Pankreatitis akutDiskusi Topik Divisi GastroenterologiIPD - FKUIdr. Fransiska

DefinisiProses inflamasi pankreas reversibel Klinis : nyeri perut enzim pankreas darahRingan (80%) berat mengancam nyawa (20%)

Practice Guidelines in Acute Pancreatitis, Am J Gastroenterol 2006;101:2379-400

EpidemiologiMortalitas:ringan < 1% berat 10-30%evaluasi dini stratifikasi risiko

MortalitasPractice Guidelines in Acute Pancreatitis, Am J Gastroenterol 2006;101:2379-400

Etiologi38%36%Hiperamilasea 35-70%

PatofisiologiFase 1: Aktivasi prematur tripsin dalam sel asiner pankreas enzim digesti pankreasFase 2: Inflamasi intrapankreas melalui berbagai mekanisme dan jalurFase 3:Inflamasi ekstrapankreas ARDS Practice Guidelines in Acute Pancreatitis, Am J Gastroenterol 2006;101:2379-400

Patogenesisbile-pancreatic duct common pathway theorypancreatic autodigestion theorygallstone migration theoryenzyme activation theorykinin and complement system activation theorymicrocirculation disturbance theoryleukocyte excessive activation theorypancreatic acinar cell apoptosis and necrosis theoryKONTROVERSIAL

Manifestasi klinisNyeri abdomen : akut Mencapai intensitas max dlm 30 menit, persisten > 24 jam tanpa perbaikanmual dan muntahepigastrium dan periumbilikal.menjalar ke punggung, dada, pinggang, bagian bawah abdomenknee-chest position kurangi nyeri

Manifestasi klinisPF:DemamHipotensiNT abdomendistres pernapasandistensi abdomensyok dan ikterus nodul kulit eritematosa 10-20% kasus ronkhi di basal, atelektasis, dan efusi pleura kiri

Manifestasi klinisPankreatitis nekrosis :Cullens signpucat kebiruan di umbilikus hemoperitoneum

Turners sign warna biru merah keunguan / hijau kecoklatan daerah pinggang katabolisme hemoglobin

Laboratoriumenzim amilase enzim lipase 85-100%DPL, diff countblood urea nitrogen (BUN)KreatininGlukosaKalsiumTrigliseridaUL # severity

RadiologiAbdomen 3 posisi obstruksi 2ndUSG abdomen batu empedu (etiologi)CT ScanPembesaran pankreas dgn edema difusParenkim pankreas heterogenPeripancreatic stranding & fluid collectionERCP/MRCP superior u anatomi duktus dan koledokolitiasisEUS

DiagnosisGuidelines American College of Gastroenterology : 2 dari 3:nyeri abdomen yang khas pankreatitis akutpeningkatan serum amilase dan lipase 3 kali normaltemuan khas pankreatitis akut pada CT scan

Practice Guidelines in Acute Pancreatitis, Am J Gastroenterol 2006;101:2379-400

Diagnosis diferensialIskemia/infark mesenterikaPerforasi ulkus gaster/duodenumKolik bilierAneurisma aorta disektaObstruksi ususInfark miokard akut inferior

Stratifikasi RisikoApache IIRansonCT severity indexImrie scoring system

Guidelines American College of Gastroenterology, 2006DiagnosticLook for risk factors of severity at admissionDetermination of severity by laboratory test at admission or 48 hDetermination of severity during hospitalizationImaging studiesOrgan failure

TatalaksanaTujuan:

Guidelines American College of Gastroenterology, 2006TreatmentSupportive carePrevent hypoxemiaFluid resuscitationTransfer to an ICUNutritional supportUse of prophylactic antibiotics in necrotizing pancreatitisTreatment of infected necrosisTreatment of sterile necrosisRole of ERCP and billiary sphincterotomy in gallstone pancreatitis

Terapi medisPuasa NGT, TPNKoreksi cairan dan elektrolit 2000-3000Koreksi metabolikAnti nyeriAntibiotik (+/-)OksigenOctreotide, PPIEndoscopic sphincterotomy (ERCP)

AntibiotikImipenem 3 x 500 mg IVCiprofloxacin 2x400 mg IV + Metronidazol 3x500 mg IVSefalosporin generasi III

Antibiotics and Severe Acute Pancreatitis: ProsSharma VK, Howden CW. Pancreas 2001; 22:28-31. [42]Antibiotic prophylaxis significantly reduced sepsis by 21.1% and mortality by 12.3% compared with no prophylaxisThere was also a non-significant trend toward a decrease in local pancreatic infectionsAntibiotic prophylaxis decreases sepsis and mortality in patients with acute necrotizing pancreatitisAll patients with acute necrotizing pancreatitis should receive prophylaxis with an antibiotic of proven efficacy

Antibiotics and Severe Acute Pancreatitis: ConsCiprofloxacin (Cip: 400mg x 2/day)+Metronidazole (Met: 500mg x 2/day) (AB) vs. Placebo (P)Switch to Open treatment: infection, sepsis and MOF114 pts with CRP >150mg/L and/or necrosis at CT (58 with AB and 56 with P)12% of AB patients developed infected necrosis vs. 9% in P (P=0.585) (expected: 40% vs. 20%)5% mortality rate in AB patients vs. 7% in P (P NS)In 76 patients with necrotizing pancreatitis, no differences (also in pts with necrosis >30% ) Cross-over rate: 28% of the AB patients require a switch to open treatment vs. 46% of P patients (P

The median penetration ratio of CIP:137.5% (11196%) in infected omental bursa fluid59.6% (3214%) in pancreatic necroses 67.1% (1250%) in peripancreatic necrosesChemotherapeutical ratios of CIP as a marker for antimicrobial potency were high against most relevant pathogens in necrotizing pancreatitis.

Conclusion: Due to its antimicrobial spectrum and the good penetration into the relevant compartments, CIP may be useful in preventing local infection in necrotizing pancreatitis.

Terapi bedahIndikasi pada 4 keadaanDiagnosis belum dapat ditegakkan (

Options for Nutrition Support in the Individual PatientENStandard Rx (Do nothing)PN Options in acutepancreatitis based on: Disease severity Timing Tolerance

Nutrisi parenteralProTidak ada efek skresi pankreasAman, efektif komplikasi lokal dan mortalitas (vs tanpa nutrisi pada penyakit berat)KontraMahalRisiko infeksiMonitoring ketat elektrolit, trigliseridaKebutuhan insulin

Nutrisi enteralProNJT sekresi minimalMurahSepsis

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The authors concluded that all patients with acute necrotizing pancreatitis should receive early antibiotic treatment [42].However, not all researchers agree that severe acute pancreatitis should be treated with early antibiotic administration [43]. This is the suggested caloric intake for the refeeding of acute pancreatitis patients [46].