Evidence Based Management of Acute Biliary Pancreatitis

Laboratory ( elevated serum lipase or amylase at least 3 times above the normal limits) is helpful in diagnosis

Acute pancreatitis is diagnosed when two of three criteria are present including:

• Clinically (abdominal pain consistent with acute pancreatitis),
• Laboratory ( elevated serum lipase or amylase at least 3 times above the normal limits)
• Imaging criteria of acute pancreatitis

helpful in diagnosis of acute pancreatitis and its etiology (Gallstones)

helpful in diagnosis of acute pancreatitis and its etiology . assist in detection of type and severity of acute pancreatitis

help in diagnosis of the etiology of acute pancreatitis elevated Bilirubin, ALT, AST and alkaline phosphatase suggest biliary pancreatitis

helpful in idiopathic acute pancreatitis diagnosis

The initial infusion rate for mild cases :

• For patients without dehydration is (130-150mL/h).
• In case of dehydration: (150-600mL/h) with close monitoring of patients with comorbidities such as cardiac problems or renal failure to avoid volume overload.

The initial infusion rate for both severe cases :

• For patients without dehydration is (130-150mL/h).
• In case of dehydration/ shock: (150-600mL/h) with close monitoring of patients with comorbidities such as cardiac problems or renal failure to avoid volume overload d. The target
• A mean arterial pressure of 65mmHg or more,
• Urine output of 0.5mL/kg per hour or more When these parameters achieved, the infusion rate decreased to the level that maintain these parameters.

Pain control (Modified World Health organization (WHO) analgesia ladder) Step1: NSAID / paracetamol Paracetamol 1gm IV infusion /8h + Diclofenac sodium 75mg /12h.

Step 2: Opiates +/- NSAID/ paracetamol Pethidine 25 mg IV/4h

Step 3: Interventional treatment (epidural analgesia) +/- opiates +/- NSAID/ paracetamol In case of severe pain not responding to the above analgesia

• Mild attack: no antibiotic prophylaxis administered.
• Severe attack:
• Timing: Antibiotic prophylaxis administered to cases presented early within 72 hrs of disease onset.
• Duration: Not more than 2 weeks
• Antibiotics given:

• Quinolones + Metronidazole ( the 1st choice in ward) Ciprofloxacin 400mg IV /12 h + metronidazole 500mg IV/8h
• Carbapenems ± Metronidazole (the 1st choice in ICU patients and in case of sensitivity to quinolones) Imipenem .5gm IV/6h + metronidazole 500mg IV/8h

b. Therapeutic (in cases with pancreatic or extrapancreatic infections)

• In case of pancreatic infection, Carbapenems ± metronidazole were given.

Severe cases Timing: Within at least 48 hrs of admission provided that there are no intestinal complications.

Route: Nasogastric tube Nutrients: Polymeric feeding formula

• Nutrient: Fresubin 2Kcal fiber drink 200ml (2Kcal/ml)
• Total caloric requirements ꞊ body weight (kg) X 30Kcal/day Pattern : Continuous infusion
• The nutrition started with small amount and increased gradually over 16hrs
• Infusion rate ꞊ Total caloric requirements / 16hrs

in case of ileus or vomiting

• General anesthesia , Supine position with 30 degree tilt towards the right side
• A left subcostal 5 cm incision is performed one finger below the left costal margin over the midaxillary line and the muscles were divided sequentially
• Then, aspiration is done from the possible collection.
• After confirmation that it was the site of the collection, the fibrotic thick wall was opened by a scissor, as the collection is opened, pus drained spontaneously.
• At first, a wide suction was introduced in the cavity and the friable loose necrotic tissue was aspirated. Then, a circuit of flushing saline was created in the residual cavity by injection of saline through the previously placed PCD followed by aspiration of the saline and detached loose necrotic tissue fragments by the wide suction tube
• After completion of the procedure, large bore surgical drain was placed into the collection. The fascia was closed over the drains. The skin closed by interrupted sutures

Open necrosectomy was done after failure of the minimally invasive techniques. The procedure was done under general anesthesia under the coverage of Tienam (.5gm/6h IV) following the results of culture and sensitivity of the percutaneous drain effluent Surgical exploration of the peritoneal cavity was done through midline exploratory incision, there were 2 large pus collections extending from the Rt. and Lt. Lumber regions deep down into the pelvis, the intervening septa were divided and the pus was aspirated by a wide suction drain.

The lesser sac was opened and necrosectomy was done The previously placed PCD repositioned in the site of necrosectomy as a port for continuous irrigation while a wide tube drain was placed in the lesser sac for drainage. Another 2 tube drains were placed in the pelvis.

for pancreatic pseudocyst Antibiotic prophylaxis with Ciprofloxacin 400mg IV /12 hour was administered before the procedure and continued for 5 days after the procedure At first the cyst morphology was evaluated by EUS and color Doppler ultrasound is used to identify nearby vessels The puncture was performed using a 19-gauge needle, which was introduced into the pseudocyst via a therapeutic linear array echoendoscope. Then, a 0.035-inch guidewire was introduced through the needle and coiled within the pseudocyst under fluoroscopic guidance.

The needle was removed and a 10F cystotome was advanced over the guidewire and the tract was dilated by the cystotome, after dilatation, a 10F double-pigtail stent was placed and a sample of the aspirate is sent for chemical and microbiological analysis

for pancreatic pseudocyst general anesthesia, 1 gm of cefotax was given IV at the induction of anaesthesia, supine position over the operating table A transverse supraumbilical incision was performed. A 5 cm horizontal anterior gastrotomy was performed (Image 23a). Hemostasis of the submucosal vessels was performed before the incision of the gastric mucosa.

First, the cyst was punctured followed by an incision of 5 cm at the posterior gastric wall. Aspiration of the cyst content was done for chemical and microbiological analysis The wall of the pseudocyst is hemmed to the gastric wall with continuous sutures made of a vicryl 2/0 alongside the entire circumference of the orifice Nasogastric tube was placed in the stomach. The procedure was completed by suturing the anterior gastrotomy with a vicryl 2/0 continous sutures in 2 layers A tube drain was inserted at the pelvis with closure of the abdominal wound in a standard way.

PCD

• The percutaneous drainage catheter placed through peritoneal approach under US guidance, the drain size was 12 F.
• After placement of the percutaneous catheter, aspirate was sent for microbiological assessment
• The PCD was flushed with 50 ml saline, three times daily to keep the drain open and improve lavage of the collection

endoscopic approach it was done to one patient in the form of EUS guided aspiration of pus in a case with infected necrosis followed by percutaneous US guided aspiration of the residual