Acute Pancreatitis

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Pancreatitis Inflammation of the pancreatic parenchy

ma Acute or Chronic

• Acute pancreatitis = A transient inflammation that resolves with or without complications

• Chronic pancreatitis = C ontinuous inflammati on

resulting in progressive anatomic and functiona l damage to the pancreas

Acute Pancreatitis Etiology

• Gallstones (45%)

• Alcohol abuse (35%) • Others (10%)

• Idiopathic (10%)

** Males (alcohol) > Females (choledocholithiasi

s)

Acute Pancreatitis

Pathophysiology

• Activation of digestive zymogens inside acinar cells

Acinar cell injury inflammatory cell recruitment + activation, generation + release of cytokines & other

mediators

Acute Pancreatitis Clinical Presentation

Mid epigastric abdominal pain Steady, boring pain Radiation to the left upper back

Anorexia, nausea ± vomiting ± diarrhea Low grade fever

Inflammation or secondary infection Presentations associated with complications

Shock Multi-system failure

Acute Pancreatitis Exam Findings

• Abdominal tenderness

• Fever (76%)

• Abdominal guarding (68%)

• Abdominal distension (65%)

• Tachycardia (65%)

• Hypoactive bowel sounds

• Jaundice (28%)

• 10Dyspnea ( %)

• ccccccc c(

10%)

• cc ccc cccc cccc c(

5%)

• cccc’

• c ccc-cccccc cccc • cccc ccccccc cccccccc

Acute Pancreatitis Cullen’s sign cccc-cccccc cccc

Investigation

Diagnosis: Biochemical Serum Amylase

elevated Nonspecific Returns to normal in

48-72 hours Normal amylase

does not exclude pancreatitis

Level of elevation does not predict disease severity

Serum Lipase elevated Specific for

pancreatic disease Returns to normal in

7-14 days Serum Electrolytes

Hypocalcemia (25%) Hyperglycemia

Complete Blood Count (CBC)

White Blood Cells increased to 15k-20k

Lipids Elevated Hypertriglyceridemia

Liver Function Tests Serum Bilirubin

elevated ALT elevated AST Hypoalbuminemia

(Poor prognosis) Lactate

Dehydrogenase (LDH) elevated (Poor prognosis)

Diagnosis Ultrasound - Most useful initial test for gallstone

etiology Dynamic contrast-enhanced CT

(CECT) - the imaging modality of choice for

diagnosis, staging, and detection of

complications of acute pancreatitis.

Severity assessment

APACHE II SCORE

Ranson's criteria On admission 

Age > 55 yrs WCC > 16,000 LDH > 600 U/l AST >120 U/l Glucose > 10

mmol/l

Within 48 hours Haematocrit fall

>10% Urea rise >0.9

mmol/l Calcium < 2 mmol pO2 < 60 mmHg Base deficit > 4 Fluid sequestration

> 6L

Mortality correlates with number of criteria

0-2 1% 3-4 15% 5-6 40% 7-8 100%

Ranson c - riteria prognosis

CT Severity index serial CT scans are important for following

the progression of the disease and for detecting additional complications.

In Balthazar’s series

Complication

Acute Pancreatitis

Mild Severe Overall mortality 10 -15% - severe disease as high as 30%

Severe Acute Pancreatitis - Definition

1. Organ failure • Shock, pulmonary insufficiency, renal fail

ure, GI bleeding

2. Local complications • Pseudocyst, abscess, pancreatic necrosis

3. >= 3 Ranson criteria 30Overall mortality % , (), ()

Local Complications

• - Peri pancreatic fluid collections • 57% of patients

• -Initially ill defined • Usually managed conservatively

• Pseudocysts • Pancreatic necrosis

Acute pseudocyst

Pancreatic necrosis

Peripancreatic and retroperitoneal edema

Treatment

Treatment of acute pancreatitis

Supportive Eliminating of oral intakeIntravenous hydrationParenteral analgesiaNG suction : ileus or severe vomitingCollection of electrolyte and glucose

abnormalities vascular, respiratory and renal supportRemoval of factors : drug or alcohol

Surgical

Kelly and Wagner Pt who underwent surgery

earlier(<48hrs) had higher mortality and morbidity rates than those who underwent surgery later(>48hrs)

This finding was even more pronounced in those with severe pancreatitis

Surgical

Stone et al. No deference in mortality between Pt

randomly assigned to early biliary surgery (<72hr) and those assigned to late surgery(3mo after admission)

Surgery

The traditional indication for surgery acute abdomen

removal of impact stone from the CBD(emergency or elective)

Drainage of pancreatic fluid collections

Debridement of necrotic tissue

Antibiotics

Three early controlled trials Ampicillin did not change the course

of mild acute alcoholic pancreatitis Imipenem reduced the incidence of

pancreatitis sepsis in pt with necrotizing pancreatitis

Inhibiting pancreatic secretion Cimetidine Atropine Calcitonin Glucagon Somatostatin Fluororacil

not been shown to change the course of the disease

Summary No specific treatment for acute

pancreatitis Supportive therapy Vigorous intravenous hydration Parenteral analgesia Collection of electrolyte and glucose

abnormalities and vascular, respiratory and renal support

Summary The use of antiproteases and inhibitor of

pancreatic secretion cannot be recommended

Immediate endoscopic removal of impacted stones in pt with severe disease appears to reduce morbidity

Summary Controlled studies are needed to

demonstrate whether debridement of sterile necrotic tissue improve outcome

Infected necrotic tissue and infected collections of fluid are best treated by surgical debridement