Pancreatitis with necrosis!?!?!?

[adagio]

Hi everyone, I want to ask about the steps in management/diagnosis of pancreatitis

what is the best initial test? I think amylase and lipase

Most accurate test? I think CT

now my questions:
1 what is the best next step after they give a description of pancreatits?
2 If we see >30% necrosis on CT what is the best next step? Antibiotics OR needle aspiration to determine what infection there is?
3 if we see <30% necrosis on CT what is the next best step?

Thank you

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[Fuzuli]

You must be following Dr. Conrad Fischer's lectures 🙂

"A 50 year old man with a history of alcohol abuse, medically controlled hypertension and T2DM presents to ED with severe epigastric pain. His pain, which has started 2 hours ago, is "bleeping bleep"/10 in severity, sharp in character and radiates to his back. His vitals are T:37.9C, BP: 90/70 mm Hg, pulse: 113/min, respiratory rate: 20/min, SaO2: %92 (ambient air). IV access is gained with an 18 G needle and a bolus of 1 L Ringer's lactate is given by the surgical intern. What is the next best step?"


a) Obtain amylase and lipase
b) Emergent abdominal USG at the bedside
c) Emergent spiral CT of abdomen, with a pancreatic window
d) Rush the patient to OR
e) Emergent ERCP

One would jump at choice A, right? But based on the information given above, can you eliminate AAA as the source of abdominal pain? Therefore, after resuscitation, performing a bedside USG would be a better choice. If AAA is detected, then this is a surgical emergency and patient should be operated ASAP.

"A 50 year old man with a history of alcohol abuse, medically controlled hypertension and T2DM presents to ED with severe epigastric pain. His pain, which has started 4 hours ago, is "bleeping bleep"/10 in severity, sharp in character and radiates to his back. His vitals are T:37.9C, BP: 90/70 mm Hg, pulse: 113/min, respiratory rate: 20/min, SaO2: %92 (ambient air). IV access is gained with an 18 G needle and a bolus of 1 L Ringer's lactate is given by the surgical intern. A bedside abdominal USG is performed and no AAA is detected. What is the best next step?"


In a suspected acute pancreatitis, the best initial test is amylase and lipase. Be warned that in alcoholic patients (who might be suffering from chronic pancreatitis and loss of exocrine pancreas), amylase levels may be normal even if acute pancreatitis is present.

"A 50 year old man with a history of alcohol abuse, medically controlled hypertension and T2DM presents to ED with severe epigastric pain. His pain, which has started 4 hours ago, is "bleeping bleep"/10 in severity, sharp in character and radiates to his back. His vitals are T:37.9C, BP: 90/70 mm Hg, pulse: 113/min, respiratory rate: 20/min, SaO2: %92 (ambient air). IV access is gained with an 18 G needle and a bolus of 1 L Ringer's lactate is given by the surgical intern. A bedside abdominal USG is performed and no AAA is detected. Obtained amylase levels show a slight increase. Since arriving to ED, the patient has started vomiting. A CXR and upright abdominal X-ray reveals no infradiaphragmatic air. What is the next best step?"


A penetrating ulcer to pancreas may be associated with a mild increase in amylase levels. In this setting, performing EGD would be appropriate.

"A 40 year old woman with a history of gallstones, medically controlled hypertension and T2DM presents to ED with severe epigastric pain. Her pain, which has started 4 hours ago, is "bleeping bleep"/10 in severity, sharp in character and radiates to his back. Her vitals are T:37.9C, BP: 90/70 mm Hg, pulse: 113/min, respiratory rate: 20/min, SaO2: %92 (ambient air). IV access is gained with an 18 G needle and a bolus of 1 L Ringer's lactate is given by the surgical intern. A bedside abdominal USG is performed and no AAA is detected. There's a threefold increase of amylase and lipase levels in the serum. What is the next best step?"


a) Perform abdominal USG
b) Perform spiral abdominal CT
c) Perform upright abdominal X-ray
d) Perform CXR
e) Perform ERCP

Pancreas = CT, right? Not necessarily - the first procedure to perform would be an USG in this patient, because of the increased risk of gallstones. USG visualization can be poor in obese patients and with patients with ileus/air in the bowels. In this case, abdominal CT should be performed.

