Scott Tenner

American College of Gastroenterology guideline: management of acute pancreatitis.

This guideline presents recommendations for the management of patients with acute pancreatitis (AP). During the past decade, there have been new understandings and developments in the diagnosis, etiology, and early and late management of the disease. As the diagnosis of AP is most often established by clinical symptoms and laboratory testing, contrast-enhanced computed tomography (CECT) and/or magnetic resonance imaging (MRI) of the pancreas should be reserved for patients in whom the diagnosis is unclear or who fail to improve clinically. Hemodynamic status should be assessed immediately upon presentation and resuscitative measures begun as needed. Patients with organ failure and/or the systemic inflammatory response syndrome (SIRS) should be admitted to an intensive care unit or intermediary care setting whenever possible. Aggressive hydration should be provided to all patients, unless cardiovascular and/or renal comorbidites preclude it. Early aggressive intravenous hydration is most beneficial within the first 12–24 h, and may have little benefit beyond. Patients with AP and concurrent acute cholangitis should undergo endoscopic retrograde cholangiopancreatography (ERCP) within 24 h of admission. Pancreatic duct stents and/or postprocedure rectal nonsteroidal anti-inflammatory drug (NSAID) suppositories should be utilized to lower the risk of severe post-ERCP pancreatitis in high-risk patients. Routine use of prophylactic antibiotics in patients with severe AP and/or sterile necrosis is not recommended. In patients with infected necrosis, antibiotics known to penetrate pancreatic necrosis may be useful in delaying intervention, thus decreasing morbidity and mortality. In mild AP, oral feedings can be started immediately if there is no nausea and vomiting. In severe AP, enteral nutrition is recommended to prevent infectious complications, whereas parenteral nutrition should be avoided. Asymptomatic pancreatic and/or extrapancreatic necrosis and/or pseudocysts do not warrant intervention regardless of size, location, and/or extension. In stable patients with infected necrosis, surgical, radiologic, and/or endoscopic drainage should be delayed, preferably for 4 weeks, to allow the development of a wall around the necrosis.

Relationship of necrosis to organ failure in severe acute pancreatitis.

BACKGROUND & AIMS Pancreatic necrosis and organ failure are principal determinants of severity in acute pancreatitis. The purpose of this study was to determine the relationship of necrosis to organ failure in severe acute pancreatitis. METHODS Patients with necrotizing pancreatitis from May 1992 to January 1996 were retrospectively studied. Pancreatic necrosis was identified by characteristic findings on dynamic contrast-enhanced computerized tomography scan and infected necrosis by computerized tomography-guided percutaneous aspiration. Organ dysfunction was defined in accordance with the Atlanta symposium. RESULTS Organ failure was present in only 26 of 51 patients (51%). There was no difference in the prevalence of organ failure in infected necrosis compared with sterile necrosis (approximately 50% in both groups). Patients with increased amounts of necrosis did not have an increased prevalence of organ failure or infected necrosis compared with those with lesser amounts of necrosis. Patients with organ failure had an increased morbidity and mortality compared with those without organ failure. CONCLUSIONS Organ failure occurred in only one half of patients with necrotizing pancreatitis. Because organ failure increases the severity of illness, studies of patients with necrotizing pancreatitis must stratify for organ failure to facilitate interpretation of results.

Early Intensive Resuscitation of Patients With Upper Gastrointestinal Bleeding Decreases Mortality

