematous pancreatitis Necrotising pancreatitis Usually pancreas + peripancreatic Less often only peripancreatic Rarely pancreas alone Small peripancreatic collection Infected necrosis Homogenous enhancement Fat stranding Rarely < 1 week Increased morbidity and mortality

4 Necrotising pancreatitis Only peripancreatic necrosis Both pancreatic and peripancreatic necrosis Only pancreatic necrosis

5 Infected necrosis Extraluminal gas in pancreatic- and peripancreatic tissues Positive gram stain/culture after FNA

6 Organ failure Modified Marshall score SOFA score reasonable alternative Transient < 48 hrs or persistent > 48 hrs

7 Local complications Acute peripancreatic fluid collection Pancreatic pseudocyst Acute necrotic collection Walled-of necrosis Gastric outlet dysfunction Splenic and portal vein thrombosis Colonic necrosis

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9 Extremely rare

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12 Severity of acute pancreatitis

13 Necrotising pancreatitis Treatment N = 639 Overall mortality 93 (15%) Entirely conservative N = 397 (62%) Intervention N = 242 (38%) Mortality 7% (N = 28) Included 11 patients with infected necrosis treated with only antibiotics Mortality 0% Mortality 27% (N = 65) Included 189 patients with infected necrosis Mortality 0% van Santvoort HC. Gastroenterology 2011;141:

14 Mortality 78% After median of 28 days Mortality 16.7% 54/130 (42%) More complications Mortality 18% Mortality 22%

15 Time of intervention 60 P < also after correction for baseline differences 45 Mortality (%) D D > 29 D

16 Organ failure 40 P < Mortality (%) No organ failure Organ failure

17 Mortality Morbidity (organ failure and infected necrosis) and mortality higher in patients with pancreatic necrosis than only peripancreatic necrosis (mortality 20 vs 9%) Overall mortality infected necrosis 20%

18 Classificeren Pancrea--s

19 Two phases of the disease: early and late. Severity is classified as mild, moderate or severe. Mild acute pancrea--s, the most common form, has no organ failure, local or systemic complica-ons and usually resolves in the first week. Moderately severe acute pancrea--s is defined by the presence of transient organ failure, local complica-ons or exacerba-on of co- morbid disease. Severe acute pancrea--s is defined by persistent organ failure, that is, organ failure >48 h.

20 local complica-ons are peripancrea-c fluid collec-ons, pancrea-c and peripancrea-c necrosis (sterile or infected), pseudocyst and walled- off necrosis (sterile or infected).

21 Diagnose Pijn acuut Amylase >4500 CT nv, echo verdacht voor pancrea-s-s Onset Klachten Opname IC progr. NF#, anurie met acidose - > CVVH Radboud 21-12

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23 CT 1 (21-12) Uitgebreide pancrea--s, mogelijk necro-serend, met mul-pele intra- abdominale vochtcollec-es zoals bovenbeschreven. Concrement in de hals van de galblaas. Pleuravocht, atelectase en meerdere consolida-es basaal in de onderkwab beiderzijds.

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25 CT 2 (25-12) Uitgebreide, mogelijk necro-serende, pancrea--s. Hierbij in essen-e ongewijzigde mul-pele intra- abdominale vochtcollec-es als boven beschreven, zonder evidente kapselvorming danwel randaankleuring. Geringe afname van vrij vocht rond de lever.

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27 CT 3 (29-12) Bekende uitgebreide, necro-serende pancrea--s. Toename van intra- abdominaal vrij vocht als boven beschreven. Toename omvang en geringe ventrale randaankleuring van de collec-e ventraal van het pancreas - onder de maag, nog geen evidente aaapseling danwel abcesvorming. Duidelijk toegenomen consolida-e met holtevorming rechts parahilair en in mindere mate ook links parahilair, beeld van pneumonie.

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29 CT 4 (7-1) Verdere afname van de aankleuring van het pancreas. Onveranderde grooce hoeveelheid vocht rondom het pancreas. Geen gasbellen. Geen afgekapselde vochtcollec-es intra- abdominaal met aankleurende wand. Grote hoeveelheid pleuravocht beiderzijds, toegenomen. Onveranderde consolida-e holte vorming rechts perihilair en in mindere mate ook links perihilair, beeld van pneumonie.

30 Type acute Pancrea--s Inters--eel oedemateuze Necro-serende Geinfecteerde necrose

31 Modified Marshall Orgaanfalen

32 Local complica-ons Acute peripancrea-c fluid collec-on - Pancrea-c pseudocyst - Acute necro-c collec-on + Walled- off necrosis? Gastric outlet dysfunc-on? Splenic and portal vein thrombosis - Colonic necrosis -

33 Systemic complica-ons Coronary- artery disease - Chronic lung disease - Precipitated by the acute pancrea--s is defined as a systemic complica-on

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36 defini-e Onze pa-ënt Severe acute pancrea--s: Persisterend orgaanfalen Mortaliteit 36-50% Late complica-es Dus erns-ge acute necro-serende pancrea--s met MOF en acuut necro-serende collec-es

37 Early vs Late Systemic disturbances result from the host response to local pancrea-c injury This early phase is usually over by the end of the first week but may extend into the second week SIRS (verhoogd risico op ontwikkelen MOF bij persisterende SIRS) Persistence of systemic signs of inflamma-on or by the presence of local complica-ons Only in moderately severe or severe acute pancrea--s