Pancreatitis aguda: complicaciones y manejo quirúrgico

Roberto Oleas Narea

Universidad Espíritu Santo

Objetivos

• Identificar la Pancreatitis aguda (PA) mediante un caso.

• Discutir el manejo en el caso presentado.

• Revisar conceptos básicos en pancreatitis.

• Identificar las complicaciones de la PA y su manejo quirúrgico.

CC: Masculino 23 años acude a ER con cc. de dolor abdominal 8 horas de evolución. Dolor tipo transfictivo (10/10) en epigastrio, irradiado a hipocondrio izquierdo. No alivia con cambio postural. No alivia con analgesia convencional. Refiere consumo excesivo de alcohol en los dos últimos días.

PMH: HIV (+),

Social: labora como DJ, alcoholismo (20 L cerveza/semana) desde hace tres años, tabaquismo, niega uso drogas ilícitas.

Después de analítica es ingresado a hospital A con el diagnóstico presuntivo de pancreatitis aguda de origen alcohólico, se instaura tratamiento de soporte con vía periférica y NPO. Al quinto día pide alta a petición.

• Hospital B:

Paciente disneico con distención abdominal.

Abdomen tenso a la palpación, tumefacto a nivel de flanco, fosa iliaca y región lumbar izquierda.

Signo de Grey Turner.

Ingreso UCI.

HR 110 lpm

RR 28 rpm

T° 38,3

BP 120/70

mmHg

Masha L, Bernard S. Grey Turner's sign suggesting retroperitoneal haemorrhage. Lancet 2014; 383:1920.

Dx: pancreatitis necrotizante hemorrágica. K85.2 Pancreatitis aguda inducida por alcohol.

SIRS

Cuerpo y cola pancreático + múltiples abscesos. Cx. Nueves ocasiones por sangrado + compromiso hemodinámico. Necrosectomía y dejado en bolsa de Bogotá. Drenaje de abscesos: 1000 ml purulento + 200 seroso. E. coli BLEE.

CBC

WBC 15,170 80 % PMN HB 6,2 HTO 20 TP 12 TTP 30 INR 1,26

ABG

pH 7,41 PCO2 35 HCO3 22,41 SAT O 97 PAFI 365

ANALISIS

Glicemia 103 CR 0,8 BUN 30 Na 139 K 3,96 Cl 100 P 3,1 Ca 8,1 Lactato 1,6

AMILASA 274 ( 3-110) LIPASA 1610 (23-300) HDL 45 LDL 120 COLESTÁSICAS NEGATIVAS. GOT GPT FA GGT

Tercer día Postopoeratorio: hemorragia cavidad abdominal + 8 unidades de sangre + FFP. Ileostomía término-terminal con bolsa recolectora.

Décimo día: abdomen se encuentra cerrado, retira la bolsa, sin dolor y se inicia alimentación enteral por sonda nasoyeyunal.

14 día: NAVM

20 día: colostomía por perforación ángulo esplénico.

35 día: Alta.

Pancreatitis aguda

Kumar, V., Abbas, A., Fausto, N., & Aster, J. (2010). Patología estructural y funcional: Robbins y Cotran. Barcelona: ELSEVIER.

Kumar, V., Abbas, A., Fausto, N., & Aster, J. (2010). Patología estructural y funcional: Robbins y Cotran. Barcelona: ELSEVIER.

FISIOPATOLOGÍA

CT scan of acute interstitial edematous pancreatitis

1. Interstitial edematous pancreatitis

•Acute inflammation of the pancreatic parenchyma and peripancreatic tissues, but without recognizable tissue necrosis Contrast-enhanced computed tomography criteria:Pancreatic parenchyma enhancement by intravenous contrast agent •No findings of peripancreatic necrosis

2. Necrotizing pancreatitis

•Inflammation associated with pancreatic parenchymal necrosis and/or peripancreatic necrosis Contrast-enhanced computed tomography criteria: Lack of pancreatic parenchymal enhancement by intravenous contrast agent, and/or •Presence of findings of peripancreatic necrosis (see below—acute peripancreatic fluid collection and walled off necrosis)

CT scan of acute necrotic collection

3. Acute peripancreatic fluid collection (APFC)

•Peripancreatic fluid associated with interstitial edematous pancreatitis with no associated peripancreatic necrosis. This term applies only to areas of peripancreatic fluid seen within the first four weeks after onset of interstitial edematous pancreatitis and without the features of a pseudocyst. Contrast-enhanced computed tomography criteria:Occurs in the setting of interstitial edematous pancreatitis •Homogeneous collection with fluid density •Confined by normal peripancreatic fascial planes •No definable wall encapsulating the collection •Adjacent to pancreas (no intrapancreatic extension)

CT scan of acute interstitial pancreatitis with acute

peripancreatic fluid collections

4. Pancreatic pseudocyst

•An encapsulated collection of fluid with a well defined inflammatory wall usually outside the pancreas with minimal or no necrosis. This entity usually occurs more than four weeks after onset of interstitial edematous pancreatitis to mature. Contrast-enhanced computed tomography criteria:Well circumscribed, usually round or oval •Homogeneous fluid density •No non-liquid component •Well defined wall (ie, completely encapsulated) •Maturation usually requires >4 weeks after onset of acute pancreatitis; occurs after interstitial edematous pancreatitis

Pancreatic pseudocyst

●Pancreatic pseudocyst

•A well-circumscribed fluid collection that is usually round or oval •The fluid collection is typically extra-pancreatic •Homogenous fluid density •No non-liquid components within the fluid •A well-defined wall that completely encapsulates the fluid collection.

