Diagnosis Of Severe Acute Pancreatitis Research Articles

Minimally invasive procedures in severe acute pancreatitis treatment - assessment of benefits and possibilities of use.

IntroductionAcute pancreatitis (AP) consists of an extremely varied complex of pathological symptoms and clinical conditions, ranging from mild gastric complaints to multi-organ failure resulting in death.AimTo present the authors’ own experience regarding surgical treatment for pancreatic necrosis complicated by infection using different methods, including classic and laparoscopic methods as well as those combined with percutaneous techniques.Material and methodsIn the period 2007–2010, 34 patients with the diagnosis of severe AP were treated at the Department of General, Gastroenterological and Oncological Surgery, Collegium Medicum, Nicolaus Copernicus University. In 7 patients classic necrosectomy with repeated peritoneal flushing was performed (type 1), in 5 patients laparotomy with active drainage (type 2), in 12 video-assisted retroperitoneal debridement (type 3), and in 10 only percutaneous drainage methods (type 4).ResultsTotal duration of hospitalisation was from 10 to 192 days. The highest death rate was observed for type 1 procedures. Significant differences with regard to the absolute number of postoperative complications between different groups were not observed; however, their quality varied. Classic methods were used in patients whose general and local condition was more severe.ConclusionsWhen AP and its complications are diagnosed, a suitable method of surgical treatment has to be selected extremely precisely and in an individualised way. Minimally invasive methods used in selected patients provide better outcomes and higher safety superseding classic, open techniques of surgical treatment.

Angiographic catheter as airway exchange device through laryngeal airway mask in unanticipated difficult airway in emergency department

Sir, Angiographic catheter (AC) is commonly used in intervention cardiology, but its application outside cardiac catheterization laboratory (CCL) is seldom reported. AC has been used for nasogastric tube insertion.[1] We used AC as an airway exchange catheter through ProSeal laryngeal airway mask (PLMA) in an unanticipated difficult airway in emergency department (ED). A 42-year-old man admitted at midnight to our ED with diagnosis of severe acute pancreatitis with respiratory failure with apparent normal airway. After preoxygenation rapid sequence intubation was tried with cricoid pressure but unable to intubate even after removal of cricoid pressure for a moment. Immediately airway was secured with size 4 PLMA. The patient needs definite airway for prolonged mechanical ventilation. But we did not have sophisticated airway gadgets in our resuscitation kit. Then we used a 9 Fr sterile AC (Medtronic, Minnesota, USA) with guide wire [Figure 1] lubricated with lignocaine 2% gelly as airway exchange catheter in airway port of PLMA [Figure 2] keeping suction catheter in gastric port. It passed smoothly into trachea and a tactile sensation was felt by keeping the palm on trachea. After 35 cm of insertion, PLMA was removed. Apnea oxygenation was supplied to the patient through the angiographic catheter after removing guide wire and an 8 mm internal diameter endotracheal tube (ET) was exchanged. ET confirmed with capnometry and 5-point chest auscultation. Figure 1 Angiographic catheter with guidewire Figure 2 Angiography catheter inside ProSeal laryngeal airway mask Repeated attempts of laryngoscopy for tracheal intubation in difficult airway are associated with decreased success, increase complications, and morbidities. Alternative airway devices like gum elastic bougies, rigid or flexible fiberoptic bronchoscope, intubating laryngeal mask airway (LMA), video laryngoscope, light wand, and cricothyroidotomy are very effective in this situation.[2]. Airway management in ED is often more difficult than operation theater due to unavailability of difficult airway gadgets, improper environment, and untrained medical stuff. As an intubation conduit LMA is used in different way like blind ET passage after proper LMA placement, using a premounted ET in LMA, bougie-aided intubation via LMA, light wand-aided intubation through LMA, fiberscope aided intubation via LMA, and so on. PLMA having narrower airway tube will not allow to pass larger ET, but absence of aperture bar allow smooth passage of AC. Above all, PLMAs have gastric drainage tube to reduced incidence of aspiration, prevent gastric insufflation, and allow ventilation with higher pressure as it was required in our patient. People used fiberoptic aided intubation through the LMA-Supreme using an Aintree Intubating Catheter (AIC) in manikin.[3] Cook et al.,[4] reported seven case of difficult intubation via PLMA using AIC. AIC are long length, atraumatic, ability to oxygenate, and ventilate during exchange process. But the guidewire in it is too thin and soft for support. We used sterilized AC with atramatic guide wire which have same function as AIC but minimum cost and easily available from CCL. This AC was previously used for angiography but sterilized with 2% glutaraldehyde for 10 min before use in this patient.[5] In conclusion, emergency resuscitation and airway kit must contain classic LMA and LMA for rescue ventilation and oxygenation, while a resterilized AC can also be a useful gadget in difficult airway situation with limited resource.

