Dr Ahmad abanamy hospital Dr Nuaman danawar general& gastrointestinal surgeon

1. Dr Ahmad abanamy hospitalDr Nuaman danawargeneral& gastrointestinal surgeon

2. Acute Pancreatitis

3. Etiology: • • Gallstones - 45% of cases. • • Ethanol - 35% cases. • • Trauma. • • Steroids. • • Mumps. • • AUI - SLE, panarteritis. • • Scorpion venom - native species to Trinidad. • • Hyperlipidaemia, hypercalcaemia (calcium activates trypsinogen). • • ERCP, abdominal surgery. • • Drugs -azathioprine, NSAID, furosemide, sulphonamides.

4. Presentation: • • Pain - severe acute epigastric, radiating to the back possibly relieved by leaning • forward. • • SIRS - systemic inflammatory response syndrome. • • Vomiting. • • Loss of appetite. • • Eponymous signs: • • Grey-Turner's - flank bruising secondary to retroperitoneal haemorrhage • tracking from anterior para-renal space to the lateral edge of quadratus • lumborum. • • Cullen's - peri-umbilical oedema and bruising secondary to pancreatic enzyme • tracking, via the gastrohepatic and falciform ligament to the anterior abdominal • wall. • • Note: Both take 24-48 hours to appear and are associated with a poorer • prognosis.

5. Investigations: • • Bedside - ECG, urine dipstick, BM. • • Blood - FBC, LFTs, Electrolytes, Calcium, Urea, Albumin, Glucose. • • Amylase - above 3 times normal level (i.e. >300) supports diagnosis. Level is not an • indicator of severity and can be normal on admission. In acute on chronic pancreatitis • amylase increase is often absent. • • Lipase - can also be used and stays elevated longer. • • CRP - > 150 indicates severe pancreatitis. • • Arterial blood gas - pH, P02, Lactate. • • Imaging: • • USS - check for gallstones. • • CT/ MRI - can be used to judge severity/complications. • • ERCP - if gallstones present can be used to further delineate and provides intervention • through sphincterotomy.

6. Prognostic score • Modified Glasgow Criteria • • Used in both gallstone and alcohol related pancreatitis. • • Both on admission and after 48hrs. • • Mortality score <2 = 1%, 3-4 = 15%, >6 = almost 100% • • Scoring: • • P02 < 8kpa • • Age >55 • • Neutrophils (WCC) >15 • • Calcium <2 mmol/l • • Renal: Urea >16 mmol/l • • Enzymes: AST>200 IU/l, LDH > 600 IU/l • • Albumin <32 g/dl • • Sugar: Glucose >10mmol/l

7. Ranson • • 2 versions for alcohol and gallstone aetiology. • • Based on score at admission and 48 hours after. • • Similar mortality scoring to modified Glasgow criteria. • • Alcohol: • • At admission: • • Age > 55 years • • WCC > 16 • • Glucose > 10 mmol/L • • AST > 250 IU/L • • LDH > 350 IU/L • • At 48 hours: • • Calcium < 2.0 mmol/L • • Hematocrit fall > 10% • • PO2 < 6 Kpa • • BUN increased by 1.8 or more mmol/L after IV fluid hydration • • Base deficit > 4 mEq/L • • Sequestration of fluids > 6

8. • Gallstones: • • At admission: • • Age > 70 years • • WCC> 18 • • Glucose > 12.2 mmol/L • • AST > 250 IU/L • • LDH > 400 IU/L • • At 48 hours: • • Calcium < 2.0 mmol/L • • Hematocrit fall > 10% • • Oxygen PO2 < 6 Kpa • • BUN increased by 1.8 or more mmol/L after IV fluid hydration • • Base deficit > 5 mEq/L • • Sequestration of fluids > 4 L

9. Management • Mainly conservative/supportive: • 1. Close monitoring. • 2. Oxygen - maintain saturations above 95%. • 3. IV fluid resuscitation: • • Manages distributive shock and therefore reduces complications/organ failure. • • Maintain urine output above 0.5ml/(kg/hr). • • Note: Some advocate the avoidance of lactate containing solutions. • 1. Analgesia • 2. PPI • 3. Anti-thrombotic • 4. Moderate to severe - HDU/ITU admission for continuous monitoring and organ • support. • 5. Nutrition - enteral or parenteral. • 6. Treat cause e.g. ERCP and sphincterotomy for gallstones. • 7. Role of antibiotics - rarely indicated unless infectious aetiology or concomitant • infection.

10. Balthazar • • Uses CT appearance to grade severity: • • Grade A – normal CT • • Grade B – focal or diffuse enlargement of the pancreas • • Grade C – pancreatic gland abnormalities and peripancreatic inflammation • • Grade D – fluid collection in a single location • • Grade E – two or more collections and/or gas bubbles in or adjacent to pancreas • APACHE-II - acute physiology and chronic health evaluation • • Severity of disease scoring system used on ITU admission. • • Score > 8 = severe.

11. Surgical: • 1. Necrosectomy - resection of necrotic pancreas can be open or laparoscopic. +/- • 1. Open - Laparoscopies for serial resections, drainage, abdominal • decompression and lavage. • 2. Closed - Large drains post resection for lavage, drainage particularly of less • sac.

12. Complications: • • Local: • • Peri-pancreatic fluid collection. • • Pseudocyst - collection of sterile fluid within lesser sac. • • Abscess - either pancreatic or peri-pancreatic. • • Necrosis/gangrene. • • Splenic vein thrombosis (note also drains pancreas and in close contact posteriorly)

13. • Systemic: • • Organ failure: • • Renal - hypovolaemia + direct damage from vasoactive peptides and • inflammatory mediators. • • Respiratory - ARDS, pleural effusions (transudative - low albumin or exudative - • inflammatory mediators). • • Cardiac - hypovolaemia, arrhythmias. • • Liver • • Haematological - DIC • • Metabolic: • • Hyperglycaemia • • Hypocalcaemia - saponification of calcium salts, reduced PTH, calcitonin release. • • Intestinal - haemorrhage, ileus. • • Death - 10%