Acute Pancreatitis- Gastroenterology

Acute pancreatitis is a disease in which the pancreas becomes inflamed over a short span of time. The condition is very painful and dangerous because it can lead to multiple organ failure. As many as a third of patients with severe acute pancreatitis succumb to the disease. Rapid diagnosis and prompt treatment are, therefore, essential to ensure better chances of survival.

Who treats acute pancreatitis?

Gastroenterologists are the specialists that diagnose pancreatitis. Surgeons will be involved if surgery is required.

Diagnosis

The diagnosis of acute pancreatitis involves:

• CT imaging: Contrast-enhanced computed tomography (CT) is a way to diagnose pancreatitis and ascertain its severity.
• Ultrasound: Abdominal ultrasound is usually performed when a doctor thinks the cause of the pancreatitis is gallstones.
• Endoscopic retrograde cholangiopancreatography (ERCP): This is an endoscopic and X-ray method that can be used to diagnose pancreatitis caused by gallstones and sometimes to treat the condition.
• X-ray imaging: Plain X-rays can indicate if there are calcium deposits in the pancreatic ducts.
• Blood tests: Levels of amylase and lipase enzymes more than three times the normal values in the blood can indicate pancreatitis. Similarly, a patient will have a high white blood cell count, showing an increase to at least 12,000 mcL. 
• Urine dipstick: In this test, a dipstick is used to measure substances excreted through the urine. The presence of trypsinogen-2 in the urine is a reliable indicator of acute pancreatitis.

The treatment methods for acute pancreatitis are discussed below.

Supportive therapy

Treatment of acute pancreatitis is often supportive and includes the following:

• Admission to ICU: Patients are put in intensive care units where they can be carefully monitored.
• Fluid resuscitation: For up to 24 hrs, lactated Ringer's solution is given at 250 to 500 mL/hour unless other comorbidities related to the kidneys or heart prevent this therapy.
• Pain relief: Hydromorphone is the recommended medicine to treat pain since morphine can possibly worsen problems with the sphincter of Oddi of the pancreatic duct.
• Antiemetic medicines: These are medications that are administered to stop nausea and vomiting, which can be severe with pancreatitis.
• Enteral nutrition: Patients are provided a low-fiber, low-fat diet.
• Antibiotics: If an infection is the cause of pancreatitis, antibiotics are administered.

Endoscopic Retrograde Cholangiopancreatography 

This procedure is usually done if gallstones are thought to be causing pancreatitis.

The method of ERCP is as follows:

• An endoscope is inserted, which passes from the mouth down as far as the duodenum.
• A smaller-sized tube than the endoscope is then passed through the endoscope down to the biliary tree. The biliary tree consists of the ducts that move through the liver and gallbladder and enter the duodenum through a small opening.
• A contrast dye is injected in the area of the biliary tree so that these will show up on an X-ray.
• X-rays are taken.
• The small tube is then moved over the pancreatic duct and the dye is injected again.
• Another set of X-rays are taken.
• Gallstones can be removed during the ERCP procedure, which helps if they are the underlying cause.
• A stent can be inserted into the duct or ducts to remove any obstructions.

Post-procedure:

After the procedure, you will be taken to a recovery room, where sometimes, an enema is given with medicine to try and prevent irritation to the pancreas. Once all your vitals are normal, and you can swallow again, you can be discharged. The procedure may be performed on an outpatient basis in some cases, but patients will need someone else to drive them home.

Complications:

Possible complications include:

• Pain in the abdomen
• Bleeding, as indicated by tarry or bloody stools
• Fever
• Nausea and vomiting
• Throat pain
• Chest pain

Gallbladder Surgery

Surgery to remove the gallbladder is termed a cholecystectomy. This is done if gallstones are the cause of pancreatitis.

• The procedure is normally done laparoscopically, with the gallbladder completely cut out and removed.
• Patients can usually leave the hospital in a day or two.

Possible complications include infection, injury to the bile duct or intestines, and bleeding.