●Walled-off pancreatic necrosis

•Heterogenous fluid collection with liquid and non-liquid density, with varying degrees of loculation •A well-defined wall that completely encapsulates the fluid collection •Intra-pancreatic and/or extra-pancreatic location

Walled-off pancreatic fluid collections can produce a wide range of clinical problems depending on the location and extent of the fluid collection and whether the fluid collection is infected.

•Expansion of the fluid collection can produce abdominal pain, duodenal or biliary obstruction, vascular occlusion, or fistula formation into adjacent viscera, the pleural space, or pericardium •Spontaneous infection can develop •Digestion of an adjacent vessel can result in a pseudoaneurysm, which can produce a sudden, painful expansion of the cyst or gastrointestinal bleeding due to bleeding into the pancreatic duct (hemosuccus pancreaticus) •Pancreatic ascites or pleural effusion can result from disruption of the pancreatic duct with fistulization to the abdomen or chest, respectively

Pancreatic abscess

CT scan in a patient with abdominal pain, fever, and jaundice shows air (thin arrow) in the central pancreas, which is necrotic and largely replaced by an acute fluid collection (thick arrows), leaving only a small residual pancreatic head (P).

CT scan of acute necrotizing pancreatitis complicated by infected pancreatic necrosis

The presence of gas bubbles is a pathognomonic sign of infection of the necrosis.

Valoración y pronóstico

AGA • Predictor de severidad: APACHE II mayor a 8,

ingreso a UCI. • Apache II 8 + falla orgánica en 78 horas:

tomografía computada con contraste para valorar grado de necrosis.

• Prueba de laboratorio: PCR 150 mg/dL en 48 horas.

• APACHE II + Criterio clínico + PCR

Manejo

• Tratamiento de soporte: - Hidratación:

- Liquidos IV especialmente en las primeras 24 horas con correción de electrolitos.

- Control de dolor: opiodes * - Monitorización de signos vitales y estadificación. - Soporte nutricional:

- NPO en cinco días, hasta una semana. - A la semana colocar tubo nasoyeyunal. - Alimentación oral según tolerancia. - Parenteral 25 Kcal/Kg de peso ideal.

Tenner S, Baillie J, Dewitt J, Vege SS. American College of Gastroenterology guideline: Management of acute pancreatitis. Am J Gastroenterol 2013

AP: Moderada: recuperan en 3- 7 días. Tratamiento de soporte: - Dolor ( morfina – fenatil) bomba de analgesia. - Fluidos intravenosos 24 horas primordialmente + control electrolitos. - Dieta de poco residuio, baja en grasa, blanda cuando no hay ileo, nausea, vomito, dolor e inflamacion ha bajado Severa: Monitoreo invasivo en busca de falla orgánica transitoria ( < 48 horas) o persistente ( > 48 horas) y complicaciones. Nutrición enteral por medio de sonsa nasoyeyunal colocada por endoscopia en vez de nutricion parenteral. (GRADO IB)

Acute peripancreatic fluid collections and acute necrotic collections (ANC) may develop less than four weeks after the onset of pancreatitis, pancreatic pseudocyst and walled-off necrosis usually occur more than four weeks after the onset of acute pancreatitis.

Both ANC and WON are initially sterile but may become infected. The occurrence of pancreatic infection is a leading cause of morbidity and mortality in acute necrotizing pancreatitis. Infected necrosis should be suspected in patients with pancreatic or extrapancreatic necrosis who deteriorate (clinical instability or sepsis physiology, increasing white blood cell count, fevers) or fail to improve after 7 to 10 days of hospitalization. In patients with suspected infected necrosis, we suggest empiric antibiotics rather than CT-guided fine needle aspiration (Grade 2C)

In patients with infected necrosis who fail to respond to antibiotics or who are clinically unstable, we recommend pancreatic debridement rather than continued conservative management (Grade 2B). Where possible we attempt to delay intervention until four weeks after initial presentation to allow the infected necrosis to become walled off. We perform necrosectomy with minimally invasive methods and reserve open surgical debridement for patients who are clinically unstable or if minimally invasive debridement is not possible or fails.

