Guidelines interpretation: diagnosis and management of complications of acute pancreatitis December 03, 2013, 09:10 The Chinese guidelines for the diagnosis and management of acute pancreatitis (2013, Shanghai) (acute pancreatitis, AP) are more organized than the 2003 version of the Chinese guidelines for the diagnosis and management of AP (draft), and the classification describes in detail the characteristics and management points of local and systemic complications. Now, some of the key points of local and systemic complications of AP are further explained in the context of the author’s clinical practice. The 2013 edition of the guidelines classifies AP local complications into five categories according to their characteristics and fate: acute peri-pancreatic fluid collection (APFC), acute necrotic collection (ANC), pancreatic pseudocyst (PPC), and pancreatic pseudocyst (PPC). (pancreatic pseudocyst), wrapped-off necrosis (WON), and peripancreatic abscess (infectednecrosis). This definition is more consistent with the progression of pancreatitis. It can be used to determine local complications more clearly and standardize the treatment behavior, as well as to facilitate clinical and basic research. Specifically, at the beginning of AP, the exudate around the pancreas that has not yet formed a complete envelope is called peripancreatic APFC, and if a complete envelope is formed at a later stage, it is transformed into a pancreatic pseudocyst, a process that often takes about 4 weeks. If the peripancreatic exudate contains more necrotic material in the early stage, it is ANC, and in the later stage, it is transformed into WON; if bacterial infection occurs during the above 2 pathological processes, it is transformed into pancreatic abscess, and the diagnosis of infection can be based on direct evidence, such as positive culture of fine needle puncture material for bacteria or fungi, or indirect signs of infection (bubble sign suggested by enhanced CT). 2013 edition of the guidelines states that local complications are not a basis for judging the severity of AP The 2013 edition of the guidelines states that local complications are not a basis for determining the severity of AP. Other local complications include pleural effusion, gastric outflow tract obstruction, gastrointestinal fistula, abdominal hemorrhage, pseudocyst hemorrhage, splenic or portal vein thrombosis, and necrotizing colitis. Most of the pseudocysts and WON can be absorbed by themselves. The drainage indication mainly depends on the patient’s symptoms, such as recurrent abdominal pain, gastric outflow tract obstruction and causing jaundice, etc. If the cyst continues to increase in clinical follow-up, or if symptoms of infection appear, drainage treatment should also be given. Endoscopic drainage is the preferred route of drainage, followed by percutaneous and surgical drainage. Endoscopic drainage is divided into transapical, transmural and combined transapical and transmural drainage. If the pseudocyst is judged by imaging to be connected with the main pancreatic duct, transapillary drainage is the first choice, and a stent or drainage tube is placed proximally into the cystic cavity, and if the stent can cross the main pancreatic duct leakage, the drainage effect is better, but when the cyst is huge, transapillary drainage may not be effective, and combined transmural drainage should be considered at this time. Transmural drainage refers to the placement of one or more drainage tubes through the gastric or duodenal wall into the cystic lumen. Ultrasonic endoscopic evaluation can better locate the puncture site and guide the puncture in real time, which helps to reduce complications. Prophylactic anti-infective therapy is routinely required after puncture and drainage, and CT is repeated after 4-6 weeks. If the cyst disappears, the endoprosthesis can be removed endoscopically. The 2013 edition of the guidelines states that peripancreatic abscesses are preferred to be drained by puncture and percutaneous puncture with thicker diameter drainage tubes, and if drainage is poor, further surgical treatment is recommended. There are also isolated reports of peripancreatic abscesses cleared by transmural drainage. Parekh et al. found that laparoscopic removal of necrotic tissue is effective and feasible, and compared with open surgery, laparoscopic removal of necrotic tissue reduces the inflammatory response of patients and is consistent with the principle of “damage control. The principle of “damage control” was found. For the treatment of local complications of pancreatitis, we emphasize the concept of individualized treatment and a comprehensive treatment system based on non-surgical treatment with appropriate and timely endoscopic radiological intervention and surgical intervention. The 2013 edition of the guidelines states that systemic complications include organ failure, systemic inflammatory response syndrome, systemic infection, intra-abdominal hypertension (IAH) or abdominal compartment syndrome (ACS), and pancreatic complications. The 2013 edition of the guideline specifies that organ failure includes respiratory, circulatory, renal and pancreatic encephalopathy, etc. The presence of more than two organs is called multi-organ failure, and organ failure determines the severity of AP. Severe acute pancreat:itis (SAP) has a common effect on the respiratory system, mainly due to reduced ventilation, disruption of the balance between ventilation and blood flow, complement-mediated neutrophil aggregation in the alveolar vessels and sludge induced