acute pancreatitis
TRANSCRIPT
Acute Pancreatitis
Shiwani Kamath
Acute Pancreatitis
• Inflammation of the gland parenchyma of the pancreas
• Acute condition presenting with abdominal pain and is usually associated with raised pancreatic enzyme levels in the blood or urine as a result of pancreatic inflammation
PathogenesisDefective intracellular transport and secretion of pancreatic zymogens
Pancreatic duct obstruction
Hyperstimulation of pancreas
Reflux of infected bile or duodenal contents into pancreatic duct
Proenzymes
Activated proteolytic enzymes
Acute Pancreatitis
(-) Pancreatic secretory trypsin inhibitors
Etiology
Common (90% of cases)– Gallstones– Alcohol– Post-ERCP– Idiopathic
Rare– Post-surgical– Trauma– Drugs– Metabolic– Pancreas divisum– Sphincter of Oddi dysfunction– Infection – Hereditary– Renal failure– Organ Transplantation– Severe hypothermia– Petrochemical exposure
Clinical FeaturesSymptoms
• Severe, constant upper abdominal pain – with increasing intensity over 15-20 minutes– radiating to back
• Nausea and vomiting
• Abdominal distension
Clinical FeaturesSigns
• Epigastric tenderness with guarding and rebound (later)
• Decreased/absent bowel sounds• Grey Turner’s Sign: Discoloration of the flanks• Cullen’s Sign: Discoloration of the periumbilical
region• Small, red, tender nodules on the skin of the legs• Abdominal distension – shifting dullness• Signs of pleural effusion
Clinical FeaturesCullen’s Sign
Clinical FeaturesTurner’s Sign
Complications Pancreatic
• Acute Fluid Collection• Pseudocyst• Abscess• Necrosis• Pancreatic Ascites and Effusion
ComplicationsSystemic and Other Systems
Systemic• Systemic inflammatory
response syndrome• Hypoxia• Hypergylcemia• Hypocalcemia• Reduced serum albumin
concentration• DIC
Gastrointestinal• Hemorrhage• Portal/Splenic Vein
Thrombosis• Erosion into colon• Duodenal Obstruction• Obstructive jaundice • Paralytic Ileus
Investigations• Serum amylase (N: 23-85 IU/L)• Serum lipase (N: 0 – 160 IU/L)• Ultrasound– Confirms diagnosis– Shows gallstones, biliary obstruction, pseudocyst
• Contrast enhanced CT– 6-10 days after admission– Decreased pancreatic enhancement – necrotizing– Gas within necrotic material – infection, abscess– Other organ involvement
Acute Pancreatitis
Normal Pancreas
CT Findings
Tail Indistinct
Intraperitoneal fluid
PANCPANCLIVERLIVER
CT FindingsSevere Pancreatitis
Peripancreatic edemaand inflammation
Necrosis(less enhancement)PANC
PANCLIVERLIVER
GBGB
• CBC: leucocytosis• Electrolyte abnormalities include hypokalemia,
hypocalcemia• Elevated LDH in biliary disease• Glycosuria ( 10% of cases)• Hyperglycaemia in severe cases• Serum phosphate• LFTs• RFTs• C – Reactive Protein - elevated
Routine
To rule out other conditionsi.e. perforated ulcer disease.
Nonspecific findings-cutoff colon sign gaseous distension seen in
proximal colon associated with narrowing of the splenic flexure
-Widening of the duodenal C loop caused by severe pancreatic head edema
Complications of lung such as pleural effusion, pulmonary edema and interstitial inflammation.
X ray
MANAGEMENT
• Establish the diagnosis• Assess severity• Early Treatment (Resuscitation)• Detection and Treatment of Complications• Treating Underlying Cause
MANAGEMENTSteps
• RANSON’S CRITERIA• MODIFIED GLASGOW CRITERIA• Acute Physiology and Chronic Health
Evaluation (APACHE II)
MANAGEMENTAssessment of Severity of Disease
• RANSON’S CRITERIA• MODIFIED GLASGOW CRITERIA• Acute Physiology and Chronic Health
Evaluation (APACHE II)
MANAGEMENTAssessment of Severity of Disease
Non-gallstone pancreatitis, the parameters are:At admission:•Age in years > 55 years•White blood cell count > 16000 cells/mm3
•Blood glucose> 10 mmol/L (> 200 mg/dL)•Serum AST > 250 U/L•Serum LDH > 700 U/L
Within 48 hours:•Serum calcium < 2.0 mmol/L (< 8.0 mg/dL)•Oxygen (hypoxemia PaO2 < 60 mmHg)•BUN increased by 1.8 or more mmol/L (5 or more mg/dL) after IV fluid hydration•Base deficit (negative base excess) > 4 mEq/L•Sequestration of fluids > 6 L
MANAGEMENTRanson’s Criteria
Gallstone pancreatitis, the parameters are:At admission:•Age in years > 70 years•White blood cell count > 18000 cells/mm3
•Blood glucose > 12.2 mmol/L (> 220 mg/dL)•Serum AST > 250 IU/L•Serum LDH > 400 IU/L
Within 48 hours:•Serum calcium < 2.0 mmol/L (< 8.0 mg/dL)•Oxygen (hypoxemia PaO2 < 60 mmHg)•BUN increased by 1.8 or more mmol/L (5 or more mg/dL) after IV fluid hydration•Base deficit (negative base excess) > 5 mEq/L•Sequestration of fluids > 4 L
MANAGEMENTRanson’s Criteria
MANAGEMENTGlasgow’s
alanine
MANAGEMENTAPACHE II
• Initial Assessment– Clinical Impression– BMI > 30– Pleural Effusion (on CX-ray)– APACHE II Score > 8
• 24 Hours After Admission– Clinical Impression– APACHE II Score > 8– Glasgow > 3– Persisting Organ Failure– CRP > 150 mg/L
• 48 Hours After Admission– Clinical Impression– Glasgow > 3– Persisting, Multiple, and Progressive Organ Failure– CRP > 150 mg/L
MANAGEMENTFactors Predicting Severity within 48 hours of admission
• Intravenous fluid administration • Analgesics• Anti-emetics• Recommended brief period of fasting• Frequent, non-invasive observation
MANAGEMENTConservative Measures
• Admission to HDU or ICU• Analgesia• Aggressive fluid rehydration• Oxygen• Monitor Vitals, central venous pressure, urine output, blood gases• Monitor hematological and biochemical parameters• Nasogastric drainage• Antibiotic prophylaxis (imipem, cefuroxime)• CT scan• ERCP• Supportive therapy for organ failure• Nasogastric feeding for nutritional support
MANAGEMENTSevere Acute Pancreatitis
• Cholecystectomy within 2 weeks following resolution of pancreatitis
• Necrotising pancreatitis/Pancreatic Abscess– Endoscopic/surgical necresectomy
• Pseudocyst– Drainage into stomach, duodenum or jejunum– Endoscopic/Surgical– After 6 weeks
MANAGEMENTSurgical Management of Severe Pancreatitis
Thank You