OBJECTIVE:Despite advances in diagnostic and therapeutic endoscopy, the mortality of patients with upper gastrointestinal bleeding (UGIB) has remained relatively constant. Inadequate early resuscitation is believed to be a major factor in the persistently high mortality rate in patients with UGIB. In order to evaluate the role of intensive resuscitation in the outcome of patients with UGIB, we conducted the following prospective study.METHODS:A consecutive series of patients with UGIB complicated by hemodynamic instability related to bleeding were enrolled in the study. An initial cohort of patients (Observation Group) was followed by a team of physicians to collect data. After recording demographic information, the time interval between presentation with UGIB and the correction of hemodynamic instability, hematocrit (HCT), and coagulopathy was prospectively recorded. Medical treatment, endoscopic intervention, and subsequent outcome were also prospectively recorded. A subsequent cohort of patients (Intensive Resuscitation Group) was then prospectively followed and similar demographic and outcome data were collected. However, in this cohort, the physicians involved in collecting the data also provided guidance to the health care team managing the patients. The goal for this group of patients was to allow a more rapid correction of hemodynamic instability, HCT, coagulopathy, and medical/endoscopic intervention.RESULTS:Seventy-two patients were included in the study, 36 males, 36 females, mean age 70 yr (range 21–94). Thirty-six patients were followed in the Observational Group, and 36 in the Intensive Resuscitation Group. There were no significant differences with regard to age, gender, number and type of comorbid diseases, history of prior gastrointestinal bleeding, or etiology of bleeding between the two groups. Patients treated in the Intensive Resuscitation Group had a significant decrease in the time interval from admission to the stabilization of hemodynamics and the correction of HCT. There were no significant differences in the time interval from admission to endoscopic intervention, length-of-stay (LOS), or the number of units of blood given. Fewer patients in the Intensive Resuscitation Group suffered myocardial infarction (p = 0.04). Mortality was lower in the Intensive Resuscitation Group (one death) compared to the Observational Group (four deaths), (p = 0.04).CONCLUSION:Early intensive resuscitation of patients with upper gastrointestinal bleeding significantly decreases mortality. Physicians involved in the care of patients with UGIB should focus on early and rapid correction of hemodynamics, HCT, and underlying coagulopathy.

Urinary trypsinogen activation peptide (TAP) predicts severity in patients with acute pancreatitis.

SummaryConclusionsUrinary TAP obtained within the first 48 h of the onset of symptoms can distinguish patients with severe acute pancreatitis.BackgroundUrinary trypsinogen activation peptide (TAP) has recently been described as an early marker of severity in acute pancreatitis.MethodsIn a multicenter study, urine samples were collected for TAP concentration at 6–12, 24, and 48 h after admission from 139 patients with acute pancreatitis (99 with mild disease, 40 with severe disease) and from 50 control patients. Severity of acute pancreatitis was defined by the presence of organ failure and/or pancreatic necrosis on dynamic contrast-enhanced computed tomography.ResultsMedian urinary TAP in the 139 patients with acute pancreatitis compared to the 50 control patients was significantly higher at admission, 4.6 vs 0.8 ng/mL (p<0.001), and 6–12 h, 1.9 vs 0.55 ng/mL (p=0.04). Among patients who presented within 48h of the onset of symptoms, the median urinary TAP for severe pancreatitis (9 patients) compared to mild pancreatitis (40 patients) was significantly higher at admission, 29.6 vs. 3.6 ng/mL (p=0.001). Also, when obtained within 48h of the onset of symptoms, all patients with severe pancreatitis had an admission urinary TAP level>10 ng/mL. The sensitivity and specificity of an admission urinary TAP≥10 for severe pancreatitis was 100 and 85%, respectively. Given a cutoff of 10 ng/mL for an admission urinary TAP obtained within 48h of the onset of symptoms, the negative predictive value was 100% for mild pancreatitis.

Does mortality occur early or late in acute pancreatitis

SummaryAbstract: Several prior studies have suggested that 80% of deaths in acute pancreatitis occur late as a result of pan-creatic infection. Others have suggested that approx half of deaths occur early as a result of multisystem organ failure. The aim of the present study was to determine the timing of mortality of acute pancreatitis at a large tertiary-care hospital in the United States.Methods: Patients with a diagnosis of acute pancreatitis (ICD-9 code 577.0) admitted to Brigham and Women’s Hospital from October 1, 1982 to June 30, 1995 were retrospectively studied to determine total mortality, frequency of early vs late deaths, and clinical features of patients with early (≤14 d after admission) or late deaths (>14 d after admission).Results: The overall mortality of acute pancreatitis was 2.1% (17 deaths among 805 patients). Eight deaths (47%) occurred within the first 14 d of hospitalization (median d 8, range 1–11 d), whereas 9 occurred after 14 d (median d 56, range 19–81). Early deaths resulted primarily from organ failure. Late deaths occurred postoperatively in 8 patients with infected or sterile necrosis and 1 patient with infected necrosis treated medically. Conclusion: Approximately half of deaths in acute pancreatitis occur within the first 14 d owing to organ failure and the remainder of deaths occur later because of complications associated with necrotizing pancreatitis. Improvement in mortality in the future will require innovative approaches to counteract early organ failure and late complications of necrotizing pancreatitis.

