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
