GI (January 2017)
Research:
Forsmark et al. “Acute Pancreatitis.” NEJM 2016.
AIR: Infectious Disease
For a Review Article
- How has reading the article changed your practice?
- What information had you believed in previously that were debunked by reading this article?
- What new information did you learn from reading this article?
- What are current areas of uncertainty on this topic that can be potential areas for research?
For an Original Research Article
- What are some strengths of the study?
- What are the limitations?
- What are the main outcomes of the study?
- Does reading this article change your practice? If so, how?
8 comments
This new acute pancreatitis review is GOLD!
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A lot of fantastic updates on prior myths and standards that no longer hold true.
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A great read for us in the ED, and for you when you rotate on the floor and in the ICU’s.
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For instance: It talks about the superiority of Ringer’s lactate as compared with normal saline in reducing inflammatory markers.
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That early low fat PO feeding reduce LOS. Use NGT if needed. Avoid TPN unless absolutely have to use it.
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Lastly, I see a lot of people order CT a/p for NOT SICK patients with lipase-confirmed acute pancreatitis in our ED. WHY?
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Perhaps you can pick up a necrotizing case early and uptriage, but that’s pretty rare. Perhaps the lipase isn’t high enough, and you are unsure, that’s not unreasonable.
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But CT evidence of severe acute pancreatitis lags behind clinical findings, and an early CT study can underestimate the severity of the disorder. Plus it almost NEVER changes your management. You can do an ultrasound to do rule out gallstones. But I see a lot of unnecessary CT a/p ordered in these stable cases. In my opinion, total waste of time and money.
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Have you heard other other reasoning for this?
Salminen: Abx vs. surgery for appy
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Very interesting history of why we treat appendicitis with surgery.
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Nevertheless, staying in the hospital for 3 days for IV abx, and still having 25% chance of need surgery doesn’t sound all that appealing. It’d be interesting to see the failure rate with PO abx and discharge.
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Still, it seems like uncomplicated appy is not the “surgical emergency” that we are led to believe, at least when patients get abx in a timely manner.
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Also an interesting discussion section that sheds light on why surgeons really want that CT regardless of how classic a presentation might be for appendicitis.
Forsmark et al.
1. How has reading the article changed your practice? According to this article, patients need to have a serum lipase or amylase be 3 times the upper limit of normal before they can receive the diagnosis of pancreatitis.
2. What information had you believed in previously that were debunked by reading this article? I thought the lipase level was correlated with the severity of pancreatitis and the prognosis. However, lipase level is not correlated with prognosis.
3. What new information did you learn from reading this article? You need to be a chronic daily drinker before you can get EtOH-induced pancreatitis (this article states 4-5 drinks daily for 5 years). Acute binge drinking does not cause pancreatitis.
4. What are current areas of uncertainty on this topic that can be potential areas for research? It would be nice to see a research study looking at if amylase levels ever change the management of pancreatitis. If not, it would encourage people to stop ordering amylase and could possibly result in modest cost savings from fewer unnecessary lab tests.
Salminen et al.
1. What are some strengths of the study?
It is a randomized control trial. Investigating an interesting question.
2. What are the limitations?
Exclusion criteria was broad. For example, patients taking metformin were excluded due to the theoretical risk of contrast administration on renal function in these patients (a controversial idea). Another limitation is that patients were treated with ertapenem, making this study less generalizable.
3. What are the main outcomes of the study?
Resolution of appendicitis and no recurrence in 1 year.
4. Does reading this article change your practice? If so, how?
No.
Salminen et al
1. Strengths of the study are it is an RCT and it is interesting – evidence for why we do what we do!
2. Study was underpowered due to difficulty with enrollment, ertapenem is very broad spectrum, control group was open appy which would likely have higher complication rate (than laparoscopic appy)
3. Appendectomy is superior to antibiotics for treating appendicitis, but interestingly the majority of patients randomized to the antibiotic group did not end up requiring surgery
4. Not at all
Forsmark et al
1. For future inpatient rotations (although I’ve yet to have a MICU pancreatitis) I will be sure to feed patients earlier, and place on a lowfat solid diet instead of starting with CLD.
2. I thought you could get acute pancreatitis from short episodes of binge drinking in the absence of chronic alcoholism – but these pts with epigastric pain are probably more like alcoholic gastritis
3. I didn’t know how high the mortality rate could be if there was persistent organ system failure! Also I’ve always given fluids without knowing that the recommended amount is 2500 to 4000 ml within the first 24 hours, or that LR is superior to NS
4. Fluid resuscitation is very important, yet there don’t seem to be many trials, so this would definitely be an important area for future research
Acute Pancreatitis Review
Changed Practice? It’s ok to not find the exact etiology of pancreatitis in the ED – check if they drink, get the US, maybe get a trigly level (which maybe won’t matter since it’s not even a fasting level!), run pt’s med list…but let the floor team handle the rest given that there are so many reasons, some of which are genetic, and that at the end of the day the pt might have ‘idiopathic pancreatitis’; another thing I’ll be considering more as I move to 3rd year is trauma associated pancreatitis (classic case being bike handle bar trauma)
Debunked info? How much etoh use is required for etoh associated pancreatitis – 4-5 drinks daily for > 5 years (ie, binge drinking in absence of long term etoh use does not precipitate etoh induced pancreatitis);
New info? That the type of etoh ingested does not affect risk; ACE inhibitors could be a culprit (!); Obesity and DM are important risk factors; 80% of dz is self limited; it’s lipase x3 for dx; definition of mod/severe pancreatitis involves either organ failure, exacerbation of preexisting dz, or local complications; similar to CXR in assessing PNA, CTAP findings lag behind clinical findings; 2 week mark is important in prognostication (if pt is not improving, mortality jumps up significantly)
Potential Research? I’m interested in learning more about admitting (or not) pts with mild pancreatitis. Had a recent pt w/ very mild epigastric pain, no n/v or decreased PO intake but with an elevated lipase. I ultimately admitted her but given the recent trends in management (ie, ok to feed) and low risk of complications for mild dz, I wanted to send her home. I was hoping the article would touch on this but will definitely be looking into this.
ABX vs APPY
– Strengths? Multicenter, randomized, sufficient power; liked that the the goal was to elucidate if abx were “non-inferior”; many secondary endpoints were of interest (pain, LOS, post op complications, adverse effects of abx, etc.); the study was also a significant improvement on prior ones by addressing previous limitations; although the study’s primary outcome did not show that abx were non-inferior, it did show inversely that about 72% of patients were successfully treated with abx; also notable was that out of the pts given abx but eventually undergoing appendectomy, none developed a serious infection suggesting that delaying sx for uncomplicated appendicitis may carry low risk for major complications.
– Limitations? The appy arm only included open procedures which potentially minimizes benefits of laparoscopic method; per authors, limitations also included difficulty in enrolling patients
– Outcomes? About a quarter of pts randomized for abx had sx w/i a year; for pts with uncomplicated appendicitis on CTAP, abx tx did NOT meet noninferiority criterion vis a vis sx
– Change practice? Notwithstanding institutional procedures (and perhaps more importantly the impending study we’re about to embark on with our sx colleagues), I think reading this study shows the potential for abx as a tx for appy. At the very least it will provide a basis for some shared decision making with the pt. Additionally, it should be noted that during the study’s enrollment period, the six trial hospitals did >4000 appendectomies…and that the negative appendectomy rate was 16% – in other words, I think I might personally be ok with trialing abx versus weighing the surgical (and post sx) risks or the 16% chance that I might not even have an appendicitis!