How Good Are Our Tests for Acute Pancreatitis?

A recent cross-sectional pediatric study (SH Orkin et al. J Pediatr 2019; 213: 143-8),  with a prospective clinical database, provides data on children presenting with acute pancreatitis, n=112 (2013-16).

Acute pancreatitis (AP): requires at least 2 of 3 criteria:

  1. Abdominal pain consistent with AP
  2. Serum amylase and/or lipase activity at least 3 times ULN
  3. Imaging findings compatible with AP

Key points:

  • Among AP patients who had a lipase level, the sensitivity was 95% whereas the sensitivity for amylase was 39%.
  • Among AP patients who had an ultrasound, the sensitivity was 52%.  In those with either CT or MRI, the sensitivity was 78%.
  • In this cohort, 5.4% did not meet diagnostic criteria based on biochemical elevation (amylase or lipase) and instead relied on imaging along with signs/symptoms.

The authors note that lipase has a delayed peak and longer duration of elevation with AP.   Amylase normalizes more rapidly.

My take: This study reinforces the view that an elevated lipase is more sensitive than amylase and that imaging (especially ultrasound) is frequently normal in AP.

Related blog posts:

Island Ford Park, Chattahoochee River

 

#NASPGHAN19 Postgraduate Course (Part 4)

Here are some selected slides and notes from this year’s NASPGHAN’s postrgraduate course. With my notes, there could be errors of omission and transcription on my part.

Link to the full NASPGHAN PG Syllabus 2019 (Borrowed with permission)

Liver/Pancreas Session

150 Miriam Vos, MD, MSPH, Emory University New news in NAFLD

Dr. Vos gave a terrific lecture. Key points:

  • NAFLD screening: recommended around age 10 years (in children with obesity) based on increasing prevalence with age
  • PNPLA3 encodes adiponutrin –> important for clearing stored triglycerides. Common polymorphism PNPLA3 rs738409‐is associated with NAFLD
  • Who to screen –all obese children >10 years. Overweight children  with risk factors: Type II diabetes,  Hispanic,  Family history,  Pituitary  disorders (GH),  Right sided  abdominal pain
  • ALT and ultrasound are imperfect screens
  • Alcohol worsens NAFLD.  Sugar/juice boxes are also culprits
  • #1 Recommendation: Sugar reduction in diet

Related blog post: “The Paramount Health Challenger for Humans in the 21st Century”

161 Saul J. Karpen, MD, PhD, Emory University School of Medicine/Children’s Healthcare of Atlanta New therapies for chronic cholestatic diseases

  • Limited therapies currently available.  A number of treatments appear promising:  Obeticholic acid, Norursodeoxycholic acid
  • For ABCB4, some drugs used for cystic fibrosis may help as well
  • ASBT inhibitor appears promising for Alagille (see ITCH study)

171 Sohail Husain, MD, Stanford Children’s Hospital Diagnosing drug-induced pancreatitis

  • In patients with IBD, thiopurines and mesalamine/ sulfasalazine (mesalamine have greater risk than sulfasalazine) are associated with pancreatitis
  • ~1/3rd of patients with drug-induced pancreatitis have other risk factors

179 Jaimie D. Nathan, MD, FACS, Cincinnati Children’s Hospital Medical Center Pediatric pancreatic masses: Steroids, surgery or surveillance?

Disclaimer: NASPGHAN/gutsandgrowth assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. The discussion, views, and recommendations as to medical procedures, choice of drugs and drug dosages herein are the sole responsibility of the authors. Because of rapid advances in the medical sciences, the Society cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure. Some of the slides reproduced in this syllabus contain animation in the power point version. This cannot be seen in the printed version.

 

#NASPGHAN18 Abstract: LR for Pancreatitis & Pumpkin Shot

At NASPGHAN18, an abstract provided more information that indicates that lactated ringer’s is probably the best intravenous fluid for most children with acute pancreatitis

Related blog posts:

 

2018 Pumpkin for our House

Pediatric Pancreatitis -Working Group Nutritional Recommendations

Abstract Link: Nutritional Considerations in Pediatric Pancreatitis: A Position Paper from the NASPHAN Pancreas Committee and ESPHAN Cystic Fibrosis/Pancreas Working Group.

M Abu-El-Haija et al. JPGN 2018; 67: 131-43.  This working group made ~27 recommendations (summarized in Table 1) and indicated the quality of evidence supporting the recommendation as well as the agreement among team members –virtually all received at least 12 of 13 votes.