There are several pathologies associated with CXR (like pleural effusion) and abdominal X-ray (sentinel loop, calcifications), but these are (as Dr. Fischer puts it) archaic choices for the diagnosis for acute pancreatitis.

 

[adagio]

"One would jump at choice A, right? But based on the information given above, can you eliminate AAA as the source of abdominal pain? Therefore, after resuscitation, performing a bedside USG would be a better choice. If AAA is detected, then this is a surgical emergency and patient should be operated ASAP."

Excellent point.


"In a suspected acute pancreatitis, the best initial test is amylase and lipase. Be warned that in alcoholic patients (who might be suffering from chronic pancreatitis and loss of exocrine pancreas), amylase levels may be normal even if acute pancreatitis is present."

What about lipase? could it also be normal?

"A penetrating ulcer to pancreas may be associated with a mild increase in amylase levels. In this setting, performing EGD would be appropriate."

No air was on the xray ... Why would you do EGD?!?!?!?!? (what if this mild elevation of amylase is due to a bout of pancreatitis over a chronically damaged pancreas)

"Pancreas = CT, right? Not necessarily - the first procedure to perform would be an USG in this patient, because of the increased risk of gallstones. USG visualization can be poor in obese patients and with patients with ileus/air in the bowels. In this case, abdominal CT should be performed."

So you would choose US here as well?? this is really perplexing .... are you saying that you would choose US so that if you saw a stone you would do Emergency ERCP?? if thats what you are saying, then what about assessing the state of the pancreas to see if its necrosed or not??


Also, can you give me your thoughts about:
- If we see >30% necrosis on CT what is the best next step? Antibiotics OR needle aspiration to determine what infection there is?
- if we see <30% necrosis on CT what is the next best step?



Are you a 285 scorer on step 2?!?!!? 😀

 

[Fuzuli]

Also, can you give me your thoughts about:
- If we see >30% necrosis on CT what is the best next step? Antibiotics OR needle aspiration to determine what infection there is?
- if we see <30% necrosis on CT what is the next best step?

"A 50 year old man with a history of alcohol abuse, medically controlled hypertension and T2DM presents to ED with severe epigastric pain. His pain, is sharp in character and radiates to his back. His vitals are T:37.9C, BP: 90/70 mm Hg, pulse: 113/min, respiratory rate: 20/min, SaO2: %92 (ambient air). IV access is gained with an 18 G needle and a bolus of 1 L Ringer's lactate is given by the surgical intern. A bedside abdominal USG is performed and no AAA is detected. There's a threefold increase of serum amylase and lipase levels. He's admitted to MICU with a diagnosis of acute pancreatitis. You've begun treating him with NPO, IV fluid replacement and pain control (Demerol 75 mg IM q4h). After 12 hours of admission, his vitals are: T:36.0C, BP:85/65 mm Hg, pulse: 116/min, respiratory rate: 22/min, SaO2: %89 (ambient air). 2 L/min O2 with mask is initiated, as well as more aggressive fluid therapy. What is the next best step?"

This patient is likely to have necrotizing pancreatitis. The next best step would be to perform an contrast-enhanced abdominal CT (CECT).

So the logical order should go like: Clinical symptoms > Amylase/lipase > Ultrasound > Assess the severity. This assessment can be done using scoring systems (like Ranson’s and APACHE-II), laboratory tests (leukocytosis with left shift, CRP elevation, IL-6, LDH, etc.) and severity of clinical signs, but the best test to assess the severity of pancreatitis is IV contrast-enhanced abdominal CT (CECT). So, if a patient is suspected to have necrotizing pancreatitis, regardless of Ranson’s or APACHE-II score, CECT should be performed.

If we see >30% necrosis on CT what is the best next step? Antibiotics OR needle aspiration to determine what infection there is?

>30% necrosis on CT confirms the diagnosis of acute necrotizing pancreatitis.

