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New progress in the diagnosis and treatment of acute pancreatitis
New progress in the diagnosis and treatment of acute pancreatitis. There are many risk stratification tools, which can be divided into clinical scoring system, laboratory inspection index system and other systems.
1. Article source
This article describes the new developments in the diagnosis and treatment of acute pancreatitis in recent years, and discusses the epidemiology, clinical manifestations, and management of pancreatitis. In addition, the idea of using pancreatitis risk stratification method to guide clinical treatment will also be mentioned.
Most patients with pancreatitis are mild, and a small part will gradually develop into moderate pancreatitis (combined with complications around the pancreas) and severe pancreatitis (combined with persistent organ dysfunction). The treatment time for mild pancreatitis is short, and treatment requires timely diagnosis and symptomatic support. The mortality rate of severe pancreatitis is very high, and the treatment requires the participation of multiple disciplines.
Based on the current guidelines, this article discusses five aspects of fluid resuscitation, nutritional support, preventive antibiotics, probiotics, and ERCP timing. At the same time, this article discusses how to reduce the incidence of pancreatitis, which mainly involves drinking, smoking, and cholecystectomy.
Acute pancreatitis, especially severe acute pancreatitis, will bring a great social burden. In the United States, acute pancreatitis was the most common gastrointestinal disease in hospitalized patients in 2012, with a total annual treatment cost of 2.6 billion US dollars. There are many guidelines to guide the treatment of pancreatitis, such as ACG2013, AGA2018, IAP2013. This article refers to the latest guidelines and literature, expounds the diagnosis and treatment of pancreatitis from the aspects of epidemiology, risk factors, etiology, diagnosis, risk stratification, and the latest developments, focusing on the fluid resuscitation, nutritional support, preventive antibiotics, and Several factors such as probiotics and ERCP timing. At the same time, the effects of drinking, smoking, preventive cholecystectomy, fluid management after ERCP and drug therapy on the prevention of pancreatitis are explained.
Regarding the research on the incidence of pancreatitis, the current data are different. Sellers and other studies have shown that the incidence of acute pancreatitis in the United States has declined from 2007 to 2014, but the Krishna study supports that the incidence of acute pancreatitis is increasing year by year. His data shows that the incidence of acute pancreatitis has increased in the past 3 years By 13.3%, the incidence of chronic pancreatitis has increased by 96%.
Smoking is a risk factor for chronic pancreatitis. If a patient smokes, the probability of chronic pancreatitis is close to 100%.
The mortality of pancreatitis caused by various causes is similar, including biliary pancreatitis and alcoholic pancreatitis (Editor’s note: AGA guidelines state that the overall mortality of pancreatitis is 5%).
Persistent organ dysfunction (POF) refers to organ dysfunction for more than 48 hours and is the main cause of death in patients with acute pancreatitis. If patients have diabetes, hospital-acquired infections, and advanced age (age> 70), the mortality rate will increase further. If patients with pancreatitis are obese, they are more prone to complications of acute kidney injury and respiratory failure, and mortality will increase.
5. Risk factors
It is generally believed that drinking and gallstones are risk factors for acute pancreatitis. Recently, it has been found that smoking marijuana, inflammatory bowel disease, pancreatic cancer, end-stage renal disease, etc. are also risk factors for pancreatitis.
Compared with non-smokers, past and current smoking are independent risk factors for acute pancreatitis. The relationship between drinking and pancreatitis is more complicated. A meta-analysis pointed out that the incidence of pancreatitis and the number of drinking are linear in male patients, but not in female patients. Drinking less than 40g per day in female patients can reduce the incidence of acute pancreatitis, but if it exceeds this threshold, it can increase the incidence of acute pancreatitis.
The occurrence of biliary pancreatitis is related to eating habits. If the intake of unsaturated fatty acids, cholesterol, beef or lamb, and alcohol, while the fiber intake is reduced, the incidence of acute pancreatitis will increase.
Recent studies have found that smoking marijuana can induce pancreatitis. If there is a basis for pancreatitis, smoking marijuana can cause pancreatitis to recur. Studies have found that the incidence of pancreatitis in patients with inflammatory bowel disease is 2.93 times that of ordinary patients. This part of patients often develop pancreatitis due to gallstones and some drugs.
