Necrotizing Pancreatitis - DBaril-1

Necrotizing Pancreatitis - DBaril-1 - Necrotizing...

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Unformatted text preview: Necrotizing Pancreatitis Necrotizing Donald Baril Department of Surgery Grand Rounds Elmhurst Hospital Center February 25, 2004 Epidemiology Epidemiology 185,000 cases of acute pancreatitis/year in U.S. 185,000 Gallstone pancreatitis accounts for 40-80% of cases Gallstone Necrosis present in 20-30% of all cases Necrosis Most common between the ages of 50 and 70 Most Presence of necrosis increases morbidity and mortality rates from 23% to 82% and <1% to 10% respectively rates Etiology Etiology Gallstones Gallstones Alcohol abuse Alcohol Endoscopic retrograde cholangiopancreatography Endoscopic Hyperlipidemia Drugs Drugs Pancreas divisum Pancreas Abdominal trauma Abdominal Pathophysiology Pathophysiology Disruption in the normal separation of lysosomal and pancreatic enzymes which leads to the exposure of pancreatic proenzymes to lysosomal enzymes leading to pancreatic autodigestion pancreatic Biliary pancreatitis Biliary obstructing stone at ampulla allows bile to reflux into the pancreatic duct the obstructing stone at ampulla produces pancreatic duct hypertension hypertension Presentation and Diagnosis Presentation History: Epigastric pain, nausea/vomiting, fever History: Physical exam: fever, tachycardia, epigastric tenderness, Physical Grey-Turner’s sign, Cullen’s sign Grey-Turner’s Laboratory values: elevated amylase and lipase, leukocytosis, elevated liver function tests elevated Radiographic studies Radiographic Abdominal x-ray Abdominal typically nonspecific typically may exclude other causes of abdominal pain may may show a sentinel loop or a “colon cutoff sign” may Ultrasound Ultrasound typically shows a diffusely enlarged, hypoechoic pancreas sensitivity of 67% and near 99% specificity in the diagnosis of acute pancreatitis the MRCP MRCP Colon cutoff sign Colon Radiographic studies – CT scan Radiographic CT (contrast-enhanced) CT gold standard for the noninvasive diagnosis of necrotizing pancreatitis affected portions fail to enhance secondary to disruption of the normal pancreatic microcirulation accuracy of > 90% when at least 30% glandular necrosis is present Severity of pancreatitis based on CT findings Severity CT findings of necrotizing pancreatitis CT CT findings of necrotizing pancreatitis CT CT findings of necrotizing pancreatitis CT Endoscopic retrograde cholangiopancreatography Endoscopic Gold standard to diagnose choledocholithiasis Gold Should be used in combination with sphincterotomy for patients with severe gallstone pancreatitis and suspected persistent biliary obstruction persistent Carries inherent risks of exacerbating the ongoing pancreatitis and introducing infection into sterile necrosis and Management aims Management Two phases of acute pancreatitis Two Initial 14 days characterized by the systemic inflammatory response syndrome (SIRS) response intensive medical support intensive prevention of infection prevention Infection of pancreatic necrosis which occurs in the second Infection and third week following the onset of symptoms and treatment of local infectious complications treatment and debridement and Infected necrosis Infected 30-70% of patients with acute necrotizing pancreatitis develop local pancreatic infection local Mortality triples in the presence of infection from 10% to 30% Mortality Risk of infection increases with the amount of necrosis and the time from onset of pancreatitis 24% of pts have bacterial contamination at 1week 71% of pts have bacterial contamination at 3weeks 71% greatest risk in pts with >50% necrosis greatest Infected necrosis Infected Sources of infection include bacterial translocation from the colon, hematogenous spread, descending infection via the biliary duct system, or ascending via the duodenum biliary Organisms Organisms Escherichia coli, Pseudomonas, Klebsiella, Enterococcus, Proteus, Bacteroides Streptococcus faecalis, Staphylococcus aureus Streptococcus Candida species Candida Prevention of bacterial infection Prevention Enteral feeding Enteral avoids central line-related infections avoids maintains gut barrier integrity maintains decreases bacterial translocations decreases Selective decontamination of the gut with non-absorbable antibiotics antibiotics Prophylactic systemic antibiotics Prophylactic Imipenem remains the antibiotic of choice Imipenem Quinolones in combination with Metronidazole are the second-line agents second-line Determination of infected necrosis Determination CT or ultrasound guided fine-needle aspiration of pancreatic necrosis is performed in patients with known necrosis who develop clinical signs of sepsis develop sensitivity of 96% and specificity of 99% sensitivity complications include risk of secondary infection, bleeding, and aggravation of acute pancreatitis Indications and timing of surgery Indications Benefit of surgery in patients with sterile necrosis remains unproven but should be pursued in cases with MSOF unresponsive to medical treatment unresponsive Infected necrosis is a clear indication for surgery Infected Surgical intervention should be postponed as long as possible Surgical demarcation between viable and necrotic tissue is more clearly defined more decreases the bleeding risk decreases minimizes surgery-related loss of vital tissue minimizes Goals of Surgical Interventions 1) Removal of pancreatogenic exudate from the peritoneal cavity and lesser sac cavity 2) Removal of infected, necrotic pancreatic and 2) peripancreatic tissue peripancreatic 3) Preservation of viable pancreatic tissue 4) Postoperative evacuation of remaining debris and exudate Surgical Interventions Surgical 1) Necrosectomy with open packing mortality of 15-17% mortality pancreatic fistula rate of 26-46% pancreatic 2) Necrosectomy with closed packing mortality of 6.2% mortality pancreatic fistula rate of 9% pancreatic 3) Necrosectomy with closed continuous lavage of the 3) retroperitoneum retroperitoneum mortality of 21% mortality pancreatic fistula rate of 19% pancreatic Percutaneous drainage Percutaneous Generally fails to be curative but may be beneficial in stabilizing septic patients stabilizing Single study utilizing large bore drainage catheters (28 French) avoided surgery in 47% of pts (16/34) with infected pancreatic necrosis necrosis Complications of necrotizing pancreatitis Complications Persistent or recurrent infection Persistent Postoperative hemorrhage Postoperative Pancreaticocutaneous fistula Pancreaticocutaneous Enterocutaneous fistula Enterocutaneous Duodenal obstruction Duodenal Pancreatic insufficiency Pancreatic Conclusions Conclusions Necrotizing pancreatitis continues to have significant morbidity and mortality despite advances in medical therapy and Patients with necrotizing pancreatitis should all receive antibiotic prophylaxis antibiotic Surgery should be delayed as long as possible and has no proven role in sterile necrosis proven ...
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This note was uploaded on 12/21/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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