Initial Management of Acute Pancreatitis: Critical Issues During the First 72 Hours

Although most patients with acute pancreatitis have a mild course, almost a quarter of patients will develop complications. It has become clear that the early management of patients with acute pancreatitis will likely affect outcome. Too often patients are admitted to the hospital with what appears to be mild desease only later to deteriorate with severe disease. This review will focus on the early management of patients with acute pancreatitis in an attempt to prevent severe disease, complications, and death.

Laboratory diagnostic tests in acute pancreatitis.

The diagnosis of acute pancreatitis depends on a combination of clinical assessment and laboratory testing. Although the serum amylase is the cornerstone laboratory test used in establishing the diagnosis of acute pancreatitis, there are limitations in the sensitivity and specificity that may be important for the clinician to recognize. The serum lipase level may be especially useful in patients with alcohol-induced acute pancreatitis. A new urinary test strip that uses trypsinogen-2 may have a role in establishing the diagnosis of acute pancreatitis. In addition, several new laboratory tests and new interpretations of old laboratory tests may assist in establishing the etiology and severity of acute pancreatitis. This review summarizes important aspects of standard laboratory tests and novel laboratory approaches in establishing the diagnosis, etiology, and severity of acute pancreatitis.

Acute pancreatitis: Nonsurgical management

The care of patients with severe acute pancreatitis is complex. Although numerous medical therapies have been proposed, few interventions have been shown to be of benefit in patients with severe disease. This review summarizes the nonoperative management of patients with acute pancreatitis, including therapies shown to be of little value, the role of antibiotics in patients with acute pancreatitis, the importance of monitoring and supportive care, and the rationale of endoscopic and surgical intervention.RésuméLe traitement des patients atteints de pancréatite aiguë sévère est complexe. La plupart des patients sont admis en soins intensifs. Parfois surviennent des complications qui nécessitent des interventions radiologiques, endoscopiques et/ou chirurgicales. Bien que beaucoupde de thérapeutiques médicales aient été proposées, peu ont été démontrées comme efficaces chez les patients ayant une pancréatite aiguë sévère. La définition de la pancréatite aiguë sévère a évolué. Au début, on a utilisé pour la définir les symptômes tels que la douleur, les nausées et les vomissements. D’autres l’ont définie par la survenue des complications telles que le faux-kyste, l’abcès et le décès, ou encore par des scores comme ceux de Ranson ou d’Imrie. Beger a développé un nouveau critère de gravité, la nécrose. Des études ultérieures ont utilisé la nécrose comme indication de gravité. En 1992, 40 spécialistes en matière de pancréatite se sont réunis à Atlanta pour développer une classification de pancréatite aiguë et ses complications. La conclusion de ce symposium a été que la gravité devait se définir par l’existence de défaillance viscérale et/ou de complications locales, comprenant la nécrose, le faux-kyste et l’abcès. A présent, il est difficile d’extrapoler les résultats de telle ou telle thérapeutique car la définition de sévérité a varié d’une publication à une autre. De plus, plusieurs publications n’ont pas fait état du nombre exact de patients atteint de nécrose ou de défaillance viscérale. Le traitement non chirurgical est résumé y compris 1) les thérapeutiques prouvée de peu de valeur, 2) le rôle des antibiotiques, 3) l’importance de la surveillance et de la réanimation et 4) les facteurs qui doivent indiquer une intervention endoscopique ou chirurgicale.ResumenEl manejo de los pacientes con pancreatitis aguda es complejo. La mayoría de los pacientes requieren admisión a una unidad de cuidado intensivo. Algunos desarrollan complicaciones para las cuales se hace necesaria la interventión radiológica, endoscópica y/o quirúrgica. Aunque numerosas terapias médicas han sido propuestas, son muy pocas las que han demostrado beneficio en pacientes con pancreatitis severa. La definitión de enfermedad severa, o grave, en pacientes con pancreatitis aguda ha evolucionado. Los primeros estudios destinados a evaluar las terapias médicas se valieron de la presencia de sìntomas severos tales como dolor, náusea y vómito, como criterio de definitión de severidad. La mayoría de los estudios han definido severidad en función de complicaciones como pseudoquistes, abscesos y muerte o de sistemas de gradatión de la gravedad, entre los cuales se incluyen los criterios de Ranson y de Imrie Beger desarrolló una nueva definitión de severidad: la presencia de necrosis pancreática. Estudios subsiguientes han utilizado la presencia de necrosis pancreática como un indicador de severidad. En 1992, 40 especialistas en pancreatitis aguda, asistieron al Simposio de Atlanta celebrado con el propósito de desarrollar un sistema de clasificación, basado en el cuadro clínico de la pancreatitis y sus complicaciones. La conclusión del Simposio fue que la severidad de la pancreatitis debe ser definida por la presencia de falla orgánica y/o complicaciones locales, incluyendo necrosis, pseudoquistes y absceso. En el momento actual, resulta dificil extrapolar el resultado de una determinada terapia, siendo que la definición de severidad ha variado entre los diferentes estudios publicados y siendo que muchos de ellos no reportan el número de pacientes con necrosis pancreática o con falla orgánica. La presente revisión resume el manejo operatorio de los pacientes con pancreatitis aguda, incluyendo: las terapias que han demostrado ser de poco valor, el rol de los antibióticos en pacientes con pancreatitis aguda, la importancia de la monitoría y de los regímenes de soporte y los factores que Ilevan a interventión endoscópica y quirúrgica.

