pancreatitis分析.ppt

Acute Pancreatitis Evidence Based Approach Pankaj Singh MD Director of Gastrointestinal Endoscopy Central Texas VA Health System, TX Assistant Professor Texas AM University Clinical Case 32-year-old man c/o acute onset abdominal pain (presumed pancreatic origin) h/o alcohol intake What do you think? Amylase or lipase Ultrasound or CT scan If yes, When? ICU or medical ward Enteral nutrition or TPN Antibiotics ERCP Surgery Evidence A. Proven 2 well designed trials, randomized B. Possible/ Probable 1 well designed study, randomized C. Consensus agreed opinion with no supportive evidence Guidelines Atlanta British Society of Gastroenterology International Association of Pancreas Santorini Conference World Congress of Gastroenterology Background Potentially fatal Mortality – 0-25% Background Mild AP (no necrosis) – 0% Diagnosis Laboratory Amylase Lipase Radiological US CT scan Blood tests Amylase and lipase Plasma level peak within 24 hours t1/2 of amylase lipase Lipase has slightly higher sensitivity and specificity and greater overall accuracy than amylase (Evidence category A) Ultra Sound (US) Little part in the diagnosis of the acute pancreatitis Role in biliary pancreatitis Stones in gallbladder Common Bile Duct dilation US findings should be examined in all patients with possible acute pancreatitis on admission (Evidence category B) CT scan Not necessary for the diagnosis Diagnostic doubt Atypical presentations Asymptomatic hyperamylasaemia or hyperlipasemia Routine use of CT scan within 24-48 hours of admission (Evidence category C) Initial Management Monitoring – temp., pulse, blood pressure, and urine output Treatment – Cardiopulmonary care Sufficient fluid resuscitation Pain control Severity Stratification Rationale Differentiate mild from severe acute pancreatitis Desirable features of Markers of Severity Accuracy - High sensitivity PPV Predictability within 24 hours of admission Easy to use C