Patients with end-stage renal disease are more likely to develop pancreatitis, especially those undergoing peritoneal dialysis, including those with advanced age, female patients, gallstones, and liver disease, the incidence of pancreatitis will further increase.
Recent studies have found that pancreatic cancer may occur after pancreatitis. A review of 500,000 patients found that 11% of pancreatic cancer patients had experienced pancreatitis, suggesting that some patients whose cause of pancreatitis cannot be confirmed clinically may have the potential for pancreatic cancer; at the same time, pancreatitis will release inflammatory factors and continue to stimulate Pancreatic tissue can cause pancreatic cancer.
6. Etiology and diagnosis
Alcohol and gallstones are the most common causes of acute pancreatitis. The proportion of biliary pancreatitis is 40-50%, and the proportion of alcoholic pancreatitis is 20%. The blood lipid standards for acute pancreatitis caused by hyperlipidemia are different. The ACG guidelines point out that triglycerides must be at least 1000 mg/dl to cause pancreatitis, while other institutions point out that the minimum standard is 885 mg/dl. In patients with high triglycerides, acute pancreatitis can be more severe and more prone to severe pancreatitis (continuous organ damage), regardless of the cause. For patients with acute pancreatitis with hyperlipidemia, hemoperfusion and other treatments can reduce blood lipid concentrations, but data shows that they cannot reduce the mortality rate.
Currently, acute pancreatitis can be diagnosed according to Atlanta criteria. (Editor’s note: According to the latest Atlanta standards, pancreatitis can be divided into mild, moderate, and severe, all of which need to be symptomatic, and amylase or lipase elevated more than 3 times. Among them, 80% of pancreatitis is mild and moderate. Degree refers to the combined transient organ dysfunction that does not exceed 48 hours, and severe refers to the combined continuous organ dysfunction that exceeds 48 hours)
If the effect is poor after 48-72 hours of treatment, cross-sectional imaging of the pancreas is recommended to understand the condition. MRCP can detect choledocholithiasis of more than 3mm and clarify the patency of the pancreatic duct, so it has certain advantages over CT scan. The guidelines point out that early pancreatic cross-sectional imaging examinations should be selectively performed. Early CT and MRCP examinations are not recommended. However, there are still many early CT or MRCP examinations (within 24 hours of pancreatitis), and there is an overexamination.
Currently, endoscopic ultrasonography and ERCP can be used to identify biliary pancreatitis. It is not recommended to use ERCP alone to diagnose pancreatitis, because it is easy to complicate pancreatitis, cholangitis, perforation, bleeding after ECRP, and there are many methods for diagnosing pancreatitis, and ERCP is only one of them. Studies have found that endoscopic ultrasonography can diagnose biliary pancreatitis very well, rarely fails, and can avoid the use of ERCP, reducing its use rate by 71.2%.
7. Risk stratification
Risk stratification of patients with acute pancreatitis can help clarify the prognosis, and indicate whether the patient will experience persistent organ damage (POF), pancreatic infection, necrosis, and death. Risk stratification is to assess the severity of acute pancreatitis from 48 hours to 72 hours, so as to facilitate appropriate treatment of the disease and reduce the mortality rate.