Pleural Effusion as a Predictor of Severity in Acute Pancreatitis

Our objective was to determine whether pleural effusion is a predictor of severity in acute pancreatitis and, if so, whether it is an independent predictor. One hundred ninety-six consecutive cases of acute pancreatitis from October 1, 1994, to September 30, 1995, were reviewed. Medical records were analyzed for evidence of pleural effusion by chest radiograph and severe acute pancreatitis by identification of pancreatic necrosis or organ system dysfunction. Data were analyzed to determine if identification of pleural effusion provided an early sign of severity. Among 135 patients who underwent chest radiography, pleural effusion was seen in 16 of 19 (84.2%) with severe pancreatitis and 10 of 116 (8.6%) of patients with mild pancreatitis (p < 0.001). Pleural effusion was noted in severe pancreatitis prior to clinical or computed tomography evidence of severity in only 20% of cases. Pleural effusion is strongly associated with severity in acute pancreatitis but provides independent information on severity in only a minority of cases.

Efficacy of recombinant human interleukin-10 in prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis in subjects with increased risk.

Objectives: Pancreatitis is the most common major complication of endoscopic retrograde cholangiopancreatography (ERCP). Inflammatory cytokines are released during acute pancreatitis. Interleukin-10 (IL-10) is a potent inhibitor of cytokines and has been shown to attenuate pancreatitis in animal models and pilot human studies. This study aimed to determine whether prophylactic IL-10 administration reduces the frequency and/or severity of post-ERCP pancreatitis in high-risk patients. Methods: A randomized, multicenter, double-blind, placebo-controlled study was conducted. Patients received IL-10 at a dose of either 8 or 20 &mgr;g/kg or placebo as a single intravenous injection 15 to 30 minutes before ERCP. Standardized criteria were used to diagnose and grade the severity of postprocedure pancreatitis. Results: A total of 305 of the planned total enrollment of 948 patients were randomized. There was a 15%, 22%, and 14% incidence of post-ERCP pancreatitis in the IL-10 (8 &mgr;g/kg), IL-10 (20 &mgr;g/kg), and placebo treatment groups, respectively (P = 0.83 for IL-10 8 &mgr;g/kg vs placebo and 0.14 for IL-10 20 &mgr;g/kg vs placebo). Due to apparent lack of efficacy, the study was terminated at an interim analysis. Conclusions: There was no apparent benefit of IL-10 treatment when compared with placebo in reducing the incidence of post-ERCP acute pancreatitis in subjects with increased risk.Abbreviations: ERCP - endoscopic retrograde cholangiopancreatography, IL - interleukin, TNF - tumor necrosis factor, AE, adverse event