PANCREATITIS: WARNING

SIGN AND MANAGEMENT IN

PRIMARY HEALTH CARE
Dr. dr. Hery Djagat Purnomo,
PEPSIN SYMPOSIUM SOLO, 18 Juli 2021
Sp.PD-KGEH
Division Gastroentero-Hepatology
Departement of Internal Medicicine
Dr Kariadi Hospital Diponegoro
University Semarang
PANCREATITIS
Pancreatitis is an inflammation (swelling) of
the pancreas.
When the pancreas inflamed, the digestive
enzyme can damage its tissues, and cause
release of inflammatory cells and toxins
 EPIDEMIOLOGY
• Global Incidence of acute
pancreatitis: 34 cases / 100,000
general population / year
• Highest prevalence in the age 45–
74 years
• Mortality rate of mild pancreatitis
High incidence region:
North America, Western
<1%, Severe pancreatitis up to 30%
Pacific
PER 100,000 PEOPLE

Women
34 👩
👨 Men
Population based data not 52

available in South-East Asia, South

America, Africa Men > Women (52 : 34 per
100,000 people)
Nat Rev Gastroenterol Hepatol. 2019
 DATA PASIEN PANKREATITIS RSUP 8 pasien terdiagnosis
DR KARIADI TAHUN 2020 Pankreatitis Akut
OUTCOME
12.5% 87.5% Mean Age Etiologi:
Meninggal
53.1 ± 12.5 y.o (median 4 3 orang
54.5; 25-70)
pasien
(N=1/8) (N=7/8) post Hidup
ERCP 5
orang

Keluhan Laboratorium
9
8 Leukositosis → mean 19.925 ± 9165;
7 median 17.750 (7600-39.500)
6
5 Peningkatan CRP mean 15 ± 8.83
4 median 13.62 (2.1-29,97)
3
2
1
7 Pasien datang dengan AKI
0
Nyeri perut Mual Demam Badan kuning Lemas 4 pasien dengan Peningkatan ringan
Keluhan ALT
 ACUTE
PANCREATITIS

PANCREATITIS

CHRONIC
PANCREATITIS (8%)
 GIANT TEMPLATE
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No further
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PANCREATITIS
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cu. Eam ex eros follow-up
utinam, ut
alii saepe dignissim usu.

No progression to
Reccurent 21% 13% chronic pancreatitis
acute during follow-up
pancreatitis

8% CHRONIC
PANCREATITIS
 Endoscopic retrograde
cholangiopancreatography (4%) Medication use (2%)
- Azathioprine - Sulfonamides
Chronic alcohol use - Didanosine - Tetracycline
(35%) - Estrogens - Valproic acid
- Furosemide

Abdominal
RISK FACTORS trauma
(1.5%)
Choledocholithiasis AND ETIOLOGY OF
(40%) PANCREATITIS
Others: - Infection
- Abnormalities of - Surgical procedure
Pancreas - Tumor
- Autoimmune - Vascular
disorder abnormalities
- Hypercalcemia
ANATOMY-
PHYSIOLOGY OF
PANCREAS

Exocrine Function

Endocrine Function
 • Reduced Appetite/Weight Loss
10 • Fatty Stool
symptoms • Bloating
of • Indigestion
pancreatitis • Back Pain
• Upper abdominal pain
to be aware
• Swollen abdomen
• Increased hearth rate,
• Fever/sweating,
• Nausea vomiting
 DIAGNOSIS CRITERIA
PANCREATITIS?
Acute pancreatitis is diagnosed when a patient
presents with two of three findings:

Abdominal Serum
pain amylase Characteristic
suggestive of and/or lipase findings on
pancreatitis levels min. 3x imaging
level
 HOW TO DIAGNOSE PANCREATITIS?

ANAMNESIS
Sudden onset of pain • Pain worsens after eating fatty food
• Pain may radiate throughout the
abdomen and into the chest or mid
EpigastriumLeft Upper
back
Quadrant
• Nausea & vomiting, worsen when
supine
• Indigestion, abdominal fullness,
Periumbilical
distension, clay-colored stools,
decreased urine output, frequent
hiccups
• Subjective fever
 HOW TO DIAGNOSE PANCREATITIS?

Physical Examination
• Fever, hypotension, tachycardia, tachypnea,
diaphoresis
• Abdominal Exam:
• Notable tenderness to palpation, guarding, and
possible signs of peritoneal irritation, distension, or
rigidity.
• Decreased bowel sound
• Cullen sign
• Grey Turner sign
HOW TO DIAGNOSE PANCREATITIS?
Indications for Lab and Radiology Testing
 HOW TO DIAGNOSE PANCREATITIS?

