CT-guided aspiration of suspected pancreatic infection: bacteriology and clinical outcome

JPN Guidelines for the management of acute pancreatitis: epidemiology, etiology, natural history, and outcome predictors in acute pancreatitis

Acute pancreatitis is a common disease with an annual incidence of between 5 and 80 people per 100 000 of the population. The two major etiological factors responsible for acute pancreatitis are alcohol and cholelithiasis (gallstones). The proportion of patients with pancreatitis caused by alcohol or gallstones varies markedly in different countries and regions. The incidence of acute alcoholic pancreatitis is considered to be associated with high alcohol consumption. Although the incidence of alcoholic pancreatitis is much higher in men than in women, there is no difference in sexes in the risk involved after adjusting for alcohol intake. Other risk factors include endoscopic retrograde cholangiopancreatography, surgery, therapeutic drugs, HIV infection, hyperlipidemia, and biliary tract anomalies. Idiopathic acute pancreatitis is defined as acute pancreatitis in which the etiological factor cannot be specified. However, several studies have suggested that this entity includes cases caused by other specific disorders such as microlithiasis. Acute pancreatitis is a potentially fatal disease with an overall mortality of 2.1%–7.8%. The outcome of acute pancreatitis is determined by two factors that reflect the severity of the illness: organ failure and pancreatic necrosis. About half of the deaths in patients with acute pancreatitis occur within the first 1–2 weeks and are mainly attributable to multiple organ dysfunction syndrome (MODS). Depending on patient selection, necrotizing pancreatitis develops in approximately 10%–20% of patients and the mortality is high, ranging from 14% to 25% of these patients. Infected pancreatic necrosis develops in 30%–40% of patients with necrotizing pancreatitis and the incidence of MODS in such patients is high. The recurrence rate of acute pancreatitis is relatively high: almost half the patients with acute alcoholic pancreatitis experience a recurrence. When the gallstones are not treated, the risk of recurrence in gallstone pancreatitis ranges from 32% to 61%. After recovering from acute pancreatitis, about one-third to one-half of acute pancreatitis patients develop functional disorders, such as diabetes mellitus and fatty stool; the incidence of chronic pancreatitis after acute pancreatitis ranges from 3% to 13%. Nevertheless, many reports have shown that most patients who recover from acute pancreatitis regain good general health and return to their usual daily routine. Some authors have emphasized that endocrine function disorders are a common complication after severe acute pancreatitis has been treated by pancreatic resection.

Surgery in the treatment of acute pancreatitis--open pancreatic necrosectomy

Management of acute necrotizing pancreatitis has changed significantly over the past years. Early management is non-surgically and solely supportive. Today, more patients survive the early phase of severe pancreatitis due to improvements of intensive-care-medicine. Pancreatic infection is the major risk factor with regard to morbidity and mortality in the late phase of severe acute pancreatitis. Whereas early surgery and surgery for sterile necrosis can only be recommended in selected cases, pancreatic infection is a well accepted indication for surgical treatment. Surgery should ideally be postponed until four weeks after the onset of symptoms as necrosis is well demarcated at that time. Four surgical techniques can be performed with comparable results regarding mortality: necrosectomy combined with (1) open packing, (2) planned staged relaparotomies with repeated lavage, (3) closed continuous lavage of the retroperitoneum, and (4) closed packing. However, closed continuous lavage of the retroperitoneum, and closed packing seem to be associated with a lower morbidity compared to the other two approaches. Advances in radiologic imaging, new developments of interventional radiology and other minimal access interventions have revolutionized the management of many surgical conditions over the past decades. However, minimal invasive surgery and interventional therapy for infected necrosis should be limited to specific indications in patients who are critically ill and otherwise unfit for conventional surgery. Open surgical debridement is the "gold standard" for treatment of infected pancreatic and peripancreatic necrosis.

[Acute pancreatitis]

While interstitial acute pancreatitis usually takes a benign course, necrotizing acute pancreatitis takes a severe course, mainly because of severe local and systemic complications. After a quick diagnosis it is necessary to rapidly assess a degree of severity of the disease and thus the prognosis. The clinical picture and the result of imaging procedures do not always correspond. The management basically includes to treat pain as well as to administer fluid, electrolyte, protein and calories. In addition, systemic treatment of complications such as shock or respiratory and renal insufficiency--if occurring--is necessary. In case of pancreatic necrosis, prophylactic administration of pancreas-penetrable antibiotics is recommended to avoid infection. In the severely ill with infected pancreatic necrosis, surgery is the treatment of choice. In approximately 10% of all patients with alcohol-induced pancreatitis, there is a gradual transition to chronic pancreatitis.

