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Presented By: Ehsan Arefnia June 2012

Acute & Chronic Pancreatitis. Presented By: Ehsan Arefnia June 2012. Anatomy. Retroperitoneal Organ Weighs 75 To 100 G 15 To 20 Cm Long Head Neck Body Tail. Physiology. Three General Functions: Neutralizing the acid chyme entering the duodenum from the stomach

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Presented By: Ehsan Arefnia June 2012

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  1. Acute & Chronic Pancreatitis Presented By: Ehsan Arefnia June 2012

  2. Anatomy Retroperitoneal Organ Weighs 75 To 100 G 15 To 20 Cm Long Head Neck Body Tail

  3. Physiology • Three General Functions: • Neutralizing the acid chyme entering the duodenum from the stomach • Synthesis and secretion of digestive enzymes after a meal • Systemic release of hormones that modulate metabolism of carbohydrates, proteins, and lipids

  4. Acute Pancreatitis

  5. Definition and Incidence • Inflammatory disease with little or no fibrosis • Initiated by several factors • Develop additional complications • 300,000 cases occur in the united states each year leading to over 3000 deaths

  6. Etiology • Biliary tract disease • Alcohol • Drugs • 30 meds identified • AIDS therapy: didanosine, pentamidine • Anti-inflammatory: sulindac, salicylates • Antimicrobials: metronidazole, sulfonamides, tetracycline, nitrofurantoin • Diuretics: furosemide, thiazides • IBD: sulfasalazine, mesalamine • Immunosuppressives: azathioprine, 6-mercaptopurine • Neuropsychiatric: valproic acid • Other: calcium, estrogen, tamoxifen, ACE-I • Hypertryglycerides • Greater than 1000 mg/dL • Trauma • External • pancreatic duct injury • Surgical • CABG, Organ transplant, ERCP, Billroth II, Splenectomy • Pancreatic duct obstruction • Neoplasms • Pancreas divisum • Ischemia • Hypoperfusion • Atheroembolic • Vasculitis • Ampullaryand duodenal lesions • Infections • Mumps, CMV, EBV, Coxaci, ECOV,HBV, Herpes • HIV • 35 to 800 times greater risk of AP c/w general pop. • Hypercalcemia • Most often secondary to hyperparathyroidism • Hereditary • Venom • Scorpion, spider, Gila Monster, lizard bites • Pregnancy • Third trimester until 6 weeks post partum • Chinese liver fluke • Cystic fibrosis

  7. Etiology: (GET SMASHED) G: Gallstone E: Ethanol T: Trauma S: Steroid M: Mump A: Alcoholism or Autoimmune S: Scorpion bits H: Hyperlipidemia E: ERCP D: Drugs

  8. Differential Diagnosis • Pancreatitis • Acute Cholecystitis • Cholangitis • Perforated Viscous • MI • Severe Pneumonia • Intestinal Obstruction • Ruptured Aaa • Diverticulitis • Bowel Ischemia • Appendicitis • Caecal Perforation • Ruptured Ectopic

  9. Clinical Presentation • Abdominal pain • Epigastric • Radiates to the back • Worse in supine position • Nausea and vomiting • Tachycardia, Tachypnea, Hypotension, Hyperthermia • Elevated Hematocrit • Cullen's sign • Grey Turner's sign

  10. Grey Turner sign Cullen’s sign

  11. serum amylase Nonspecific Returns to normal in 3-5 days Normal amylase does not exclude pancreatitis Level of elevation does not predict disease severity Urinary amylase P-amylase Serum Lipase Serum Electrolytes Hypocalcaemia (Poor prognosis) Hyperglycemia (Poor prognosis) Hypoalbuminemia CBC Increased Hb Thrombocytosis Leukocytosis Liver Function Test Serum Bilirubin elevated Alkaline Phosphatase elevated Aspartate Aminotransferase elevated Diagnosis: Biochemical

  12. Assessment of Severity • Ranson Criteria • Biochemical Markers • Computed Tomography Scan

  13. Admission Age > 70 WBC > 18,000 Glucose > 220 LDH > 400 AST > 250 During first 48 hours Hematocrit drop > 10 points Serum calcium < 8 Base deficit > 5.0 Increase in BUN > 2 Fluid sequestration > 4L Ranson CriteriaCriteria for acute gallstone pancreatitis <2 pos sign: mortality rate is 0 3-5 pos sign: mortality rate is 10 to 20% >7pos sign: mortality rate is >50%