Lab and Radiology Testing

Signs and Test for Diagnosis of Pancreatitis

 REVISED ATLANTA CRITERIA
SEVERITY FOR ACUTE PANCREATITIS
SEVERITY CRITERIA
MILD No organ failure (shock, hypoxemia, high creatinine
level, gastrointestinal bleeding)
No local complication (necrosis, abscess, or
pseudocyst)
No systemic complications
Typically resolves in first week
MODERATE Transient organ failure (≤48 hours), or
Local complications, or
Exacerbations of comorbid disease
SEVERE Persistent organ failure (>48 hours)
 BALI SCORE
• BUN level ≥25mg per dl (8.9 mmol per L)
• Age ≥65 years
• Lactate dehydrogenase level ≥300 U per L
• Interleukin-6 Level ≥300pg per mL
______________________________

-Measurements obtained at admission or

over the first 48hours of admission
-3 positive variables ~ mortality rate ≥25%
-4 positive variables ~ mortality rate ≥50%
 CT SCORE
CT Findings (grade) Points
Normal pancreas (A) 0
Edematous pancreas (B) 1 CT SEVERITY INDEX
Edematous pancreas and mild 2
extrapancreatic changes (C)
Severe extrapancreatic changes plus 3 • CT severity index score =
one fluid collection (D) CT Grade + Necrosis Score
Multiple or extensive fluid collection (E) 4
NECROSIS SCORE • CT severity index score ≥5 ~
longer length of
Level of Necrosis Points
hospitalization and 15x
None 0 greater mortality rate
<33% 2
≥33% and <50% 4
≥50% 6
19
 Differential Diagnosis
Acute myocardial infarction Hepatitis
Cholangitis Intestinal infarction
Cholecystitis Pancreatic cancer
Diabetic ketoacidosis Perforated peptic ulcer
Gastric outlet obstruction Tubo-ovarian abscess
Gastric volvulus
 PRIMARY MANAGEMENT OF ACUTE PANCREATITIS AT
EARLY STAGE Admission

• Vigorous intravenous hydration

• Severity stratification
• Assessment of etiology
• Physical examination & Examination

Severe Moderate and mild Gallstone pancreatitis

• Correction of fluid • Correction of fluid • Antibiotics - Cholangitis

resuscitation resuscitation • Correction of fluid - Disturbed bile
• Analgesics, antibiotics, • Protease inhibitiors resuscitation flow
oxygen • When required Analgesics, • Protease inhibitiors
• Protease inhibitiors antibiotics, oxygen • Analgesics, oxygen
• CRAI, CHDF
• Enteral feeding
Aggravation
Aggravation
Aggravation
Improvement
Urgent therapeutic ERCP or EST
Refer to high specialist unit (Refer to specialist unit)

Consensus of primary care in acute pancreatitis in Japan, NCBI

• NUTRITIONAL MANAGEMENT IN ACUTE PANCREATITIS
Acute Pancreatitis
Treat AP according to
HTG confirmed severity, irrespective of
Assessment of etiology
within 48 hours Severity

Nutritional Support

Mild AP Moderate & Severe

AP

If oral feeding not

If oral feeding not In case of
If tolerated, tolerated/impossible, initiate early
abdominal
initiate oral tolerated, initiate EN (24-72h from admission) EN via NGT
compartment
feeding syndrome,
‘open
EN not tolerated or inadequate targeted
abdomen’ or
nutritional requirement intolerance to
EN
Initiate supplemental or total PN, but
EN should perform in a small amount
INITIAL MANAGEMENT OF
ACUTE PANCREATITIS
Within 24 hours after onset:
• Initial vigorous intravenous hydration
• Severity stratification
• Assessment of etiology
• All patients with severe acute pancreatitis should
be transferred to a high special unit or intensive
therapy unit.
From 24-48 hours after onset:
• Re-evaluation of severity
• All patients with severe acute pancreatitis should be
transferred to a high special unit or intensive therapy
unit

After 48 hours of onset:

• Fundamental conservative therapy in moderate and
mild cases
• All patients with severe acute pancreatitis should be
transferred to a high special unit or intensive therapy
unit.
 INITIAL TREATMENT OF
ACUTE PANCREATITIS
Within 24 hours after onset:
• Initial fluid resuscitation (60-160 mL/kg
body weight/day)
• For the first 6 hours, fluid resuscitation of
about ½ - ⅓ of required amount for the
first 24 h ours
• Analgesics and oxygen, as required
• Protease inhibitors
• Antibiotics for severe cases and infection
of the bile duct
Goal:
• Consider CRAI CHDF in severe cases
- Maintain urine output of 0.5
• Urgent therapeutic ERCP or EST in patients
mL/kg/hour
with cholangitis or with disturbed bile flow
- Decreasing BUN
(refer to a specialist unit where facilities
and expertise are available for ERCP and
EST)
 INITIAL TREATMENT OF
ACUTE PANCREATITIS
After 24 hours after onset:
• Similar to the above-mentioned
treatment
• In addition
• Correction of fluid resuscitation
Goal: • Enteral feeding in patients without
- Maintain urine output of clear signs and symptoms of ileus
0.5 mL/kg/hour and GI bleeding
- Decreasing BUN
 COMPLICATIONS OF
ACUTE PANCREATITIS
LOCAL COMPLICATIONS
• Acute peripancreatic fluid
collections
• Pancreatic pseudocysts
• Acute necrotic collections
• Walled-off pancreatic necrosis
SISTEMIC COMPLICATIONS &
ORGAN FAILURE
• Respiratory: PaO2/FiO2 ≤ 300
• Cardiovascular:
• Systolic BP < 90mmHg (off
inotropic support)
• Not fluid responsive, or
• pH < 7.3
• Renal: serum creatinine
≥170mmol/L
 CONSIDERATION OF TRANSFER TO A
MONITORED UNIT
• APACHE II Score > 8
• CRP > 14 286 nmol/L (150 mg/L), or 1.
Severe acute
• Organ dysfunction for >48 hours pancreatitis
despite adequate resuscitation; Cardiovascular