Staging and surgical management of pancreatic and biliary cancer and inflammation

Management of benign and malignant diseases of the pancreas, liver, and biliary tract has made remarkable progress in the last two decades. Advances in minimally invasive surgery, interventional radiology, and diagnostic and therapeutic endoscopy have changed the treatment of common diseases such as cholelithiasis and more serious diseases such as pancreatic adenocarcinoma. Advances in biliary tract and pancreatic surgery have paralleled the advances in ultrasonographic imaging, CT, and MR imaging. This article outlines the surgeon's perspective on radiologic imaging and preoperative staging of benign and malignant biliary and pancreatic disease.

Optimising outcomes in acute pancreatitis

Acute pancreatitis is a common cause for presentation to emergency departments. Common causes in Western societies include biliary pancreatitis and alcohol (the latter in the setting of chronic pancreatitis). Acute pancreatitis also follows endoscopic retrograde pancreatography in 5 to 10% of patients, a group that could potentially benefit from prophylactic treatment. Although episodes of pancreatitis usually run a relatively benign course, up to 20% of patients have more severe disease, and this group has significant morbidity and mortality. Therefore, attempts have been made to identify, at or soon after presentation, those patients likely to have a poor outcome and to channel resources to this group. The mainstay of treatment is aggressive support and monitoring of those patients likely to have a poor outcome. Pharmacotherapy for acute pancreatitis (both prophylactic and in the acute setting) has been generally disappointing. Efforts initially focused on protease inhibitors, of which gabexate shows some promise as a prophylactic agent. Agents that suppress pancreatic secretion have produced disappointing results in human studies. Infection of pancreatic necrosis is associated with high mortality and requires surgical intervention. In view of the seriousness of infected necrosis, the use of prophylactic antibacterials such as carbapenems and quinolones has been advocated in the setting of pancreatic necrosis. Similarly, data are accumulating to support the use of prophylactic antifungal therapy. Recently, it has become apparent that the intense inflammatory response associated with acute pancreatitis is responsible for much of the local and systemic damage. With this realisation, future efforts in pharmacotherapy are likely to focus on suppression or antagonism of pro-inflammatory cytokines and other inflammatory mediators. Similarly, animal studies have demonstrated the importance of oxidative stress in acute pancreatitis, although to date there is a paucity of information regarding the efficacy of antioxidants. Although the clinical course for most patients with acute pancreatitis is mild, severe acute pancreatitis continues to be a clinical challenge, requiring a multidisciplinary approach of physician, intensivist and surgeon.

Necrotizing pancreatitis: contemporary analysis of 99 consecutive cases

OBJECTIVE

To analyze the impact of a conservative strategy of management in patients with necrotizing pancreatitis, reserving intervention for patients with documented infection or the late complications of organized necrosis.

SUMMARY BACKGROUND DATA

The role of surgery in patients with sterile pancreatic necrosis remains controversial. Although a conservative approach is being increasingly used, few studies have evaluated this strategy when applied to the entire spectrum of patients with necrotizing pancreatitis.

METHODS

The authors reviewed 1,110 consecutive patients with acute pancreatitis managed at Brigham and Women's Hospital between January 1, 1995, and January 1, 2000, focusing on those with pancreatic necrosis documented by contrast-enhanced computed tomography. Fine-needle aspiration, the presence of extraintestinal gas on computed tomography, or both were used to identify infection.

RESULTS

There were 99 (9%) patients with necrotizing pancreatitis treated, with an overall death rate of 14%. In three patients with underlying medical problems, the decision was made initially not to intervene. Of the other 62 patients without documented infection, all but 3 were managed conservatively; this group's death rate was 11%. Of these seven deaths, all were related to multiorgan failure. Five patients in this group eventually required surgery for organized necrosis, with no deaths. Of the 34 patients with infected necrosis, 31 underwent surgery and 3 underwent percutaneous drainage. Only four (12%) of these patients died, all of multiorgan failure. Of the total 11 patients who died, few if any would have been candidates for earlier surgical intervention.