  14. 50 year-old woman Stomach Pancreas Liver V A L Kidney R Kidney Spleen CT scans of normal kidneys and pancreas

  15. Gallstone-induced pancreatitis in 27 year-old woman Large, edematous, homogeneously attenuating pancreas (1). Peripancreatic inflammatory changes (white arrows). There is no pancreatic necrosis. Calcified gallstones are seen in gallbladder (black arrow)

  16. Pancreatic Necrosis

  17. Treatment of Mild Pancreatitis • Pancreatic rest • Supportive care • fluid resuscitation – watch BP and urine output • Pain Control • NG tubes and H2 blockers or PPIs are usually not helpful • Refeeding(usually 3 to 7 days) If: • Bowel Sounds Present • Patient Is Hungry • Nearly Pain-free (Off IV Narcotics) • Amylase & Lipase Not Very Useful

  18. Treatment of Severe Pancreatitis • Pancreatic Rest & Supportive Care • Fluid Resuscitation – may require 5-10 liters/day • Careful Pulmonary & Renal Monitoring – ICU • Maintain Hematocrit Of 26-30% • Pain Control – PCA pump • Correct Electrolyte Derangements (K+, Ca++, Mg++) • R/O necrosis • Contrasted CT scan at 48-72 hours • Prophylactic antibiotics if present • Surgical debridement if infected • Nutritional support • May be NPO for weeks • TPN vs. enteral support (TEN)

  19. Complications • Local • Phlegmon, Abscess, Pseudocyst, Ascites • Involvement of adjacent organs, with hemorrhage, thrombosis, bowel infarction, obstructive jaundice, fistula formation, or mechanical obstruction • Systemic • A. Pulmonary: Pneumonia, atelectasis, ARDS, Pleural Effusion • B. Cardiovascular: Hypotension, Hypovolemia, Sudden Death, Nonspecific ST-T wave changes, Pericardial effusion • C. Hematologic :Hemoconcentration, DIC • D. GI: Hemorrhage, Peptic ulcer, Erosive gastritis, Portal vein or splenic vein thrombosis with varices • E. Renal: Oliguria, Azotemia, Renal artery/vein thrombosis • F. Metabolic :Hyperglycemia, Hypocalcemia, Hypertriglyceridemia, Encephalopathy, Sudden Blindness (Purtscher's retinopathy) • G. CNS: Psychosis, Fat Emboli, Alcohol withdrawal syndrome • H. Fat necrosis: Intra-abdominal saponification, Subcutaneous tissue necrosis

  20. Acute Pseudocyst

  21. Management

  22. Chronic Pancreatitis

  23. Definition and Prevalence • Incurable, Chronic Inflammatory Condition • 5 To 27 Persons Per 100,000 • Fibrosis • Alcohol

  24. Etiology • Alcohol, 70% • Idiopathic (including tropical), 20% • Other, 10% • Hereditary • Hyperparathyroidism • Hypertriglyceridemia • Autoimmune pancreatitis • Obstruction • Trauma • Pancreas divisum

  25. Signs and Symptoms • Steady And Boring Pain • Not Colicky • Nausea Or Vomiting • Anorexia Is The Most Common • Malabsorption And Weight Loss • Apancreatic Diabetes

  26. Laboratory Studies

  27. Pancreatic calcifications. CT scan showing multiple, calcified, intraductal stones in a patient with hereditary chronic pancreatitis Endoscopic retrograde cholangiopancreatography in chronic pancreatitis. The pancreatic duct and its side branches are irregularly dilated

  28. Treatment • Analgesia • Enzyme Therapy • Antisecretory Therapy • Neurolytic Therapy • Endoscopic Management • Surgical Therapy

  29. Complications • Pseudocyst • Pancreatic Ascites • Pancreatic-Enteric Fistula • Head-of-Pancreas Mass • Splenic and Portal Vein Thrombosis

  30. Management

  31. References • Schwartz's Principles of Surgery, Ninth Edition • Sabiston Textbook of Surgery, 18th Edition. • WWW.UpToDate.COM • WWW.MDConsult.COM

  32. THANKE YOU Questions, If any….??

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