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Evidence-based approach in managing acute pancreatitis

Evidence-based approach in managing acute pancreatitis. James Fung Department of Surgery Tseung Kwan O Hospital. Topic for discussion. Serum amylase – how to use it in diagnosis? Severity assessment Antibiotic prophylaxis in SAP – is it useful?. Serum amylase – how to use it? .

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Evidence-based approach in managing acute pancreatitis

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  1. Evidence-based approach in managing acute pancreatitis James Fung Department of Surgery Tseung Kwan O Hospital

  2. Topic for discussion • Serum amylase – how to use it in diagnosis? • Severity assessment • Antibiotic prophylaxis in SAP – is it useful?

  3. Serum amylase – how to use it? • Peaks within 12 – 24 hr from onset, normalize within 3 – 5 days • Pitfalls: • Falsely high level: intra-abdominal inflammation; salivary gland pathology • Falsely normal level: delayed presentation; pancreatic insufficiency; hypertriglyceridaemia1 • Spechler SJ et al. Prevalence of normal serum amylase levels in patients with acute alcoholic pancreatitis. Dig Dis Sci 1983; 28:865-9

  4. Serum amylase – how to use it? • Sn and Sp varies with diagnostic cut-off value • Steinberg WM et al. Diagnostic assays in acute pancreatitis. A study of sensitivity and specificity. Ann Intern Med 1985;102:576-80 • Thomson HJ et al. Diagnosis of acute pancreatitis: a proposed sequence of biochemical investigations. Scand J Gastroenterol 1987;22:719-24

  5. Use of serum amylase – summary • Useful only when used in a correct clinical context • Diagnostic accuracy depends on threshold • Use supplementary tools when in doubt

  6. Severity assessment

  7. Glasgow score1 Within 48 hrs PaO2 <60mmHg Albumin <32 g/L Ca++ <2mmol/L WBC >15 x 109/L AST/ALT >200U/L LDH > 600U/L Glucose >10mmol/L Urea >16mmol/L Ranson score2 On admission: Age, WBC, glucose, LDH, AST Within 48 hr: Haematocrit, BUN, estimated fluid shift, PaO2, base deficit, Ca++ Severity scoring systems • Blamey et al. Prognostic factors in acute pancreatitis. GUT 1984; 25:1340-6 • Ranson et al. Etiological and prognostic factors in human acute pancreatitis: a review. Am J Gastroenterol 1982;77:633-8

  8. Severity scoring systems • Sn for predicting poor outcome: • Glasgow score – 61%1 • Ranson score – 70%2 • 48hr for complete scoring • Corfield et al. Prediction of severity in acute pancreatitis: Prospective comparison of three prognostic indices. Lancet 1985;2:403-7 • Ranson et al. Etiological and prognostic factors in human acute pancreatitis: a review. Am J Gastroenterol 1982;77:633-8

  9. Severity scoring systems • APACHE II • 12 physiological / biochemical findings + age + chronic health survey • Sn up to 95%1 • Daily / repeated scoring as reassessment • Immediate scoring after admission • Too complicated for use outside ICU • Wilson C et al. Prediction of outcome in acute pancreatitis: a comparative study of APACHE II, clinical assessment and multiple factor scoring systems. BJS 1990;77:1260-4

  10. Severity assessment – CRP • CRP • Serum level increase the degree of SIRS • Cut-off value of 150mg/L (Sentorini Consensus)1 • Sn and Sp (prediction of septic complication) ~ 80%2 • Peaks by 36hr after onset • Dervenis C et al. Diagnosis, objective assessment of severity, and management of acute pancreatitis. Santorini Consensus Conference. Int J Pancreatol 1999;25:195-210 • Vesentini S et al. Prospective comparison of CRP level, Ranson score and contrast-enhanced computed tomography in the prediction of septic complications of acute pancreatitis. BJS 1993;80:755-7

  11. Severity assessment – summary • Should not rely on scoring system for severity assessment • Frequent clinical +/- biochemical assessment is most important • Aim at early detection of organ dysfunction

  12. Treatment – antibiotics prophylaxis? • Rationale: • To prevent the life threatening bacterial infection of pancreatic necrosis • Concerns: • Antimicrobial resistance1 • Opportunistic fungal infection2 • Bassi C et al. Controlled clinical trial of Pefloxacin versus Imipenem in severe acute pancreatitis. Gastroenterology 1998; 115:1513-17 • Eatock FC et al. Fungal infection of pancreatic necrosis is associated with increased mortality. BJS 1999;86 supp 1:78

  13. Treatment – antibiotics prophylaxis?

  14. Treatment – antibiotics prophylaxis? • Cochrane review 2007 • Included 5 RCTs comparing antibiotics prophylaxis vs no prophylaxis • Significant reduction of mortality in antibiotics prophylaxis group (6% vs 15%) • Both significant reduction of infected necrosis (16% vs 29%)and mortality (6% vs 17%) in beta-lactam prophylaxis subgroup

  15. Antibiotics prophylaxis – summary • Current evidence is still not concrete enough to make clear conclusion • Antibiotics prophylaxis probably gives a marginal benefit to SAP patients • Duration of treatment should last for at least 14 days

  16. Thank you

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