Acute Necrotizing Pancreatitis

Intern:
Date: 2003-5-26

Topics
What is acute necrotizing pancreatitis ?
The recognition of pancreatic necrosis
To manage with acute necrotizing
pancreatitis

Review of acute pancreatitis

Presentations
Causes: gallstones, alcohol abuse
Severity: variable, mild, severe
Severity classification:
Ranson score, APACHE II

Causes of acute pancreatitis

Severity classification
Ransons Score

APACH-II score

Classification of acute pancreatitis

~ from The International Symposium on Acute Pancreatitis, Arch Surg 1992 ~

Acute pancreatitis
Severe acute pancreatitis
Mild acute pancreatitis
Acute necrotizing pancreatitis

Classification of acute pancreatitis

~ from The International Symposium on Acute Pancreatitis, Arch Surg 1992 ~

Acute Pancreatitis:
Definition
acute inflammation of pancreatitis,
variable involvement of regional tissues or remote organ systems
Pathology
interstitial edema,
fat necrosis of parenchyma,
pancreatic and peripancreatic necrosis and hemorrhage

Severe Acute Pancreatitis

Definition
organ failure, local complications (necrosis, abscess, pseudocyst)
Pathology
a clinical presentation of pancreatic necrosis

Classification of acute
pancreatitis
~ from The International Symposium on Acute Pancreatitis, Arch Surg 1992 ~

Mild Acute Pancreatitis

Definition
minimal organ dysfuntion, uneventful recovery,
lacks the features of severe acute pancreatitis
Pathology microscopic interstitial edema

Pancreatic Necrosis
Definition diffuse or focal area(s) of nonviable pancreatic parenchyma
typically associated with peripancreatic fat necrosis
Pathology
devitalized parenchyma, peripancreatic fat necrosis, hemorrhage,
extensive interstitial fat necrosis with vessel damage an necrosis

Recognition of clinically severe acute

pancreatitis
~ from The International Symposium on Acute Pancreatitis, Arch Surg 1992 ~

Ransons score >= 3

APACH II score >= 8
Organ failure:
Shock: systolic BP < 90 mmHg
Pulmonary insufficiency: PaO2 <= 60 mmHg
Renal insufficiency: Cre >= 2mg/dL after rehydration
GI bleeding: >= 500 ml/24 hours

Substantial pancreatic necrosis

at least 30% glandular necrosis according to contrast-enhanced CT

Definition of Acute
Necrotizing Pancreatitis

Nonviable pancreatic parenchyma,

Peripancreatic fat necrosis,
Extensive interstitial fat necrosis, vessel damage

Affect acinar cells, islet cells, and pancreatic ductal

system
Increasing severity, morbidity and mortality
Importance of recognition for appropriate management

Recognition of Pancreatic
Necrosis
~ Imaging and Intervention in Acute Pancreatitis, Radiology 1994 ~

Clinical recognition of severe acute

pancreatitis
Gold standard of diagnosis:
Constrast-enhanced CT
Criteria: nonenhanced pancreatic parenchyma >= 3cm or 30% area
Mechanism: normal density 100~150 HU, necrosis <50 HU
Semiquantitative measure: compare with spleen density

 Normal unenhanced pancrease (a)

Normal enhanced pancrease (b)

Statistical Results about Necrotizing

Acute Pancreatitis
~ From NEJM 1999 ~

Necrosis: 20 ~ 30% of acute pancreatitis

Mortality:
sterile necrosis 10%
infected necrosis 100% without surgery
>15%, usually 20~40% with surgery

Infected necrosis:
30~70% of necrotizing pancreatitis
account for more than 80% of deaths from acute
pancreatitis

Management of acute
necrotizing pancreatitis
Early management:
Intensive medical care
Prevention of infection with prophylactic antibiotics

Late management
Treatment of local infectious complications
Aggressive debridement

Management of acute
necrotizing pancreatitis
Prophylactic antibiotics ?
ERCP and Biliary sphincterotomy ?
Nutritional support: TPN or Enteral feeding
(jejunal feeding) ?
Surgical debridement (Necrosectomy) ?

Prophylactic Antibiotics
Prophylactic antibiotics in acute pancreatitis
no significant benefit
( Ann Intern Med 1975, J Surg Res 1975)

Prophylactic antibiotics in acute necrotizing

pancreatitis?