CONCLUSIONS

These results suggest that conservative strategies can be applied successfully to manage most patients with necrotizing pancreatitis, although some will eventually require surgery for symptomatic organized necrosis. Few if any patients seem likely to benefit from a more aggressive strategy.

Does mortality occur early or late in acute pancreatitis?

Several prior studies have suggested that 80% of deaths in acute pancreatitis occur late as a result of pan-creatic infection. Others have suggested that approx half of deaths occur early as a result of multisystem organ failure. The aim of the present study was to determine the timing of mortality of acute pancreatitis at a large tertiary-care hospital in the United States.

METHODS

Patients with a diagnosis of acute pancreatitis (ICD-9 code 577.0) admitted to Brigham and Women's Hospital from October 1, 1982 to June 30, 1995 were retrospectively studied to determine total mortality, frequency of early vs late deaths, and clinical features of patients with early (< or = 14 d after admission) or late deaths (> 14 d after admission).

RESULTS

The overall mortality of acute pancreatitis was 2.1% (17 deaths among 805 patients). Eight deaths (47%) occurred within the first 14 d of hospitalization (median d 8, range 1-11 d), whereas 9 occurred after 14 d (median d 56, range 19-81). Early deaths resulted primarily from organ failure. Late deaths occurred postoperatively in 8 patients with infected or sterile necrosis and 1 patient with infected necrosis treated medically.

CONCLUSION

Approximately half of deaths in acute pancreatitis occur within the first 14 d owing to organ failure and the remainder of deaths occur later because of complications associated with necrotizing pancreatitis. Improvement in mortality in the future will require innovative approaches to counteract early organ failure and late complications of necrotizing pancreatitis.

Diagnosis, objective assessment of severity, and management of acute pancreatitis. Santorini consensus conference

BACKGROUND

The diagnosis, early assessment, and management of severe acute pancreatitis remain difficult clinical problems. This article presents the consensus obtained at a meeting convened to consider the evidence in these areas. The aim of the article is to provide outcome statements to guide clinical practice, with an assessment of the supporting evidence for each statement.

METHOD

Working groups considered the published evidence in the areas of diagnosis, assessment of severity, nonoperative treatment, and surgical treatment of severe acute pancreatitis. Outcome statements were defined to summarize the conclusions on each point considered. The findings were discussed and agreed on by all participants. A careful assessment was made of the strength of the available evidence (proven, probable, possible, unproven, or inappropriate).

FINDINGS AND CONCLUSIONS

There is reliable evidence to support much current practice. Clear guidance can be given in most areas examined, and several areas were identified where further investigation would be helpful. Diagnosis using plasma concentrations of pancreatic enzymes is reliable. Rapid advances are taking place in the assessment of severity. Several new therapeutic strategies show real promise for the reduction of morbidity and mortality rates. Surgical debridement is required for infected pancreatic necrosis, but is less often necessary for sterile necrosis.

Complicated Acute Pancreatitis

The treatment of severe, complicated pancreatitis requires: Rapid assessment and recognition of severity, determined by using APACHE or equivalent scoring systems. Aggressive resuscitation with crystalloid and colloid solutions using central venous monitoring for guidance, and to help identify and treat early organ failure. Nutritional support including total parenteral feeding, which can assist in maintaining nutrition during the prolonged period that may ensue. Nasojejunal feedings, bypassing the duodenum, supply nutrition and may decrease infectious complications. Judicious use of imaging studies, mainly dynamic-bolus contrast computed tomography (CT) of the abdomen. These studies will identify necrosis and other local complications of pancreatitis that are treatable by endoscopic, radiological or surgical means. Antibiotics, whose role has evolved to that of prophylaxis to prevent infection of necrotizing pancreatitis. Other medications such as octreotide have a limited role in the management of certain specific complications such as fistulas and post-pancreatic surgery. A multidisciplinary approach, including the use of endoscopic techniques and surgery to treat complicated pancreatitis. This approach provides optimal care of this challenging group of patients.

Acute pancreatitis: nonsurgical management

The care of patients with severe acute pancreatitis is complex. Although numerous medical therapies have been proposed, few interventions have been shown to be of benefit in patients with severe disease. This review summarizes the nonoperative management of patients with acute pancreatitis, including therapies shown to be of little value, the role of antibiotics in patients with acute pancreatitis, the importance of monitoring and supportive care, and the rationale of endoscopic and surgical intervention.