Antibiotic prophylaxis for these patients is said to be controversial, but every single resource I've seen have mentioned it, so I guess it is exam material. IV imipenem is recommended for these patients (for no more than 2 weeks)

Decision to perform FNA depends on the results of CT scan. If there’s gas in the pancreas, then it may have become infected. Now this infection could be in the form of an abscess (pancreatic abscess) or it may be infected necrotic material (“infected necrotizing pancreatitis”). If CT results suggest infection, CT/USG guided FNA should be peformed and Gram stain and culture for the obtained tissue should be done. If the tissue is infected, antibiotic treatment for the isolated agent and surgical debridement is appropriate. If FNA-obtained material is negative for infection (“sterile pancreatitis”), then surgical debridement should be withheld.

So: If CECT has indications of infection > Perform radiology-guided FNA

--> FNA (+): Appropriate antibiotics and debridement
--> FNA (-): Continue aggressive supportive treatment

if we see <30% necrosis on CT what is the next best step?

Now there would be discrepency between the case and this CT result 🙂 In this case, a supportive treatment (NPO, IV fluids, pain control) is more appropriate.

 

[adagio]

So basically you are saying ((Necrosis per se)) is NOT indication to Aspiration, but IT IS an indication for prophylactic Imepenem (IF its more than 30 percent necrosis). However, the book master the boards step 3 mentioned that always when there is more than 30 percent necrosis we should perform both (Aspiration & Imepenem) thats why i was confused.

Ughhh, this is very perplexing.

 

[Fuzuli]

So basically you are saying ((Necrosis per se)) is NOT indication to Aspiration, but IT IS an indication for prophylactic Imepenem (IF its more than 30 percent necrosis). However, the book master the boards step 3 mentioned that always when there is more than 30 percent necrosis we should perform both (Aspiration & Imepenem) thats why i was confused.

Ughhh, this is very perplexing.

"INFECTIONS - If there is an indication of infection (e.g., retroperitoneal air on CT scan), then a CT- or US-guided fine-needle aspiration (FNA) should be performed for Gram's stain and culture of the fluid or tissue, and the indicated antibiotic therapy initiated.However, antibiotics alone may not be effective in infected necrosis, which has a mortality of nearly 50% unless débrided surgically (Fig. 33-15). The long-held opinion that antibiotic prophylaxis in necrotizing pancreatitis is of little use has been altered by studies showing a beneficial prophylactic effect with antibiotics such as metronidazole, imipenem, and third-generation cephalosporins..."

"STERILE NECROSIS -...It must be emphasized that current opinion is against débridement in sterile necrosis unless it is accompanied by life-threatening systemic complications"

("Acute Pancreatitis" in Schwart's Principles of Surgery, 9th edition)

In this instance, MTB is incorrect. The algorithmic approach should be something like this:

Perform CECT

a) Mild pancreatitis (<%30 necrosis): Supportive care
b) Severe ("necrotizing") pancreatitis: (>%30 necrosis)

Initiate prophylactic antibiotics (IV imipenem)​

If there's signs of infection on CECT, perform CT/US guided FNA​

FNA (+): Appropriate antibiotics (e.g. ceftriaxone) and surgical debridement​

FNA (-): Aggressive supportive care; do not perform debridement​

 

[adagio]

Very clear and useful ... Thanks again ... Are you done with Step 2?!?!

 

[Fuzuli]

What about lipase? could it also be normal?

Yes, I suppose so. But I think different scenarios with amylase (alcoholics: little elevation; intestinal obstruction: increased amylase levels without pancreatitis) is more important.

A penetrating ulcer to pancreas may be associated with a mild increase in amylase levels. In this setting, performing EGD would be appropriate."

No air was on the xray ... Why would you do EGD?!?!?!?!? (what if this mild elevation of amylase is due to a bout of pancreatitis over a chronically damaged pancreas)

Lack of infradiaphragmatic air would indicate that there's no perforation. But an ulcer (like an posterior duodenal ulcer) may still penetrate an intestinal organ, like pancreas. So for that vignette, the patient has symptoms of pancreatitis with slight elevation of amylase, but also vomiting without obvious signs of obstruction. Maybe I should've explicitly written that patient had a history of peptic ulcer disease. The main point is, complications of a peptic ulcer (penetration and gastric obstruction) may present themselves like pancreatitis.