Renal (hypotension despite

Evidence of Organ
Dysfunction 2.
• Hemoglobin [Hb] > 160
• Hematocrit [HCT] > 0.500
aggressive fluid
Respiratory (≥ 1.5-fold increase in
resuscitation
serum creatinine over 7
(PaO2/FiO2 ≤ 300
or d, increase of ≥ 26.5 [systole < 90 mm Hg
off of inotropic
RR>20times/min) μmol in serum
creatinine over 48 h, support or drop of sBP
urine output < > 40], need for
0.5mL/kg/h for ≥ 6 h); vasopressors [not
fluid responsive], or
pH <7.3)
Severe
3. hemoconcentration
 HOLISTIC PREVENTION OF
PANCREATITIS

Primary Secondary Tertiary

Prevention Prevention Prevention

Aim to Apply effective Minimizing its

reduce intervention sequelae and
disease early and reduce resulting burden
incidence morbidity
 HOLISTIC PREVENTION OF
PANCREATITIS
Primary Secondary Tertiary
Prevention Prevention Prevention

First Acute
Pancreatitis PPDM

General Reccurent EPI

Population Acute
Pancreatitis

EPI, exocrine pancreatic insufficiency Osteoporosis

Chronic
PPDM, post-pancreatitis diabetes mellitus. Pancreatitis
KASUS Pasien masuk tanggal 30/06/2021

Tn. W, 44 tahun

Keluhan Utama : Nyeri perut atas

Nyeri dirasakan sangat berat sejak 5 jam sebelum masuk RS ,

mual dan muntah , makan dan minum tidak bisa masuk. Nyeri
menjalar hingga ke punggung, tidak tertahankan.
 Tekanan darah : 210 /120 mmHg
Nadi : 130 x/menit
RR : 28x/menit Nyeri VAS = 9
Suhu : 36,50 C
Spo2 : 99 %

Mata : Konjungtiva Palpebra Pucat -/-, Sklera ikterik -/-

Leher : JVP R+2
Paru : dalam batas normal
Jantung : Kardiomegali, Suara Jantung I-II murni,
Gallop -, Bising –

Abdomen : Perut cembung

Bising usus menurun
PEMERIKSAAN Hepar dan lien tak teraba, liver span 10 cm,
FISIK nyeri ulu hati dan perut atas
Ekstremitas : tidak didapatkan oedem, eritema palmaris (-)
 •Diagnosis

1. Akut Pancreatitis derajat sedang

2.Hipertensi Urgensi
3.Cholesistitis kronis, Kolesitolitiasis
Terapi :

Oksigenasi
Puasakan-24-48 jam, diet enteral
Pasang NGT
INFUS RL rehidrasi
Anti hipertensi
Analgetik continue NSAID- Fentanyl
Antibiotik
39
 Klinis membaik :
Nyeri terkontrol baik dgn
analgetik minimal
T : 140 / 85 mmhg
RR 20 x/mn
Mulai diet enteral bisa
masuk

40
41
Hepatomegali, parenkim homogen
Gambaran cholecysytitis kronis dengan multiple cholecysytolithiasi
(ukuran sekitar 0,44 cm).
Pancreas membesar ringan dengan ekogenitas pancreas yg
menurun dan inhomogen------dapat mendukung gambaran
pancreatitis akut
42
 Take home messeges
Prevalensi Pancreatitis acute di populasi tdk tinggi, tetapi bisa mengancam
jiwa, dan komplikasi

Tanda dan gejala penting : 2 dari 3 hal berikut ; nyeri perut di

jalarkan ke punggng, amilase/lipase >3 N, gambaran imaging jelas

Pengelolaan utama :
Rehidrasi adekuat, Analgesik dan oksigenasi,
antibiotik pada kasus berat dan infeksi.

Dokter umum berperan besar dalam diagnosis dan penangan pertama

Untuk mencegah perburukan /ancaman jiwa dan komplikasi
43
THANK YOU