acute respiratory distress SAP can also have varying degrees of cardiac effects, with milder patients experiencing symptoms such as increased heart rate and heart rhythm. The effect of SAP on renal function is manifested as abnormal renal tubular or glomerular function, manifested as transient oliguria in patients with mild disease, and acute renal failure in patients with severe disease. In SAP, a large amount of active protein hydrolase and phospholipase A enter the brain and affect the brain tissue and blood vessels, causing a syndrome of central nervous system damage, which is called pancreatic encephalopathy. The common symptoms are unresponsiveness, disorientation, delirium, confusion, coma, irritability, depression, fear, delusions, hallucinations, speech disorders, ataxia, tremor, hyperreflexia or loss of reflexes, and hemiparesis. The 2013 edition of the guideline is more detailed on fluid resuscitation, which is the basis of other treatments. 2013 edition of the guideline is more detailed on the application of continuous renal replacanent therapy (CRRT) in SAP and the management of ARDS. The 2013 edition of the guideline is more detailed and practical than the 2003 edition of the guideline in terms of the management of ARDS. CRRT is an extracorporeal blood purification therapy that replaces impaired renal function for a longer period of time, treating up to 24 h per day, removing not only excess fluid but also small and medium-sized molecular waste, regulating electrolyte and acid-base balance, and removing inflammatory mediators such as TNF-1 and IL-1 from the blood by combined blood adsorption. CRRT is recommended for patients with systemic inflammatory response syndrome who have poor results with conventional treatment, CRRT can effectively improve the systemic inflammatory response and maintain the stability of the internal environment. ARDS is the most serious respiratory complication of AP, seen in 15%-20% of AP patients, usually occurring in the first 2-7 d of the disease, but can also occur rapidly in the early stages. The pulmonary pathological changes and clinical manifestations are similar to those of ARDS due to other etiologies. Patients present with markedly accelerated respiration (35-40 breaths/min), respiratory distress, cyanosis, and a marked decrease in PaO2 (<8.0 kPa), and the above symptoms are difficult to correct with oxygen. Diffuse reticular or lamellar shadows were seen on chest X-ray. Although the incidence of ARDS is higher in SAP patients, pure edema type AP also has the risk of complicating ARDS. Once suspected early ARDS, mechanical ventilation should be performed immediately if Paoz is still <8 kPa after high concentration oxygenation. Intermittent positive pressure breathing or end-expiratory positive pressure breathing should be used according to the patient's condition to improve functional residual air, improve pulmonary compliance, prevent alveolar atrophy, and reduce intrapulmonary shunts. V. Postoperative pancreatitis after endoscopic retrograde cholangio-pancreatography (ERCP) Postoperative pancreatitis after ERCP is one of the most common and serious complications of ERCP because it can lead to prolonged hospitalization, comorbidities, and occasionally death. . Post-ERCP pancreatitis can be clinically diagnosed based on the presence of abdominal pain, low back pain, nausea (with or without vomiting), and elevated blood amylase after ERCP operation. contrast-enhanced abdominal CT should be performed 24-48 h after ERCP to clarify local complications. Once the diagnosis of post-ERCP pancreatitis is confirmed, the treatment is basically the same as that for pancreatitis of other etiologies, and the results of a recent study showed that emergency placement of pancreatic duct stents for post-ERCP pancreatitis was clinically effective, but the results of a large-scale clinical study are still needed to support this. The key to the diagnosis and treatment of post-ERCP pancreatitis is prevention rather than treatment. Prevention of post-ERCP pancreatitis is a comprehensive system that includes preoperative evaluation, technical operation, and postoperative management. The most basic principle of preventing post-ERCP pancreatitis is to perform ERCP consultation and treatment only when the benefit of ERCP is clear, that is, the less strong the indication of ERCP, the greater the risk of post-operative pancreatitis. If the cause of abdominal pain is unknown in a young woman, with suspected malfunction of the papillary sphincter of the jugular abdomen and imaging suggesting no significant biliary tract dilatation, performing ERCP is particularly dangerous, with a risk of postoperative pancreatitis exceeding 40%. Second, skilled use of the duodenoscope and its accessories and strict training in ERCP operation are required. During the operation, repeated intubation, guidewire into the pancreatic duct and pancreatic duct visualization should be minimized. 5 Fr, 3 cm short pancreatic duct stent is recommended to be placed in patients at high risk of post-ERCP pancreatitis, and endoscopic removal is recommended if it falls off at the end of 5-10 d to avoid further damage to the pancreatic duct. Several studies have shown that NSAIDs can reduce the occurrence and severity of post-ERCP pancreatitis. Routine postoperative intrarectal administration of indomethacin is recommended for high-risk patients. Some studies have shown that growth inhibitors, octreotide, and protease inhibitors are effective in preventing post-ERCP pancreatitis and can be used in the clinic as appropriate.