Bedside index for severity in acute pancreatitis: comparison with other scoring systems in predicting severity and organ failure

The early identification of severe acute pancreatitis is important for the management and for improving outcomes. The bedside index for severity in acute pancreatitis (BISAP) has been considered as an accurate method for risk stratification in patients with acute pancreatitis. This study aimed to evaluate the comparative usefulness of the BISAP. We retrospectively analyzed 303 patients with acute pancreatitis diagnosed at our hospital from March 2007 to December 2010. BISAP, APACHE-II, Ranson criteria, and CT severity index (CTSI) of all patients were calculated. We stratified the number of patiants with severe pancreatitis, pancreatic necrosis, and organ failure as well as the number of deaths by BISAP score. We used the area under the receiver-operating curve (AUC) to compare BISAP with other scoring systems, C-reactive protein (CRP), hematocrit, and body mass index (BMI) with regard to prediction of severe acute pancreatitis, necrosis, organ failure, and death. Of the 303 patiants, 31 (10.2%) were classified as having severe acute pancreatitis. Organ failure occurred in 23 (7.6%) patients, pancreatic necrosis in 40 (13.2%), and death in 6 (2.0%). A BISAP score of 2 was a statistically significant cutoff value for the diagnosis of severe acute pancreatitis, organ failure, and mortality. AUCs for BISAP predicting severe pancreatitis and death were 0.80 and 0.86, respectively, which were similar to those for APACHE-II (0.80, 0.87) and Ranson criteria (0.74, 0.74) and greater than AUCs for CTSI (0.67, 0.42). The AUC for organ failure predicted by BISAP, APACHE-II, Ranson criteria, and CTSI was 0.93, 0.95, 0.84 and 0.57, respectively. AUCs for BISAP predicting severity, organ failure, and death were greater than those for CRP (0.69, 0.80, 0.72), hematocrit (0.45, 0.35, 0.14), and BMI (0.41, 0.47, 0.17). The BISAP predicts severity, death, and especially organ failure in acute pancreatitis as well as APACHE-II does and better than Ranson criteria, CTSI, CRP, hematocrit, and BMI.

Vacuum Assisted Closure Therapy in Severe Acute Pancreatitis: Case Report and Literature Review

Context Abdominal compartment syndrome (ACS) is one of the most worrisome complications of hemorrhagic necrotic pancreatitis (HNP) and its prevention or correct treatment is crucial for patient survival. Case report A 29-year-old male patient with clinical history of sarcoidosis and alcoholic consumption was admitted to our Surgical Unit in March 2012 with diagnosis of severe acute pancreatitis. Clinical evaluation and laboratory tests revealed concurrent sepsis and anemia (WBC 34.91 x10 3 /µL; PCR 34.76 mg/dL; LDH 714 U/L; Hb 10.1 g/L); a CT scan showed a wide pancreatic necrosis and multiple abdominal collections. These findings were suggestive of an infected pancreatic necrosis. A surgical abdominal toilette, necrosectomy and drainage of a large serous-hematic retroperitoneal collection were performed. In postoperative day 3, a gradual increase of intra-abdominal pressure (IAP: 22 mmHg) led up to an ACS, with respiratory distress, acute renal failure and paralytic ileus. Therefore, the patient underwent a second abdominal toilette, with laparostomy covered by a Bogota bag. This latter was replaced every 72 hours. In postoperative day 12, the onset of severe anemia brought to a third operation consisting in abdominal toilette, wide necrosectomy, hemostasis of proper hepatic artery and replacement of the Bogota bag. In postoperative day 22, the Bogota bag was replaced with a vacuum assisted closure (VAC) therapy. VAC therapy was then changed every 48-72 hours. Clinical conditions improved rapidly, in postoperative day 43 the laparostomy was closed with a biological mesh and a CT scan, performed in postoperative day 45, showed the complete resolution of abdominal inflammation and peripancreatic collections. Patient was discharged in postoperative day 68. Conclusion In literature, a standardized surgical strategy for ACS developed from HNP is missing. While the use of laparostomy is widely accepted, only few cases treated with VAC therapy are described. In our experience, laparostomy seemed a good “bridge” treatment, but the best results in terms of clinical response have been gained with the use of VAC therapy.