There are many risk stratification tools, which can be divided into clinical scoring system, laboratory inspection index system and other systems. The most commonly used clinical scoring systems are APACHE-II score, BISAP score, EWS system, etc. The BISAP score includes five aspects: B (blood urea nitrogen) stands for urea nitrogen, I (impaired mental status) stands for impaired consciousness, S (systemic inflammatory response syndrome) stands for systemic inflammatory response, and A (age) stands for It is age, P (pleural effusion) refers to abdominal effusion (abdominal effusion), each of which is positive for 1 point. BISAP indicators can clearly predict the fatality rate. If BUN>25 mg/dL, there is disturbance of consciousness, systemic inflammation, age>60, and abdominal exudation (abdominal effusion), then the fatality rate will increase. Studies have pointed out that BISAP indicators are as accurate as APACHE-II scores and CT scores. (Editor’s note: BISAP score ≥3 points can be considered moderate or severe pancreatitis, APACEH-II score ≥8 points can be considered moderate or severe pancreatitis)
Figure 1. Classification criteria of mild, moderate and severe in the Chinese Pancreatitis Guidelines
8. Liquid management
Acute pancreatitis, fluid resuscitation and supportive treatment within 12 to 24 hours are critical. In patients with acute pancreatitis, fluid will transfer to the third space, and the intravascular volume will be insufficient. The guidelines recommend early fluid resuscitation to compensate for insufficient blood vessel volume and reduce mortality. However, there is no precise standard to guide fluid resuscitation of acute pancreatitis. The 2018 AGA guidelines recommend conditional fluid resuscitation, the use of goal-oriented fluid resuscitation management, there is no clear preference for the use of saline and lactated Ringers, both can be used, but the use of hydroxyethyl starch is opposed. However, this kind of recommendation evidence level is too low to form a strong recommendation. Some recent literature and meta-analysis pointed out that the end point of the initial resuscitation (12-24 hours) is: decreased BUN and decreased hematocrit. (Editor’s note: Maintain urine output 0.5ml/kg.h)
For the feeding support of acute pancreatitis, opinions fluctuate. Earlier, it was not recommended for patients with acute pancreatitis to eat. This is to prevent food from stimulating pancreatic secretion, causing aggravation of inflammation and aggravating the condition. However, recent opinions have begun to oppose this understanding, and began to recommend early enteral nutrition to protect the gastrointestinal mucosal barrier. Recent guidelines recommend early nutritional support (oral feeding, within 24 hours) for patients with mild acute pancreatitis. The AGA guidelines reviewed 11 RCT trials and did not find that early enteral nutrition can increase the mortality rate, nor that early feeding can increase the incidence of organ dysfunction. If pancreatic necrosis occurs in fasting pancreatitis patients, clinical intervention is required in more cases. It is pointed out that feeding will reduce the clinical intervention rate. For patients with severe pancreatitis, if oral administration is not possible, enteral nutrition support is recommended within 24 to 72 hours. Even with moderate to severe pancreatitis, enteral nutrition support is better than parenteral nutrition support. Studies have found that enteral nutrition support can reduce infectious pancreatic necrosis.
Recent guidelines do not recommend the use of prophylactic antibiotics for necrotizing pancreatitis and severe pancreatitis. The AGA guidelines also do not recommend the use of prophylactic antibiotics. In 10 RCT studies involving 701 patients, it was found that prophylactic antibiotics did not reduce the infusion of the pancreas and the periphery of the pancreas, did not reduce mortality, and did not improve organ damage.
The current guidelines do not recommend the use of probiotics for severe pancreatitis. A randomized double-blind trial by Besselink found that the use of preventive probiotics did not reduce the probability of infection in patients, but it could increase intestinal ischemic events. Meta-analysis of various RCT studies also found that probiotics did not reduce the incidence of pancreatic infection, the length of hospital stay, and the mortality rate.
12. ERCP timing
Cholangitis and acute biliary pancreatitis require emergency ERCP (ERCP within 24 hours). This view has been generally recognized. However, if cholangitis is not combined, even with biliary obstruction, the timing of ERCP is currently unclear. The current AGA2018 guidelines and some systematic reviews do not support routine ERCP for patients with biliary pancreatitis. AGA reviewed 8 RCT studies, including 935 patients, and came to the following conclusions: For acute biliary pancreatitis, emergency ERCP does not improve the prognosis compared with conservative treatment, mortality, organ function, infectious pancreas Indicators such as necrosis did not improve. Only a few studies have shown that ERCP can improve the prognosis of patients with persistent biliary obstruction and shorten the length of hospital stay.
There are few studies on when to undergo ERCP for patients with acute pancreatitis without cholangitis but with biliary obstruction. Cochrane analysis suggests that ERCP is appropriate within 72 hours of pancreatitis. At present, AGA recommends ERCP treatment 24 to 28 hours after diagnosis of biliary pancreatitis with biliary obstruction but no cholangitis.
13. Quit smoking and alcohol
Smoking and drinking are independent risk factors for recurrence of acute pancreatitis and chronic pancreatitis. AGA recommends that patients with alcoholic pancreatitis abstain from alcohol during hospitalization. Studies have found that strengthening alcohol abstinence education can reduce the recurrence rate of acute pancreatitis.