Prophylactic antibiotics in acute

necrotizing pancreatitis
Early antibiotics treatment in acute necrotizing
pancreatitis ~ from Lancet 1995 ~
Design:
30 patients cefuroxime (4.5 g/day, IV)
30 patients no antibiotics
Mortality rate:
antibiotic group: 1/30
non-antibiotic group: 7/30

(p = 0.03)

Prophylactic antibiotics in acute

necrotizing pancreatitis
The Role of Antibiotic Prophylaxis in Severe Acute
Pancreatitis ~ from Arch Surg. 1997 ~
Retrospective, 180 patients with severe acute pancreatitis
3 periods: 50 pt (1982~1989) no Abx,
55 pt (1990~1992) non-protocol use,
75 pt (1993~1996) with Abx (imipenem-cilastatin sodium)
Results: Significant reduction in infection rate (P = 0.04)
Only a trend toward improved survival (P = 0.11)
80%
70%
60%
50%
40%

Pan. Infection

30%

Mortality rate

20%
10%
0%

1982~89

1990~92

1993~96

ERCP and Endoscopic Sphincterotomy

(ES)
In acute pancreatitis due to gallstones

Controlled trial of urgent ERCP and ES versus conservative

treatment for acute pancreatitis due to gallstones
~ from The
Lancet 1988 ~
121 patients, acute pancreatitis, gallstones related, randomized control
Results: improved outcome only with clinically severe pancreatitis

ERCP and Endoscopic Sphincterotomy (ES)

In acute pancreatitis due to gallstones
Early treatment of acute biliary pancreatitis by endoscopic papillotomy
~ from NEJM 1993 ~

195 patients, acute pancreatitis,

randomized control
Results:
Reduction in biliary sepsis (both
mild and severe pancreatitis)
No difference of local and

systemic complications
Mortality rate: slightly lower
(5 v.s 9 patients, P = 0.4)

Nutritional Support
The concept of pancreatic rest and TPN
Not improving outcome or further benefit except
decreasing pain
Disadvantages: complications, high cost
(Clinical nutrition in pancreatitis

from Dig Dis Sci 1997)

Nutritional Support
TPN v.s EF (enteral feeding)
from Br J Surg 1997
38 patients, randomized into EF group (n=18) and TPN group ( n=20)
Results: EF well tolerated, without adverse effects,
fewer complications (p< 0.05), 1/3 the cost of TPN

Nutritional Support
TPN v.s TEN (total enteral nutrition)
Compared with parenteral nutrition, enteral feeding attenuated the acute phase
response and improved disease severity in acute pancreatitis ~from Gut 1998~
Methods: 34 patients, randomized to TPN or TEN group
Results: SIRS, sepsis, organ failure, and ITU were improved in TEN group
The CRP and disease severity scores significantly improved

Nutritional Support

Surgical debridement
Who? When? and How?
Acute necrotizing pancreatitis: sterile v.s infected
Infected ANP:
Uniformly fatal without intervention(100%),
Necrosectomy soon after confirmation of infected necrosis

Sterile ANP:
Mortality 10%, benefit of surgery remain unproved,
Frequently indicated for surgical debridement

Surgical debridement
Who? When? and How?

Diagnosis of infected necrosis:

CT-guided fine-needle aspiration:
safe, Sensitivity 96%, Specificity 99%

Surgical debridement
Who? When? and How?
CT-guided fine-needle aspiration

Surgical debridement
Surgical treatment modalities for infected necrosis
Surgical Treatment of Infected Necrosis

~ from World J. Surg. 1997 ~

Surgical debridement
Mortality among patients with infected necrosis
Surgical Treatment of Infected Necrosis

~ from World J. Surg. 1997 ~

Conclusions
Pancreatic necrosis is being increasingly recognized
(due to physicians awareness, improved radiologic imaging)

Importance of identification of pancreatic necrosis:

high morbidity and mortality

Diagnosis of pancreatic necrosis: Constrast-enhanced CT

Aggressive medical care with prophylactic
antibiotics

Conclusions
ERCP with sphincterotomy in severe acute gallstone
pancreatitis with biliary obstruction (hyperbilirubinemia,
cholangitis)

Enteral feeding superior than TPN

Surgery with necrosectomy with drainage in patients
with infected necrosis