Intra‐abdominal vacuum‐assisted closure (VAC) after necrosectomy for acute necrotising pancreatitis: preliminary experience

Infection of pancreatic necrosis, although present in less than 10% of acute pancreatitis, carries a high risk of mortality; debridment and drainage of necrosis is the treatment of choice, followed by 'open' or 'close' abdomen management. We recently introduced the use of intra-abdominal vacuum sealing after a classic necrosectomy and laparostomy. Two patients admitted to ICU for respiratory insufficiency and a diagnosis of severe acute pancreatitis developed pancreatic necrosis and were treated by necrosectomy, lesser sac marsupialisation and posterior lumbotomic opening. Both of the patients recovered from pancreatitis and a good healing of laparostomic wounds was obtained with the use of the VAC system. Most relevant advantages of this technique seem to be: the prevention of abdominal compartment syndrome, the simplified nursing of patients and the reduction of time to definitive abdominal closure.

Faster Rate of Initial Fluid Resuscitation in Severe Acute Pancreatitis Diminishes In-Hospital Mortality

Background/Aims:We evaluated the impact of the initial intravenous fluid resuscitation rate within the first 24 h of presentation to the emergency room on important outcomes in severe acute pancreatitis. Methods: Patients presenting directly with a diagnosis of severe acute pancreatitis were identified retrospectively. Patients were divided into two groups — those who received ≥.33% (‘early resuscitation’) and <33% (‘late resuscitation’) of their cumulative 72-hour intravenous fluid volume within the first 24 h of presentation.The primary clinical outcomes were in-hospital mortality, development of persistent organ failure, and duration of hospitalization. Results: 17 patients were identified in the ‘early resuscitation’ group and 28 in the ‘late resuscitation’ group and there were no baseline differences in clinical characteristics between groups. Patients in the ‘late resuscitation’ group experienced greater mortality than those in the ‘early resuscitation’ group (18 vs. 0%,p<0.04) and demonstrated a trend toward greater rates of persistent organ failure (43 vs. 35%, p = 0.31). There was no difference in the total amount of fluid given during the first 72 h. Conclusions: Patients with severe acute pancreatitis who do not receive at least one third of their initial 72-hour cumulative intravenous fluid volume during the first 24 h are at riskfor greater mortality than those who are initially resuscitated more aggressively.

Fundamental and intensive care of acute pancreatitis

Patients who have been diagnosed as having acute pancreatitis should be, on principle, hospitalized. Crucial fundamental management is required soon after a diagnosis of acute pancreatitis has been made and includes monitoring of the conscious state, the respiratory and cardiovascular system, the urinary output, adequate fluid replacement and pain control. Along with such management, etiologic diagnosis and severity assessment should be conducted. Patients with a diagnosis of severe acute pancreatitis should be transferred to a medical facility where intensive respiratory and cardiovascular management as well as interventional treatment, blood purification therapy and nutritional support are available. The disease condition in acute pancreatitis changes every moment and even symptoms that are mild at the time of diagnosis may become severe later. Therefore, severity assessment should be conducted repeatedly at least within 48 h following diagnosis. An adequate dose of fluid replacement is essential to stabilize cardiovascular dynamics and the dose should be adjusted while assessing circulatory dynamics constantly. A large dose of fluid replacement is usually required in patients with severe acute pancreatitis. Prophylactic antibiotic administration is recommended to prevent infectious complications in patients with severe acute pancreatitis. Although the efficacy of intravenous administration of protease inhibitors is still a matter of controversy, there is a consensus in Japan that a large dose of a synthetic protease inhibitor should be given to patients with severe acute pancreatitis in order to prevent organ failure and other complications. Enteral feeding is superior to parenteral nutrition when it comes to the nutritional support of patients with severe acute pancreatitis. The JPN Guidelines recommend, as optional continuous regional arterial infusion and blood purification therapy.

