Acute Pancreatitis: Current Perspectives On Diagnosis and Management

Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES

Nabua, Camarines Sur
GRADUATE SCHOOL
COURSE: MASTERS OF ARTS IN NURSING

SUBJECT: ADVANCED MEDICAL SURGICAL 2
PREPARED BY: ELAINE FRANCES M. ILLO, RM, RN
TOPIC: NURSING MANAGEMENT of LIVER, PANCREAS AND BILIARY
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ACUTE PANCREATITIS: CURRENT PERSPECTIVES ON DIAGNOSIS

AND MANAGEMENT
By: Adarsh P Shah, Moustafa M Mourad, and Simon R Bramhall
Published: March 9. 2018
10.2147/JIR.S135751
Abstract
The last two decades have seen the emergence of significant evidence that has
altered certain aspects of the management of acute pancreatitis. While most cases of
acute pancreatitis are mild, the challenge remains in managing the severe cases and
the complications associated with acute pancreatitis. Gallstones are still the most
common cause with epidemiological trends indicating a rising incidence. The surgical
management of acute gallstone pancreatitis has evolved. In this article, we revisit and
review the methods in diagnosing acute pancreatitis. We present the evidence for the
supportive management of the condition, and then discuss the management of acute
gallstone pancreatitis. Based on the evidence, our local institutional pathways, and
clinical experience, we have produced an outline to guide clinicians in the management
of acute gallstone pancreatitis.
Conclusion
Acute pancreatitis is frequently encountered on the emergency surgical take.

Once the diagnosis is made, clinical efforts should simultaneously concentrate on
investigating for the underlying etiology and managing the condition by anticipating its
complications, which can be aided by using any of the severity scoring systems
described. Management of acute pancreatitis is largely supportive. There is still no
consensus on the ideal type and regimen of fluid for resuscitation, but goal-directed fluid
therapy is associated with better outcomes. Early enteral nutrition modulates the
inflammatory response and improves outcomes by decreasing infective complications of
acute pancreatitis. Antibiotics should be used judiciously as prophylactic antibiotics
have not shown any benefit in preventing infective complications of acute pancreatitis.
Patients with mild acute gallstone pancreatitis should be recommended to undergo a
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laparoscopic cholecystectomy at the index admission, while those with severe gallstone
pancreatitis and evidence of cholangitis and/or choledocholithiasis benefit from early
ERCP. Patients with mild acute gallstone pancreatitis and concurrent
choledocholithiasis benefit from single-stage laparoscopic cholecystectomy and bile
duct exploration, subject to available local expertise. There is no difference in mortality
and morbidity between the single-stage and double-stage management of
choledocholithiasis. However, the single-stage approach reduces the length of hospital
stay and need for recurrent admissions.
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2019 WSES GUIDELINES FOR THE MANAGEMENT OF SEVERE