Here are the ones that grabbed my attention:

For Acute Pancreatitis (AP):

  • 1a & 1aa. Children with mild AP should be started on a regular diet –preferably via mouth as compared to nasogastric route
  • 1b. Enteral nutrition (EN) should be attempted in children with severe AP within 72 hours from presentation, once deemed hemodynamically stable.
  • 1.4 Even in severe AP, jejunal tube feeding should be reserved for those unable to tolerate oral or NG tube feeding

For Acute Recurrent Pancreatitis (ARP):

  • 2.1a & 2.1b. Children should receive a regular-fat diet in between bouts of ARP and a regular-fat diet can safely be started within 1 week after the onset of a bout of AP (except in those with very elevated triglycerids (>1000 mg/dL)
  • 2.2a & 2.3a. PERT is NOT recommended in children with ARP without eocrine pancreatic insufficiency (EPI). Antioxidants are NOT recommended (insufficient supporting evidence)

For Chronic Pancreatitis (CP):

  • 3.1b & 3.12a. Recommends routine followup every 3-6 months and a regular diet
  • 3.3a, 3.4a, & 3.5a Monitoring: recommends checking fat-soluble vitamin levels every 6 to 12 months, checking for EPI with elastase (or 72 hr fecal fat) every 6-12 months, and BMD (bone mineral density) if CP and malnutrition (especially if Vit D deficiency or hx/o fractures)

My take: This report provides a methodical approach for the care of children with these pancreatic disorders.

Related blog posts:

Tide pools and wide beach at Cumberland Island 2018

Acute Pancreatitis: Clinical Report from NASPGHAN

There are no surprises in a recent clinical report on acute pancreatitis (M Abu-El-Haija et al. JPGN 2018: 66: 159-76) from NASPGHAN.

Here are a few of the points:

  • The authors recommend ultrasound for initial imaging and checking liver enzymes, GGT, calcium and triglycerides.
  • For fluids, they indicate that in adults there is evidence suggesting that lactated ringer’s (LR) is likely preferable to normal saline.  In children, on presentation, “if evidence of hemodynamic compromise, a bolus of 10 to 20 mL/kg” of crystalloid is recommended followed by “1.5 to 2 times maintenance IV fluids.”
  • For pain management not responding to acetaminophen or NSAIDs, “IV morphine or other opioids should be used.”
  • They recommend early oral/enteral nutrition (within 48 to 72 hours of presentation).
  • They recommend against prophylactic antibiotics in severe acute pancreatitis.
  • They recommend against probiotics, anti-proteases, and antioxidant therapy.
  • For fluid collections that need drainage or necrosectomy, nonsurgical approaches are favored.
  • Acute biliary pancreatitis, “Cholecystectomy safely can and should be performed before discharge in cases of mild uncomplicated acute biliary pancreatitis.”

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American Ingenuity!!

ACG World Congress -Useful Tweets

I wanted to share several tweets from this year’s ACG World Congress that looked helpful.

Topic: SBBO and IBS-D

A positive breath test is the ONLY variable that can predict response to Rifaximin in IBS-D: ACG and Mark Pimenthal. tweet from @AllRezale, MD

Topic: Polyps -slides recommend cold forceps for polyps 1-3 mm and cold snare for 4-5  mm polyps.

Topic: Hereditary Colorectal Cancer Syndromes

Topic: Aggressive fluids for pancreatitis

Rising BUN is Associated with mortality with pancreatitis. Tauseef, Ali @ibdtweets: “Pancreatitis pearls: aggressive fluid hydration 250-500 cc lactated ringer’s (my personal favorite also) and ensure BUN dropping #WCOGatACG2017”

Pancreatitis Update (part 1)

Our group received a very helpful update on pancreatitis from Maisam Abu-El-Haija (GI) and Jaime Nathan (surgery). My notes may include some errors in transcription and errors of omission. Some pictures of the slides are included below as well.

Key points:

  • About 30% of acute pancreatitis patients have a 2nd bout of pancreatitis. Obesity is a risk factor for recurrence.
  • There has been a recent increase in incidence of acute pancreatitis.
  • Cincinnati has a gene panel to examine the four most common mutations which cause hereditary pancreatitis (PRSS1, SPINK1, CFTR, and CRTC) along with 6 other relevant genes. (28 day turnaround) In addition, there is a pancreatitis insufficiency panel.
  • Discussed screening for pancreatic insufficiency.  Directly measuring pancreatic enzymes are more sensitive for early insufficiency, but may be unnecessary if good growth and normal stool elastase.
  • There are NO proven medical/dietary therapies to prevent recurrent or chronic pancreatitis and eliminate pain symptoms.