Assessment of severity of acute pancreatitis according to new prognostic factors and CT grading

The assessment of severity at the initial medical examination plays an important role in introducing adequate early treatment and the transfer of patients to a medical facility that can cope with severe acute pancreatitis. Under these circumstances, "criteria for severity assessment" have been prepared in various countries, including Japan, and these criteria are now being evaluated. The criteria for severity assessment of acute pancreatitis in Japan were determined in 1990 (of which a partial revision was made in 1999). In 2008, an overall revision was made and the new Japanese criteria for severity assessment of acute pancreatitis were prepared. In the new criteria for severity assessment, the diagnosis of severe acute pancreatitis can be made according to 9 prognostic factors and/or the computed tomography (CT) grades based on contrast-enhanced CT. Patients with severe acute pancreatitis are expected to be transferred to a specialist medical center or to an intensive care unit to receive adequate treatment there. In Japan, severe acute pancreatitis is recognized as being a specified intractable disease on the basis of these criteria, so medical expenses associated with severe acute pancreatitis are covered by Government payment.

Severe Acute Pancreatitis in China

Many epidemiological studies have recently been published on acute pancreatitis; however, there is no known published report on pancreatitis in China. The present study aims to assess the etiology and mortality of severe acute pancreatitis in China. Fifteen medical centers located throughout mainland China were involved in this retrospective study. The medical records of 1976 patients, who were admitted to these centers with the diagnosis of severe acute pancreatitis from December 1990 to December 2005, were reviewed. Epidemiological, laboratory, radiological, and therapeutic data for each case were collected on a standardized form for analysis. Severity of pancreatitis was graded according to established criteria. Of the 1976 patients (1028 men, 948 women; mean age, 56.2 +/- 16.5 years; range, 9-94 years). Biliary tract disease (58.7%) was the main etiologic factor, whereas in 25.2%, the cause was identified as idiopathic. Endotherapy was performed in 9.1% of the severe biliary cases, but only in 33%, it was performed within 72 hours. The mean duration of hospitalization was 22.5 +/- 21.4 days, and the overall mortality rate was 11.8%. In this retrospective study, biliary tract disease was the main etiologic factor of severe acute pancreatitis in China. The highest mortality occurred in severe idiopathic pancreatitis, and there was no clear relationship between mortality and age.

Perfusion Computed Tomography for the Diagnosis of Severe Acute Pancreatitis

Perfusion Computed Tomography for the Diagnosis of Severe Acute Pancreatitis

Contrast-enhanced computed tomography in acute pancreatitis: does contrast medium worsen its course due to impaired microcirculation?

An early and accurate diagnosis of severe acute (necrotizing) pancreatitis is important to allow timely institution of therapy to limit the extra-pancreatic sequelae of this necrotizing process and to minimize the incidence of super-infection of the necrosis (i.e., progression to infected necrosis). Contrast-enhanced computed tomography (CECT) has become the cornerstone of diagnosis by confirming the clinical diagnosis of severe acute pancreatitis based on the various clinical scoring criteria. Moreover, CECT serves as an anatomic roadmap for guiding radiological and surgical interventions. However, still-controversial experimental studies in animals in the mid-1990s suggested that the use of intravenous radiographic contrast media early in the course of the disease might exacerbate the necrotizing process by further impairing the already compromised pancreatic microcirculation. A series of experimental and clinical studies followed that have both refuted and supported this claim; unfortunately, none is conclusive, and the topic remains, as yet, unresolved. Our objective was to review objectively the available literature found by a Medline search on this subject. Meta-analysis and review. Our conclusion, after analysis of these studies, is that there are no well-substantiated data that could resolve the controversy. However, several caveats will be offered.

Acute Pancreatitis after Aortic Surgery

Acute pancreatitis (AP) after aortic surgery has rarely been reported. A retrospective review of all abdominal and thoracoabdominal aortic operations complicated with AP from January 1982 to March 1992 was performed to study the presentation and outcome of this infrequently recognized complication. Thirteen cases of AP were found among 1965 abdominal aortic operations (0.7% incidence). The distribution of the original aortic operations was as follows: eight elective abdominal aortic aneurysm repairs, two aortoiliac grafts for aortoiliac occlusive disease, and three aortorenal bypasses. Two cases of pancreatitis complicated 170 thoracoabdominal aortic operations (1.2% incidence). Ten patients had mild pancreatitis, nine were discharged without any pancreatic complications after receiving supportive treatment. Five patients with severe AP died of multisystem organ failure despite aggressive surgical treatment; 4 had infected necrosis. The overall mortality was 40 per cent; severe AP resulted in a 100 per cent mortality. The diagnosis of severe AP was usually made in the second postoperative week, significantly later (P < 0.01) than for patients with mild disease. Typically, patients with mild AP presented with hyperamylasemia at a median of 5 postoperative days, and severe AP was found at reoperation or autopsy after a period of unexplained sepsis. Five patients with mild AP were found to have biliary tract stones, with one requiring endoscopic stone extraction. In conclusion, pancreatitis is an uncommon, although perhaps underreported complication. Underreporting may be due to a lack of hyperamylasemia when severe pancreatitis is diagnosed. The severe form is diagnosed late in patients with postoperative sepsis, associated with infected necrosis, and lethal. The complication may be reduced by incidental cholecystectomy for cholelithiasis.