ACUTE PANCREATITIS
By: Ari Leppäniemi, et. Al.
Published: 13 June 2019
https://wjes.biomedcentral.com/articles/10.1186/s13017-019-0247-0
Abstract
Although most patients with acute pancreatitis have the mild form of the disease,
about 20–30% develops a severe form, often associated with single or multiple organ
dysfunction requiring intensive care. Identifying the severe form early is one of the major
challenges in managing severe acute pancreatitis. Infection of the pancreatic and
peripancreatic necrosis occurs in about 20–40% of patients with severe acute
pancreatitis, and is associated with worsening organ dysfunctions. While most patients
with sterile necrosis can be managed nonoperatively, patients with infected necrosis
usually require an intervention that can be percutaneous, endoscopic, or open surgical.
These guidelines present evidence-based international consensus statements on the
management of severe acute pancreatitis from collaboration of a panel of experts
meeting during the World Congress of Emergency Surgery in June 27–30, 2018 in
Bertinoro, Italy. The main topics of these guidelines fall under the following topics:
Diagnosis, Antibiotic treatment, Management in the Intensive Care Unit, Surgical and
operative management, and Open abdomen.
Discussion
Acute pancreatitis (AP) represents a disease characterized by acute
inflammation of the pancreas and histologically acinar cell destruction [6]. The diagnosis
of AP requires at least the presence of two of the three following criteria: (i) abdominal
pain consistent with the disease, (ii) biochemical evidence of pancreatitis (serum
amylase and/or lipase greater than three times the upper limit of normal), and (iii)
characteristic findings from abdominal imaging.
Most patients (80–85%) will develop a mild disease course (self-limited, mortality
< 1–3%), but around 20% will have a moderate or severe episode of AP, with a mortality
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rate from 13 to 35%. Thus, it is important to diagnose (or better predict) an episode of
severe acute pancreatitis (SAP), and to identify the patients with high risk of developing
complications.
On admission, the etiology of AP should be determined, to project the need of
definitive treatment (e.g., gallstone disease) and to avoid recurrence (e.g., alcohol
intake, hypertriglyceridemia). The treatment and follow-up depend on the etiology of the
AP. A transabdominal US should be performed on admission (to perform
cholecystectomy for biliary pancreatitis when appropriate). Almost all the AP guidelines
worldwide (based on revisions and meta-analyses) recommend performing US on
admission or in the first 48 h.
Serum pancreatic enzyme measurement is the “gold standard” for the diagnosis of AP.
In an episode of AP, amylase, lipase, elastase, and trypsin are released into the
bloodstream at the same time but the clearance varies depending on the timing of blood
sampling. Amylase is an enzyme secreted by the pancreas, and also salivary glands,
small intestine, ovaries, adipose tissue, and skeletal muscles. There are two major
isoforms of amylase: pancreatic and salivary, and the leading function is digestion of
starch, glycogen, and related poly- and oligosaccharides, by hydrolysis. In AP, serum
amylase levels usually rise within 6 to 24 h, peak at 48 h, and decrease to normal or
near normal levels over the next 3 to 7 days.
Lipase is another enzyme secreted by the pancreas. AP is the main reason for
an increase in lipase, and many investigators emphasize that lipase is more specific,
but can be found elevated also in non-pancreatic diseases such as renal disease,
appendicitis, acute cholecystitis, chronic pancreatitis, bowel obstruction, etc. In AP,
serum lipase remains elevated for a longer period than serum amylase. It rises within 4
to 8 h, peaks at 24 h, and decreases to normal or near normal levels over the next 8 to
14 days.
Trypsinogen is the zymogen of the pancreatic enzyme trypsin. In AP, the serum
and urinary concentrations of trypsinogen usually rise to high levels within a few hours
and decrease in 3 days
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CONCLUSIONS
These guidelines present evidence-based international consensus statements on

the management of severe acute pancreatitis from collaboration of a panel of experts. It
contains 55 statements on diagnosis, management in the ICU, surgical and operative
management, open abdomen, and antibiotic treatment. For some of the statements
such as severity grading, imaging, use of prophylactic antibiotics and most aspect of the
management in the ICU, the evidence is strong. For others, such as laboratory
diagnostics and surgical strategies, for example, the evidence is quite weak requiring
further studies. With accumulating knowledge, the statements need to be regularly
updated.
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PATHOLOGICAL ACUTE INFLAMMATION IN CHRONIC PANCREATITIS

By: Pavankumar Vijayaraj1, Biju Pottakkat1, Raja Kalayarasan1, Sandip Chandrasekar1,
Surinder Kumar Verma2
Published: July 04th, 2019
https://pancreas.imedpub.com/pathological-acute-inflammation-in-chronic-
pancreatitis.php?aid=25079
Abstract
Mechanism of pain in Chronic Pancreatitis is not fully understood. Recurrent
acute inflammation is one of the proposed hypotheses for pain in chronic pancreatitis.
The actual incidence and prevalence of ongoing acute inflammation in chronic
pancreatitis have been under-noticed in literature. This study aims to examine the
prevalence of acute pancreatic inflammation in chronic pancreatitis patients. Methods:
Fifty patients who underwent surgery for chronic pancreatitis were analyzed. Those with
clinical, biochemical or radiological features of acute on chronic pancreatitis were
excluded. Intra operative fine needle aspiration cytology was taken from the head and
body of pancreas. Pancreatic tissue was sent for histopathological examination in all
patients. Results: Intraoperative fine needle aspiration cytology from pancreas showed
features of acute inflammation in twenty 23 (46%) cases. Biopsy from pancreas showed
features of acute inflammation in 12 patients (24%). 30/50 (60%) patients had some
features of acute inflammation in either fine needle aspiration cytology or biopsy.
Conclusion
Significant proportion of patients with chronic pancreatitis has pathological
features of acute inflammation in pancreas despite clinical, biochemical and radiological
features showing no evidence of acute pancreatitis. Ongoing pathological acute
inflammatory process in the pancreas might be a major cause for initiation and
progression of chronic fibrosis in chronic pancreatitis.

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Republic of the Philippines

CAMARINES SUR POLYTECHNIC COLLEGES

COURSE: MASTERS OF ARTS IN NURSING