Pankreatitis akut

dr. Fransiska
Diskusi Topik Divisi Gastroenterologi
IPD - FKUI

Definisi
Proses inflamasi pankreas reversibel
Klinis : nyeri perut
enzim pankreas darah
Ringan (80%) berat mengancam
nyawa (20%)

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

Epidemiologi
Mortalitas:
ringan < 1%
berat 10-30%

evaluasi dini
stratifikasi risiko

Mortalitas

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

36
%

38
%

Etiologi

Hiperamilasea 35-70%

Patofisiologi
Fase 1: Aktivasi prematur tripsin
dalam sel asiner pankreas enzim
digesti pankreas
Fase 2: Inflamasi intrapankreas
melalui berbagai mekanisme dan jalur
Fase 3:Inflamasi ekstrapankreas
ARDS

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

Patogenesis

bile-pancreatic duct common pathway theory

pancreatic autodigestion theory
gallstone migration theory
enzyme activation theory
kinin and complement system activation theory
microcirculation disturbance theory
leukocyte excessive activation theory
pancreatic acinar cell apoptosis and necrosis
theory

KONTROVERSIAL

Manifestasi klinis
Nyeri abdomen :
akut
Mencapai intensitas max dlm 30 menit,
persisten > 24 jam tanpa perbaikan
mual dan muntah
epigastrium dan periumbilikal.
menjalar ke punggung, dada, pinggang,
bagian bawah abdomen
knee-chest position kurangi nyeri

Manifestasi klinis
PF:
Demam
Hipotensi
NT abdomen
distres pernapasan
distensi abdomen
syok dan
ikterus
nodul kulit eritematosa
10-20% kasus ronkhi di basal,
atelektasis, dan efusi pleura kiri

Manifestasi klinis
Pankreatitis
nekrosis :
Cullens sign
pucat kebiruan di
umbilikus
hemoperitoneum

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

Laboratorium

enzim amilase
enzim lipase 85-100%
DPL, diff count
blood urea nitrogen (BUN)
Kreatinin
Glukosa
Kalsium
Trigliserida
UL

# severity

Radiologi
Abdomen 3 posisi obstruksi 2nd
USG abdomen batu empedu (etiologi)
CT Scan
Pembesaran pankreas dgn edema difus
Parenkim pankreas heterogen
Peripancreatic stranding & fluid collection

ERCP/MRCP superior u anatomi

duktus dan koledokolitiasis
EUS

Diagnosis
Guidelines American College of
Gastroenterology :
2 dari 3:
nyeri abdomen yang khas pankreatitis
akut
peningkatan serum amilase dan lipase
3 kali normal
temuan khas pankreatitis akut pada CT
scan
Practice Guidelines in Acute Pancreatitis, Am J Gastroenterol 2006;101:2379-400

Diagnosis diferensial

Iskemia/infark mesenterika
Perforasi ulkus gaster/duodenum
Kolik bilier
Aneurisma aorta disekta
Obstruksi usus
Infark miokard akut inferior

Stratifikasi Risiko

Apache II
Ranson
CT severity index
Imrie scoring system

Guidelines American College of Gastroenterology, 2006

Diagnostic

Look for risk factors of severity at

admission
Determination of severity by laboratory
test at admission or 48 h
Determination of severity during
hospitalization
Imaging studies
Organ failure

Tatalaksana
Tujuan:
<< stimulus sekretorik pankreas
Koreksi ketidakseimbangan elektrolit dan
cairan

Guidelines American College of Gastroenterology, 2006

Treatment

Supportive care
Prevent hypoxemia
Fluid resuscitation

Transfer to an ICU
Nutritional support
Use of prophylactic antibiotics in
necrotizing pancreatitis
Treatment of infected necrosis
Treatment of sterile necrosis
Role of ERCP and billiary sphincterotomy in
gallstone pancreatitis

Terapi medis

Puasa NGT, TPN

Koreksi cairan dan elektrolit 2000-3000
Koreksi metabolik
Anti nyeri
Antibiotik (+/-)
Oksigen
Octreotide, PPI
Endoscopic sphincterotomy (ERCP)

Antibiotik
Imipenem 3 x 500 mg IV
Ciprofloxacin 2x400 mg IV +
Metronidazol 3x500 mg IV
Sefalosporin generasi III

Antibiotics and Severe Acute

Pancreatitis: Pros
Antibiotic

prophylaxis significantly reduced sepsis by

21.1% and mortality by 12.3% compared with no
prophylaxis

There

was also a non-significant trend toward a

decrease in local pancreatic infections

Antibiotic

prophylaxis decreases sepsis and mortality

in patients with acute necrotizing pancreatitis

All

patients with acute necrotizing pancreatitis should

receive prophylaxis with an antibiotic of proven
efficacy
Sharma VK, Howden CW. Pancreas 2001; 22:28-31. [42]

Antibiotics and Severe Acute

Pancreatitis: Cons

Ciprofloxacin (Cip: 400mg x 2/day)+Metronidazole (Met: 500mg x

2/day) (AB) vs. Placebo (P)
Switch to Open treatment: infection, sepsis and MOF
114 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<0.05)

Isenmann R, et al. Gastroenterology 2004;126:997-1004. [4

 The median penetration ratio of CIP:

137.5% (11196%) in infected omental bursa fluid
59.6% (3214%) in pancreatic necroses
67.1% (1250%) in peripancreatic necroses

Chemotherapeutical 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 bedah
Indikasi pada 4 keadaan
Diagnosis belum dapat ditegakkan (<<<)
Pancreatic sepsis nekrosis pankreas terinfeksi
Abses 5%

Penyakit traktus bilier

Perburukan status klinis (kontroversial)

Options for Nutrition Support

in the Individual Patient
Options in acute
pancreatitis based on:
Disease severity
Timing
Tolerance

Standard Rx
(Do nothing)

EN

PN

Nutrisi parenteral
Pro

Kontra

Tidak ada efek

skresi pankreas
Aman, efektif
komplikasi lokal
dan mortalitas (vs
tanpa nutrisi pada
penyakit berat)

Mahal
Risiko infeksi
Monitoring ketat
elektrolit, trigliserida
Kebutuhan insulin

Nutrisi enteral
Pro

Kontra

NJT sekresi
minimal
Murah
Sepsis <<<
APACHE score &
CRP
LOS & mortalitas

sekresi pankreas
gaster/duodenal
Kesulitan mencapai
akses jejunal

Tahap

Hari perawatan

2-5

3-7
(nyeri perut #,
enzim )

Nutrisi
Puasa
Resusitasi cairan
Diet enteral:
- tinggi KH
- moderat protein & lemak
Diet N (25-35 kkal/kgBB/hr):
-Prot 1,2-1,5 g/kgBB/h
-KH 4-6 g/kgBB/h
-Lemak 2 g/kgBB/h

Suggested Caloric and Fat Content During

the First Five Days of Refeeding
Caloric content (kcal)

Lipids (g)

250

<5

1,000

5-10

1,500

15-20

1,600

25-30

1,700

35-40

Day

Levy P, et al. Gut 1997; 40:262-6. [46]

Algoritma

Terima Kasih