If there's a suspicion of a complicated peptic ulcer (unless it's a perforating peptic ulcer), EGD can be performed.

So you would choose US here as well?? this is really perplexing .... are you saying that you would choose US so that if you saw a stone you would do Emergency ERCP?? if thats what you are saying, then what about assessing the state of the pancreas to see if its necrosed or not??

For that vignette, USG is appropriate because the likelihood of a biliary pancreatitis is high. USG is the best choice for the visualization of gallstones. Let's say USG is performed and a diagnosis of acute biliary pancreatitis is made. Like you've said, I still need to assess the severity of this patient. The best way to assess the severity is indeed CECT, but other methods (like APACHE-II, Ranson's criteria or a combination of CECT and Ranson's criteria) are used and can be given as choices. But whatever method is used, patients are either mild or severe and should be managed according to discussion above.

So what's all the ruckus about the biliary part? It has two important points: when to perform cholecystectomy and if the impacted stone needs to be extracted surgically.

Cholecystectomy should definitely performed in such a patient, but the timing of the procedure is controversial (perform within 48-72 hours vs. after 72 hours but before discharge).

The other problem is surgical removal of the stone. Let's say that I've assessed the severity of the patient and she has mild pancreatitis. If her condition deteriorates despite supportive treatment, ERCP should be done and the stone should be extracted. However, ERCP itself may cause/aggravate pancreatitis, so examination of bile duct should not be performed. If there's a suspicion of a remaining stone in the bile duct, then an appropriate radiological study like MRCP, CT or endoscopic USG should be done.

 

[adagio]

The main point is, complications of a peptic ulcer (penetration and gastric obstruction) may present themselves like pancreatitis.

If there's a suspicion of a complicated peptic ulcer (unless it's a perforating peptic ulcer), EGD can be performed

But shouldnt we investigate the possibilities in term of seriousness of the underlying illness? What i mean is, pancreatitis, even if its mild, is definitely more dangerous than an unperforated ulcer that is irritating the pancreas, so wouldnt CT be the better step (which may also demonstrate the ulcer). (I dont want to argue too much lol, but I am trying to see how USMLE reasons).

The other problem is surgical removal of the stone. Let's say that I've assessed the severity of the patient and she has mild pancreatitis. If her condition deteriorates despite supportive treatment, ERCP should be done and the stone should be extracted. However, ERCP itself may cause/aggravate pancreatitis, so examination of bile duct should not be performed. If there's a suspicion of a remaining stone in the bile duct, then an appropriate radiological study like MRCP, CT or endoscopic USG should be done.

What if the cause is Biliary sludge? it wouldnt be apparent on CT, but it would still cause pancreatitis.

 

[Fuzuli]

But shouldnt we investigate the possibilities in term of seriousness of the underlying illness? What i mean is, pancreatitis, even if its mild, is definitely more dangerous than an unperforated ulcer that is irritating the pancreas, so wouldnt CT be the better step (which may also demonstrate the ulcer). (I dont want to argue too much lol, but I am trying to see how USMLE reasons).

Sure, but a penetrated and obstructed ulcer takes precedence. Think about it: What is the treatment for mild pancreatitis? How many of them recover? What is the treatment of a complicated ulcer? What is the likelihood of such a patient having another complication (like bleeding or perforation)? How many of these patients die?

What if the cause is Biliary sludge? it wouldnt be apparent on CT, but it would still cause pancreatitis.

Of course, in fact it's one of the more common causes of pancreatitis. USG is still the first imaging choice for it. In any way, it wouldn't alter the basic approach: Make the diagnosis, assess the severity and manage accordingly.

 

[adagio]

I can only bow to your wisdom and reasoning .... I hope that you would stay around, as I have lots of other inquiries, and would love to gain from your insight ... respect