Treatment of Acute Pancreatitis PDF

Pancreatic diseases Treatment of Acute Pancreatitis Acute pancreatitis is autodigestion of the pancreas and surrounding tissue, leading to intense local in ammation and a systemic in ammatory response that can be fatal. This process has no speci c a...

Pancreatic diseases Treatment of Acute Pancreatitis Acute pancreatitis is autodigestion of the pancreas and surrounding tissue, leading to intense local in ammation and a systemic in ammatory response that can be fatal. This process has no speci c antidote or therapy. It can not be switched o by drugs such as steroids and NSAIDS. Care is therefor directed towards symptoms, organ supportive management and anticipation and early managment of complications. During or once an attack of acute pancreatitis has been treated successfully, the cause has to be identi ed, so that future attacks can be prevented. For example, biliary pancreatitis requires a laparoscopic cholecystectomy and IOC before discharge. For your purposes acute pancreatitis is either de ned as mild or severe (see Atlanta Classi cation for full classi cation if interested) and the treatment of these two forms di er as below: Mild acute pancreatitis: Rest the pancreas. Identify the cause - Keep patient nil per mouth. - Administer PPI to suppress gastric secretions. (Previously, a nasogastric tube was used in an attempt to keep gastric secretions from reaching the duodenum. Today, nasogastric tube only used as long as persistent vomiting is present. PPI has additional advantage of preventing acute gastric mucosal lesions. Support the patient Intravenous uids; replacement of losses and maintenance. Urinary output is a good indicator as to whether uid administration is adequate. In haemodynamically unstable patients, a central line is placed and uid administered according to the CVP, Ringer’s Lactate currently recommended Analgesia; Opioid analgesia is almost always required and Morphine or Pethidene are good choices. Intravenous Paracetomol also a good adjunct. Anti-emetics IV e.g Metoclopramide Antibiotics are not administered routinely, even inpatients with predicted severe pancreatitis but are indicated later on if infection of pancreatic necrosis occurs, or if infection in other sites occurs Serial clinical assessment and careful monitoring of cardio respiratory function. If necessary, support is given (Heart – inotropic drugs; lungs – assisted ventilation, kidneys- dialysis). Severe acute pancreatitis ff fi fl fl fi fi fl fi fl fl fi ff rests on the following principles, additional to the care of patients with mild pancreatitis described above: Identify the cause Early recognition of the patient with severe pancreatitis; in practical terms these are patients with severe dehydration that do not respond with urine output after uid resuscitation, and/or tachypnoea and/or signi cant abdominal distention, as these patients need to be referred for ICU care. Early enteral feeding to maintain the mucosal GIT barrier and prevent translocation of bacteria to the necrosis Support of failing organs, e.g. pulmonary ventilation, TPN, renal dialysis, circulatory support with inotropes Treatment of infected necrosis with appropriate antibiotics, percutaneous drainage and surgery as required ERCP is indicated if there is objective evidence of biliary obstruction in patients with biliary pancreatitis (rising bilirubin, cholangitis, stone demonstrated in common bile duct on imaging) Surgical Treatment:- Surgical procedures only necessary for:- Prevention of further attacks, e.g. cholecystectomy for gallstone pancreatitis. Complications:- infected pancreatic necrosis – occurs towards the end of the second week and is suspected on grounds of swinging fever, high CRP and white cell count, and clinical deterioration of the patient’s organ function. After starting appropriate antibiotics, the infected necrosis can be addressed in a stepwise fashion by percutaneous drain placement, endoscopic transgastric stenting +/- debridement, minimally invasive retroperitoneal debridement or laparotomy. The aim is to drain pus, establish drainage, irrigate the area and remove as much of the necrosis as safely possible sterile necrosis - does not require debridement unless patients struggle to feed and lose weight. Sometimes considered for patients with intractable pain that does not settle after a prolonged period of observation. Pseudocyst – persistent abdominal pain, serum lipase/amylase remains elevated ± palpable abdominal mass and cystic lesion visible on sonar. This diagnosis is not an automatic indication for surgical intervention, as a signi cant number of pseudocysts will resolve spontaneously. Surgery is indicated when, on serial ultrasound the size of cyst increases after 3-4 weeks or complicates (e.g. becomes infected). “Internal” drainage by endoscopic ultrasound or surgery is preferred, i.e. creation of a communication between the cyst and GIT (usually to the stomach – cyst-gastrostomy). External drainage is sometimes performed for secondary infection; has disadvantage of potentially creating a pancreatic stula (with prolonged drainage of pancreatic uid to the exterior). fi fi fi fl fl  Treatment of chronic pancreatitis Mainly medical, i.e. dietary adaptations, supplementation of pancreatic enzymes, of diabetes mellitus, stop alcohol and smoking(± psychological/social support), analgesia. Strong analgesics avoided (patients have a strong tendency to become dependent). * Indications for intervention (surgical or endoscopic) i) Pain, where medical management with simple analgesics cannot afford control. Surgery indicated if pain persists after alcohol cessation and start requiring opioids. Earlier surgery for persistent pain has better outcomes. ii) Leak of pancreatic juice (pseudocyst, ascites). iii) Obstruction of neighbouring organ/structure. * Technique You are not required to know details. For obstruction of bile duct or duodenum, bypass of obstruction usually performed. For leak of pancreatic juice, anastomosis between pseudocyst