Management of acute pancreatitis: experience of a tertiary care hospital in Peshawar
Abstract
Objectives: To document the frequency, age, gender, etiology, mortality and morbidity of patients suffering from acute pancreatitis (AP) and managed at a tertiary care hospital.
Methodology:This prospective, descriptive, institution-based study was conducted in Department of Surgery, Rehman Medical Institute (RMI), Peshawar (Pakistan), from June 2010 to June 2013. All patients with acute pancreatitis admitted to our institute were managed with a set protocol. Consecutive, non-probability sampling was done. Data were collected from all patients by a single investigator using a researcher-administered questionnaire, which included patient demographics, various risk factors, treatment options, complications and mortality.
Results: A total of 47 patients were included in the study; 28 female and 19 male patients. Out of 47 patients 35 (74%) were of Afghan origin, while 12 (26%) were Pakistani. Majority of patients (57%) were between 20-40 years of age. Gall stone pancreatitis (GSP) was the cause of AP in 13 (28%), dyslipidemia in 9 (19%), and traumatic AP in one patient, while in 24 patients (51%) it was idiopathic. Ten (21%) patients developed pseudocyst. Out of a total of 47 patients, 3 (6%) expired.
Conclusion: Patients suffering from acute pancreatitis and presenting to our hospital had a predominance of females. Majority of patients were between ages of 20-40 years. Idiopathic pancreatitis was the most common type followed by GSP. Mortality and morbidity in this study was low in comparison to other local studies.
Key words: Acute pancreatitis; Gall stone pancreatitis; Octreotide
Citation: Khan ZA, Shahab F, Khan RA. Management of acute pancreatitis: experience of a tertiary care hospital in Peshawar. Anaesth Pain & Intensive Care 2014;18(2):176-79
INTRODUCTION
Acute pancreatitis (AP) is a disease with a broad spectrum of clinical findings ranging from self-limiting mild disease to a very severe and lethal disease. It has an incidence of approximately 40 cases per 100,000 adults in the United States.1It has been observed that the incidence of acute pancreatitis is rising over the past several decades.2 It is a very lethal disease and the mortality due to pancreatitis ranges between 4% and 15% for all cases and between 15% and 90% for more severe cases.3
The etiology and pathogenesis of this disease has been studied in great detail over the past decades. Gall stone pancreatitis (GSP) and alcohol abuse are the most common causes of AP.4 There have been several descriptive studies which have shown the treatment outcomes in AP but these varied considerably due to a very broad spectrum of the severity of the disease.5
The objectives of this study were to document the frequency, age, gender, etiology, mortality and morbidity of patients suffering from acute pancreatitis that presented to a tertiary care hospital in Peshawar.
METHODOLOGY
A prospective, descriptive, institution-based study was conducted in Department of Surgery, Rehman Medical Institute (RMI), Peshawar (Pakistan); from June 2010 to June 2013. RMI is a 300-beded tertiary care hospital, which is the largest private sector hospital in Khyber Pakhtunkhwa province and receives patients from all over the province as well as from the neighboring Afghanistan.
Patients presenting with abdominal pain, raised serum amylase and lipase >3x the normal limits and diagnosed as suffering from acute pancreatitis were included in the study. Patients with abdominal pain due to all other causes were excluded from the study. Consecutive, non-probability sampling was done. Data were collected from all patients by a single investigator using a researcher-administered questionnaire which included patient demographics, various risk factors, treatment options, complications and prognosis.
The diagnosis of acute pancreatitis was made within 48 hours of admission in the surgical unit. In this regard, serum lipase estimation was considered as the most important factor because of its only source of production being the pancreas. To predict the severity and prognosis of disease, we used clinical evaluation of the cardiovascular and the respiratory systems, as well as renal function evaluation along with Ranson`s criteria, the Acute Physiology and Chronic Health Evaluation (APACHE II) score >8 and CRP >150 mg/L.
Management of Acute Pancreatitis:
After diagnosis, the management was done preferentially in our intensive care unit for the initial 48 hours and was mainly supportive; oxygen inhalation, vital sign monitoring, urinary catheterization and intake-output record. Patients were kept nil by mouth, hydrated with IV fluids, electrolyte replacement, pain relief and pancreatic rest. Antibiotics preferably imipenem were routinely given to all patients in a dose of 500 mg–1 Gm TID. Symptomatic treatment with antiemetics was added. Inj. octreotide (Sandostatin®, Novartis Pharma) 50 µg subcutaneously TID, inj. calcium gluconate 10 ml IV daily along with stress ulcer prophylaxis was also started. In severe cases with deranged liver function tests having low albumin, 20% human albumin (50-100 ml) was infused for three days. Infusion containing amino acid supplements was initiated to prevent protein catabolism. On improvement of Ranson’s criteria and APACHE scores, the patients were shifted to ward.
All patients with biliary pancreatitis underwent definitive surgical treatment of gall stones during the same hospital admission preferably in the second week, after the acute attack of pancreatitis was over. However, early ERCP for severe gall stone pancreatitis with endoscopic sphincterotomy and stenting was done in order to decompress and relieve cholangitis. In such cases, surgery was delayed till the severity of the disease subsided and the patient was advised elective surgery after 4-6 weeks.
CT scan was done in patients with persisting organ failure, signs of sepsis or deterioration in clinical status on the 4th/5th day of admission to avoid underestimation of the severity of the disease. Belthazar severity score was used and was considered as the main prognostic tool.
Data Analysis:
Data were recorded and analyzed using Statistical Package for Social Sciences v20.0 (SPSS, Inc., Chicago, IL, USA). Results were recorded as frequencies, mean ± standard deviation (SD).