In patients with gallstone pancreatitis, we recommend urgent (<24 hours) endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy for patients with cholangitis (Grade 1B). CHOLECYSTECTOMY SHOULD BE PERFORMED AFTER RECOVERY in all operable patients with gallstone pancreatitis.

MANEJO QUIRÚRGICO Treatment options for walled-off pancreatic fluid collections include surgical drainage, endoscopic transmural drainage, transpapillary stent placement (for pseudocysts), and percutaneous drainage.

Transmural puncture through the gastric or duodenal wall into the cyst can be performed in patients who have a large, symptomatic walled-off pancreatic fluid collection that is compressing the stomach or duodenum when there is close apposition of the fluid collection to the bowel lumen.

Endoscopic transmural drainage (with or without necrosectomy) is the primary method used for endoscopic management of walled-off pancreatic fluid collections. If necrotic material is present within the fluid collection, endoscopic necrosectomy can be performed.

Endoscopic management of walled-off pancreatic fluid collections is over 90 percent technically successful with a 10 to 15 percent morbidity rate, a 70 to 80 percent resolution rate, and a 10 to 15 percent recurrence rate. Success rates are lower if pancreatic necrosis is present because of higher rates of infectious complications and because solid debris is much more difficult to remove. Recurrence rates exceeding 30 percent have been observed in this setting.

Endoscopic ultrasound (EUS) provides visualization of the walled-off pancreatic fluid collection and facilitates drainage. Studies have reported technical success rates for EUS-

guided fluid collection drainage of 84 to 94 percent, with fluid collection recurrence rates of 3 to 18 percent.

Infection is a common complication following endoscopic drainage of fluid collections. Peri- and post-procedural antibiotics are typically given to help reduce the risk of secondary infection of a sterile fluid collection. Infection can often be managed with antibiotics and endoscopic drainage. The most common cause of bleeding during endoscopic drainage is the inadvertent puncture of intervening blood vessels.

The management of a walled-off pancreatic fluid collection depends on the patient's symptoms, characteristics and location of the fluid collection, and whether complications such as a pseudoaneurysm have developed: •In patients with a walled-off pancreatic fluid collection with minimal or no symptoms and no pseudoaneurysm, we suggest expectant management rather than a drainage procedure (Grade 2C). Limited natural history data suggest that up to 40 percent of walled-off pancreatic fluid collections resolve without intervention. If a pseudoaneurysm is present but the patient has minimal or no symptoms, we recommend embolization of the aneurysm followed by expectant management. •For patients who are symptomatic, we suggest a drainage procedure rather than expectant management (Grade 2C). The choice of drainage procedure is largely determined based on local expertise and the location of the fluid collection. In centers with the appropriate expertise, pancreatic fluid collections that abut the stomach or duodenum are often approached via an endoscopic approach, reserving surgical drainage procedures for endoscopic failures, for recurrence following successful endoscopic drainage, or for those not meeting criteria for endoscopic or percutaneous drainage.

Open surgical debridement is the gold standard for management of pancreatic

necrosis. Laparoscopic debridement is primarily limited to patients with walled-off

pancreatic necrosis.

Pancreatic debridement is indicated for patients with pancreatic necrosis and progressive clinical sepsis as a complication of severe acute pancreatitis.

Infected pancreatic necrosis and symptomatic sterile necrosis are both accepted indications for debridement. The goal of pancreatic debridement is to excise all dead and devitalized pancreatic and peripancreatic tissue, while preserving viable functioning pancreas, controlling resultant pancreatic fistulas, and limiting extraneous organ damage

The optimal timing for pancreatic debridement is three to four weeks following the onset of acute pancreatitis. Delayed debridement allows clinical stabilization of the patient, resolution of early organ failure, and a decrease in the intense inflammatory reaction in the retroperitoneum.

RESUMEN Y RECOMENDACIONES • En las primeras 24 horas una PA severa puede ser predecida

mediante la clínica, laboratorio, imágenes y los scores como SIRS, APACHE II, BISAP y el índice de severidad tomográfico. La AGA sugiere el uso de la SIRS por ser simple, económica y disponible.

• Se recomienda realizar una TC con contraste en pacientes con PA severa valorado por clínica y APACHE II para detectar tejido necrótico.

• La TC no se requiere en el primer día, se requieren días para la aparición de tejido necrótico, siendo normal en las primeras 48. Siendo indicado este procedimiento a las 72 horas según la AGA en pacientes con PAS predicha o con evidencia de falla orgánica. TC temprana relacionada con PAS??? Medio de contraste???...

• La AGA sugiere el empleo de la cuantificación de Proteina C-reactiva, siendo un valor mayor a 150 mg/L a las 48 horas como prueba idonea para discriminar a pacientes severos.

The dry formal lecture never, or at any rate rarely, touches the heart, but it is in [the] conversational method of the seminar, or

in the quiet evening at home, with a select group and a few good editions of a favorite author, that the enthusiasm of the teacher

becomes contagious.

Sir. William Osler