or defect on the pancreas to GIT is performed (cyst-gastrostomy or pancreatico-jejunostomy). Also done by endoscopic stenting * Surgical management of pain Anastomosis between (dilated) pancreatic duct in body of pancreas and small bowel (longitudinal pancreatico-jejunostomy) was previously the procedure of choice. Results are variable and the procedure is only technically satisfactory if a long segment of duct is dilated. Most patients have an in ammatory mass in the head of the pancreas ( “motor” that drives the disease) and a dilated pancreatic duct. Procedure of choice is the Frey procedure(duodenum preserving pancreatic head resection and pancreatico- jejunostomy) or pancreatico-duodenectomy if concern regarding malignancy (5% risk). Total pancreatectomy does not give better results with respect to pain relief and has the disadvantage of creating/aggravating diabetes. Considered for persistence of pain after above operations. Morbidity of a Whipple procedure is high. A popular operation currently is to do a longitudinal pancreatico-jejunostomy, but to prolong its extent into the head of the pancreas, where tissue is “cored out” down to the level of the duct. This operation known as a Frey procedure and combines elements of drainage and resection. On balance, in terms of bene t vs risk, the Frey procedure is probably the most suitable operation for pain of chronic pancreatitis. Every patient is, however, evaluated individually and type of surgical procedure determined on clinical grounds, radiological ndings (CT, ERCP) and operative ndings. Treatment of pancreatic tumours Pancreatic tumours are either cystic or solid fi fl fi fi Cystic tumours Cystic tumours are ofter incidentally detected in the pancreas during investigations for other conditions such as kidney stones or staging of other cancers. Cystic tumours only lead to symptoms if they ar elarge or compress neighbouring structures such as the common bile duct or splenic vein. Various guideline systems aim to direct the management of cystic tumours and attmept to balance the risk of observation of tumours with benign features vs the risk of pancreatic surgery. Thes patients are monitored with serial contrasted MRCP or Endoscopic Ultrasound(EUS) CT, MRCP and EUS are used as necessasry to con dently distinguish between the various cystic tumours: · Serous cystic neoplasm: Benign, rarely resected · Mucinous cystic neoplasms(non-invasive and invasive forms): Mostly benign, risk of conversion to malignancy in all lesions. (solid areas, calci cations and larger size associated with presence of malignancy). Middle aged females, Usually offered resection · Intraductal papillary mucinous neoplasm (IPMN), males more common, mostly >60yr. Main duct and brand duct IPMN subtypes. Main duct types have high malignant potential and are resected while Brand Duct IPMN have lower risk and are often diagnosed incidentally — their surveillance and treatment is strati ed accoring to standard guidelines. · Solid pseudopapillary neoplasm: Young females (second decade) malignancy rare, but always considered for curative resection Some solid tumours may have a cystic variant, especially neuro-endocrine tumours. Solid tumours Pancreatic cancer (ductal adenocarcinoma) and neuro-endocrine tumours are the most common sold pancreatic tumours Pancreatic ductal adenocarcinoma (pancreatic cancer) is the 4th leading cause of cancer death worldwide, presents mostly at advanced stages and is notoriously resistant to single chemotherapy agents. Around 15% of patients presenting with pancreatic tumours have no metastases and are locally resectable. Even though patients are deemed resectable, Neo- adjuvant multi-agent chemotherapy is considered to select patients better and improve surgical results. Patients are discussed and treated in a multidisciplinary environment (MDT). After staging patients with metastases or unresectable disease ar eplaced into a pallitive care programme. The focus of palliation is to correct the complications caused by the tumour and support the patient as much as possible: - Refer to social worker and closect hospice service - Assist nutrition - supplements and pancreatic enzyme replacement (Creon) if indicated fi fi fi - Analgesia - step-up from oral therapy to opioids as necessary, amitrytilline and pregabalin sometimes invaluable for neurogenic pain - For pain coeliac plexus blockade and fractions of radiation are considered - Obstruction of the bile duct is palliated by stenting (ERCP > PTC) - Obstruction of duodenum stented or surgically bypassed Is staging reveals a non-metastatic pancreatic cancer that is potentially resectable, a strategy with curative intent is pursued: - Stent placed for obstructive jaundice by ERCP - Biopsy of tumour by EUS - Discussion at MDT - Resection followed by adjuvant chemotherapy vs Neo-adjuvant chemotherapy and resection, depending on radiological, clinical and laboratory ndings. Surgery for pancreatic ancer: For tumours in head/peri-ampullary region, this involves a pancreaticoduodenectomy (Whipple operation). A Whipple procedure is a complex and dangerous operation and should only be performed in specialized centres and in patients with a realistic chance of “cure” (in other words, no known metastatic disease present and reasonable anaesthetic/ operative risk). Lesions of the body/tail require a “distal” pancreatectomy, with excision of the spleen and splenic vessels. Resection of Adenocarcinoma of the body/tail is, however, very seldom possible because of delayed diagnosis. Pancreatic Neuro-endocrine Tumours (PNETS Non-functional tumours are considered for resection if non-metastatic or with metastatic disease due to their indolent nature and good prognosis. Multiple factors such as grade and extent of disease are taken into account. Other treatments also have good results and are used in combination with surgery - Somatostatin suppression, PRRT (Lutetium 177 Peptide receptor radiotherapy) Functional tumours are usually not metastatic and are loclaised for resection. fi