A CASE OF DUODENAL STENOSIS DUE TO ACUTE PANCREATITIS AFTER CONTINUOUS INTRA-ARTERIAL ADMINISTRATION

A 49-year-old man was admitted to the hospital because of severe epigastric pain. White blood cell count and serum CRP were high, the serum amylase, tripsin, phospholipase A2 and lipase were remarkably high on admission. The diagnosis of severe acute pancreatitis was made by CT scan of the abdomen. We performed continuous intra-arterial administration of FOY for 11 days, and pancreatitis improved. But he had nausea and vomiting, and the diagnosis of duodenal necrosis and stenosis was made by gastrofiberscope. The stenosis did not improve after 20 days, so PPPD was performed. Although leakage of duodenum-jejunum anastomosis was complicated, it was conservatively treated and he was discharged from the hospital 68 days after the operation. A duodenal stenosis due to pancreatitis is very rare. In a review of the Japanese literature, only 47 cases of duodenal stenosis due to pancreatitis including our case have been reported so far. We present a case of duodenal stenosis due to pancreatitis, together with some bibliographical comments.

Human Pancreatic Secretory Trypsin Inhibitor in the Assessment of the Severity of Acute Pancreatitis

We assessed the ability of serum human pancreatic secretory trypsin inhibitor (hPSTI) to establish the severity of acute pancreatitis and compared it in this respect to that of serum C-reactive protein (CRP). Of 26 patients studied with acute pancreatitis, 16 had mild pancreatitis, and 10, severe disease. Initial studies were performed at onset of the disease in 20 patients, on the second day of illness in two, and on the third day of illness in the remaining four. In all, serum hPSTI and CRP concentrations were determined on admission and daily for the following 5 days using commercial kits; Ranson's score was evaluated within the first 48 h of admission. Sixty-three healthy subjects and 31 patients with nonpancreatic acute abdomen were also studied. Values of 70 ng/ml for serum hPSTI and 10 mg/dl for serum CRP were taken as limits to distinguish severe from mild-to-moderate acute pancreatitis. When assessed within the first 24 h of pain, serum hPSTI correctly classified 71% of the patients with severe acute pancreatitis, whereas serum CRP did so for 29%. In subsequent days, the two markers showed a similar sensitivity in predicting severe acute pancreatitis. Serum hPSTI and CRP were alike in excluding a diagnosis of severe acute pancreatitis. Ranson's score correctly identified 50% of patients with severe illness and 63% of patients with mild pancreatitis. This study indicates that, when assessed within 24 h of pain onset, serum hPSTI is a better predictor of the severity of acute pancreatitis than serum CRP or Ranson's criteria.

A CASE REPORT OF PRIMARY HYPERPARATHYROIDISM WITH ACUTE PANCREATITIS IN PREGNANCY

Promary hyperparathyroidism with acute pancreatitis during pregnancy is considerably rare. We report a case of primary hyperparathyroidism found by chance with signs and symptoms of acute pancreatitis at 20 week's gestation. A 28-year-old woman at 20 week's gestation consulted us with an intense abdominal pain. Clinical and laboratory findings suggested the diagnosis of severe acute pancreatitis demanding an emergency operation. The operation revealed the intensively swollen pancreas with plenty of serous ascites, against which pancreatic mobilization and extraperitoneal drainage were performed. Postoperative elevations in serum calcium and parathyroid hormone made a possible diagnosis of primary hyperaparathyroidism. It was confirmed by radiography and ultrasonography that revealed a tumor, 2cm in diameter, locating behind the lower pole of the right lobe of thyroid. The parathyroid tumor was removed on day 71 after the initial laparotomy.