Patients with acute pancreatitis should also quit smoking. The study found that the incidence of non-biliary pancreatitis in smoking patients is twice that of non-smokers, and the incidence of the two tends to be the same after 20 years of quitting smoking.
Many studies, including AGA2018, recommend cholecystectomy in the first hospitalization for mild gallstone pancreatitis. Compared with delayed cholecystectomy, early cholecystectomy can reduce the complications of gallbladder stones in patients with gallstone pancreatitis, reduce the recurrence rate of pancreatitis, and reduce pancreaticobiliary duct complications, but it does not improve the 6-month mortality rate. Cholecystectomy in patients with moderate to severe biliary pancreatitis at 6 weeks can improve the mortality rate. For patients undergoing surgery, simultaneous ERCP can improve the prognosis.
15. Prevention of pancreatitis after ERCP
Studies have found that the incidence of pancreatitis has increased after ERCP. The incidence of mild pancreatitis has increased from 2.9% to 5.9%. This may be because ERCP has been used more as a means of treatment of pancreatitis than a diagnostic means.
Many studies have found that rectal administration of non-steroidal anti-inflammatory drugs (indomethacin, diclofenac) can reduce the incidence of pancreatitis after ERCP and improve the prognosis. Oral non-steroidal drugs cannot prevent pancreatitis after ERCP. A 2014 study found that adequate fluid load during ERCP can reduce the incidence of pancreatitis after moderate to severe ERCP and shorten the length of hospital stay. The latest research shows that the use of lactated Ringers can reduce the occurrence of pancreatitis after ERCP. A multi-center randomized controlled trial called FLUYT is currently underway to explore what kind of fluid replacement can reduce the incidence of pancreatitis after ERCP.
16. Clinical Revelation
The diagnosis and management of acute pancreatitis requires the participation of multiple disciplines, and its prognosis is affected by early or late organ dysfunction. Late organ dysfunction is often caused by infectious necrosis. The risk stratification of patients with pancreatitis can facilitate the treatment of implementation issues.
Regardless of the severity of pancreatitis, goal-oriented fluid resuscitation and early oral feeding or feeding via gastrointestinal catheters as much as possible are recommended to avoid during treatment.
Preventive use of antibiotics and probiotics.
Biliary pancreatitis with cholangitis requires emergency ERCP. Patients with acute biliary pancreatitis can undergo cholecystectomy in order to prevent recurrence. It is recommended that patients with pancreatitis quit smoking and alcohol. For pancreatitis after ERCP, it is recommended to use non-steroidal anti-inflammatory drugs for anal plugs and adequate fluid resuscitation.
Recent developments in acute pancreatitis:
- The incidence of acute pancreatitis is increasing and the mortality rate is decreasing
- Alcohol and gallstones are the most common causes of acute pancreatitis
- Smoking is an independent risk factor for pancreatitis
- Smoking cannabis can cause acute pancreatitis
- Acute pancreatitis in patients with inflammatory bowel disease may be related to gallstones and drugs
- Periodic peritoneal dialysis is a risk factor for acute pancreatitis in patients with end-stage renal disease
- Pancreatic cancer and pancreatitis can cause each other
- Elevated triglycerides easily complicate severe pancreatitis
- The initial assessment of acute pancreatitis still has the overuse of tomography
- Risk stratification helps to assess the severity of the patient’s disease
- Recommend goal-oriented fluid resuscitation for early pancreatitis
- Liquid resuscitation for acute pancreatitis can be normal saline or lactated Ringer, but hydroxyethyl starch is not recommended
- Early nutritional support is recommended. For mild patients, you can eat within 24 hours
- Patients with severe pancreatitis are recommended to use enteral nutrition instead of total parenteral nutrition
- Prophylactic antibiotics are not recommended for necrotizing pancreatitis
- Probiotics are not recommended for severe pancreatitis
- Acute cholangitis caused by biliary pancreatitis can be used early (within 24 hours) ERCP
- Urgent ERCP is not recommended for simple biliary pancreatitis
- Pancreatitis caused by drinking requires abstinence
- Recommended cholecystectomy for mild biliary pancreatitis
- Indomethacin anal plugs and fluid resuscitation can be used to reduce pancreatitis caused by ERCP
(source:internet, reference only)