Related blog posts:

Triglyceride Levels and Pancreatitis

A recent study (JAMA Intern Med 2016; 176: 1834-42) suggests that even mild to moderate hypertriglyceridemia may increase risk of pancreatitis.

Among two large cohorts that were followed prospectively for a median of 6.7 years, 434 out of 116,550 patients developed acute pancreatitis.

Key finding (which persisted after adjustment of multiple potential confounding factors):

screenshot-140

More complete summary at GI & Hepatology News: “Mild, moderate hypertriglceridemia tied to pancreatitis”

 

Acute Pancreatitis Review

A succinct review (CE Forsmark et al. NEJM 2016; 375: 1972-81) provides some useful pointers regarding acute pancreatitis.

The review covers the causes, epidemiology, diagnosis, prediction of severity and management.  With regard to management:

  • The authors advocate for aggressive fluid resuscitation during the initial 24 hrs -though care to avoid fluid overload.  “One trial suggested the superiority of Ringer’s lactate as compared with normal saline in reducing inflammatory markers.”
  • “Total parenteral nutrition is…more expensive, riskier, and no more effective than enteral nutrition.”
  • “In patients with mild acute pancreatitis who do not have organ failure or necrosis, there is no need for complete resolution of pain or normalization of pancreatic enzyme levels before oral feeding is started.”
  • “A low-fat soft or solid diet is safe and associated with shorter hospital stays than is a clear-liquid diet with slow advancement to solid foods.”  Thus, most patients with mild acute pancreatitis can start a low-fat diet soon after admission, “in the absence of severe pain, nausea, vomiting and ileus.”
  • By day 5, one can predict the need for enteral feeding.  Early initiation of nasoenteric feeding “is not superior to a strategy of attempting an oral diet at 72 hours, with tube feeding only if oral feeding is not tolerated” by day 5.
  • “Whether an elemental or semielemental formula is superior to a polymeric formula is not known”
  • “Prophylaxis with antibiotic therapy is not recommended for any type of acute pancreatitis unless infection is suspected or has been confirmed.”  Infection in necrotic fluid collection “is the main indication for therapy” but is rare in the first 2 weeks of illness.
  • For pancreatitis triggered by gallstones, after removal of any residual stones in the ducts, “cholecystectomy performed during the initial hospitalization…reduces the rate of subsequent gallstone-related complications by almost 75%” compared to waiting for 25-30 days.

Related blog posts:

  • Changing Practice Patterns with Pediatric Pancreatitis | gutsandgrowth
  • Why an ERCP Study Matters to Pediatric Care | gutsandgrowth This post explains why LR may be best.
  • Nutrition University / gutsandgrowth What are the nutritional management recommendations for acute pancreatitis? Justine Turner indicated that too many centers continue to rely on parenteral nutrition.  Yet, guidelines recommend the use of enteral nutrition due to lower risk of poor outcomes (eg. infections when NPO and on parenteral nutrition). ‘Resting pancreas is not helpful.’ With acute pancreatitis, enzyme secretion is reduced.  Her approach is to start nasogastric (NG) feedings at about 24 hours after presentation, as long as hemodynamically stable.  She indicated that nasojejunal (NJ) feedings can be done if NG is not well-tolerated.  NJ feedings are effective at reducing enzyme secretion.  However, Praveen Goday stated that his practice was often starting with NJ feeds.  “Sometimes there is only one shot” before the ICU team starts HAL.  Both physicians indicated that polymeric formulas were probably acceptable; however, starting with semi-elemental or elemental feedings are often done, again as a practical matter to minimize the likelihood of reverting to parenteral nutrition.
Glacier National Park

Glacier National Park

World Congress 2016 Postgraduate Course

I’ve attached (with permission) the syllabus from the World Congress 2016 Postgraduate Course: 2016-world-congress-postgraduate-course-syllabus

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One lecture that I will highlight with a few slides is from Dr. Martin Martin (pg 53-62) which emphasizes a new model for evaluating neonatal intestinal failure/congenital diarrhea by using whole exome sequencing –see slides below.

Other pointers:

  • Pg 82.  Breastmilk associated with shorter duration of TPN dependence in short bowel syndrome
  • Pg 137. Look for vasculopathy (MRI/MRA) and renal disease in Alagille syndrome
  • Pg 152. Lactated ringer’s likely better in acute pancreatitis than normal saline.
  • Pg 171. If constipation at less than 1 year is untreated, >60% have issues with constipation at age 3.

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Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.