Drainage

Drainage of fluid is sometimes necessary in severe cases of acute pancreatitis. This can be done either percutaneously or surgically. Sometimes a combined (hybrid) approach is used, which may combine percutaneous drainage with an endoscopic or another approach.

Percutaneous drainage

This is done by inserting a large catheter through the skin and into the abdomen and then draining infected fluid out of the abdomen. The mortality rate is about 1 in 5 for this procedure.

The possible complications of percutaneous drainage are listed below.

• Bleeding inside the abdomen
• Pancreatic fistula
• Gastrointestinal fistula
• Perforation of the colon

Surgical drainage and debridement

This becomes necessary if the patient develops necrotic tissue. The specific approach depends on the location of the dead tissue that needs to be removed. The various approaches are described below:

Open surgical debridement

Often, a patient needs to have dead tissue removed from or around the pancreas. The removal of dead tissue is called a necrosectomy. Open surgical debridement is when a patient must undergo open surgery to remove the necrotic tissue. Open surgery is not usually recommended except in cases where there is no other choice because of multiple possible complications. The mortality rate of this procedure is as high as 18%.

Complications of open surgical debridement:

• Pancreatic fistula
• Hernia
• Biliary tree injury
• Pancreatic insufficiency
• Hemorrhage

Endoscopic approach

• This is not as invasive as some of the other approaches because it is completed via an endoscope. Endoscopic ultrasound (EUS) guidance is often used to visualize the positioning of the endoscope during the procedure.
• A needle and guide wire are inserted via the endoscope. A balloon and stents are also used in the procedure.
• Necrotic tissue and fluid are collected into a net or polypectomy snare.

The procedure has an 80% success rate and a mortality rate of about 7%. The most common complication is bleeding.

Laparoscopic approach

The pancreas and abdomen are accessed via laparoscopic ports to remove dead tissue. This approach works best if the necrotic area is walled off. The approach is unpopular because it is difficult to access and remove all the fluid and tissue properly.

The success rate for the laparoscopic approach is about 77%, and the mortality rate is 11%. There are various ways that the pancreas can be accessed depending on the location of the necrotic tissue.

• Transperitoneal debridement: This crosses the peritoneum.
• Transgastric debridement: This is done through the stomach.  

Complications of laparoscopic procedures include pancreatic fistula formation and infection.

Retroperitoneoscopic approach

An incision is made just below the ribs or in a translumbar position.

• A laparoscope or nephroscope can be used to widen the area so that the necrotic tissue can be seen better.
• CT-guided placement is done for inserting drainage tubes. The procedure is often called video-assisted retroperitoneal debridement (VARD) because the CT is used to visualize the area.
• A retroperitoneal percutaneous drainage tube is placed to remove the infected material.
• The success rate of this approach is about 88%, with mortality ranging from 0% to 20%.

Complications include enteric fistulas and bleeding.

References:

• Barreto, S. G., Habtezion, A., Gukovskaya, A., Lugea, A., Jeon, C., Yadav, D., ... & Pandol, S. J. (2021). Critical thresholds: key to unlocking the door to the prevention and specific treatments for acute pancreatitis. Gut, 70(1), 194-203.
• Fagniez, P. L., Rotman, N., & Kracht, M. (1989). Direct retroperitoneal approach to necrosis in severe acute pancreatitis. British journal of surgery, 76(3), 264-267.
• Kokosis, G., Perez, A., & Pappas, T. N. (2014). Surgical management of necrotizing pancreatitis: an overview. World Journal of Gastroenterology: WJG, 20(43), 16106.
• Sáez, J., Martínez, J., Trigo, C., Sánchez-Payá, J., Compañy, L., Laveda, R., ... & Perez-Mateo, M. (2005). Clinical value of rapid urine trypsinogen-2 test strip, urinary trypsinogen activation peptide, and serum and urinary activation peptide of carboxypeptidase B in acute pancreatitis. World journal of gastroenterology, 11(46), 7261.

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