Acute Pancreatitis
Presented By:
Dr. Arif
Gen. Surgery Department
Capital Hospital
Islamabad
Objectives
Introduction
Definition
Aetiology & Pathogenesis
Signs & Symptoms
Investigations
Management
Complications
Mortality
Anatomy
PancreasAll Flesh
Soft, lobulated
elongated gland
with both
exocrine and
endocrine
functions
Exocrine
pancreatic juice
Endocrine-insulin
Location
epigastric & left
hypochondriac
regions
behind the
stomach and
lesser sac
Transversely across
the posterior
abdominal wall at
the level of the L2
&L3
Shape, Size and Parts
J shaped or
retort
shaped.
Length-15-
20 cm
Thickness-
1.2-1.8 cm
Wt-90 gm
Ducts system
Exocrine
part of
pancreas is
drained by
the 2 ducts
Main
Accessory.
Endocrine Portion
Islets
of
Langerhans
Pancreatitis
Inflammation of the pancreatic parenchyma.
Types:
1. Acute: Emergency condition.
2. Chronic: Prolonged & frequently lifelong
disorder resulting from the development of
fibrosis within the pancreas.
Acute Pancreatitis
Definition:
Acute condition of diffuse pancreatic
inflammation & autodigestion, presents with
abdominal pain, and is usually associated
with raised pancreatic enzyme levels in the
blood & urine.
Reversible inflammation of
the pancreas
Ranges from mild to severe.
Etiology
80% of the cases are due to gallstones &
alcohol.
The remaining 20 % of cases are due to:
1. Congenital: Pancreatic divisum
2. Metabolic: Hyperlipidemia, Hypercalcemia.
3. Toxic: Scorpion venom
4. Infective: Mumps, Coxsackie B, EBV, CMV.
5. Drugs: Azathioprine,
Sulfonamides, Steroids,
Thiazides, Estrogens.
6. Vascular: Ischemia,
Vasculitis (SLE, PAN).
7. Autoimmune:
Hereditary pancreatitis.
8. Traumatic.
9. Miscellaneous: CF,
Hypothermia,
Periampullary Tumors.
10. Idiopathic.
Mnemonic for the causes of Acute
Pancreatitis:
I get smashed
Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion / Snakes
Hyperlipidaemia / Hypercalcaemia
ERCP
Drugs
Biliary
Pancreatitis:
1. Common channel
theory
2. Incompetent
sphincter of Oddi
3. Obstruction of
the pancreatic
duct
Alcoholic Pancreatitis:
- Direct toxic effect on the pancreatic
acinar cells
- Stimulation of the pancreatic
secretion
- Constriction of the sphincter of
Oddi
Symptoms
Upper Abdominal pain,
sudden onset, sharp,
severe, continuous,
radiates to the back,
reduced by leaning
forward.
Generalized abdominal
pain, radiates to the
shoulder tips. Patient lies
very still.
Nausea, non-projactile
vomiting, retching
Anorexia
Fever, weakness
Signs
Distressed, moving continuously, or sitting still
Pale, diaphoretic. Confusion
Low grade fever
Tachycardia, Tachypnea
Shallow breathing
Hypotension
Mild icterus
Abdominal distension (Ileus, Ascites)
Grey Turners sign, Cullens sign, Foxs sign
Rebound tenderness, Rigidity
Shifting dullness, reduced bowel sounds
Cullens Sign Grey
Turners Sign
Foxs Sign
Differential Diagnosis
Perforated viscus (DU)
Acute cholecystits, Biliary colic
Acute intestinal obstruction
Esophageal rupture
Mesenteric vascular obstruction
Renal colic
Dissecting aortic aneurysm
Myocardial infarction
Basal pneumonia
Diabetic ketoacidosis
Investigation
s
Should be aimed at answering
three questions:
1. Is a diagnosis of acute pancreatitis correct ?
2. How severe is the attack ?
3. What is the aetiology ?
Investigations
Blood tests:
Complete Blood Count
Serum amylase & lipase
C-reactive Protein
Serum electrolytes
Blood glucose
Renal Function Tests
Liver Function Tests
LDH
Coagulation profile
Arterial Blood Gas Analysis
Serum Amylase:
Sensitivity: 72%
Specificity: 99%
Released within 6-12 hours
of the onset, & Remains
elevated for 3-5 days.
Elevation 3X normal is
significant.
Serum Lipase:
More pancreatic-specific than s. Amylase.
Sensitivity: about 100% Specificity: 96%
Remains elevated longer than amylase (up
to week).
Useful in patients presenting late to the
physician.
S. Amylase tends to be higher in gallstone
pancreatitis
S. Lipase tend to be higher in alcoholic
pancreatitis
Imaging Investigations:
Plain erect chest X-ray: not
diagnostic on pancreatitis, but to rule out other
D/D
Pleural effusion, diffuse alveolar infiltrate
(ARDS)
Sentinel Loop Sign
Colon cut-off sign
CT Scan: not indicated in every patient,
only in:
1. Diagnostic uncertainty.
2. Severe acute pancreatitis.
3. Clinical deterioration, with multi-organ
failure, sepsis, progressive deterioration.
4. Local complications occurs (fluid collection,
pseuodocyst, pseudo-aneurysm).
Axial CT Scan: Peripancreatic
stranding (arrow). Multiple
gallstones in the gallbladder
Contrast-enhanced CT: acute
necrotising pancreatitis. Pancreatic
area of reduced enhancement,
peripancreatic edema and stranding
of the fatty tissue
Pancreatic pseudocyst
occupying the head of the
pancreas. The pancreatic duct
(arrow) is dilated
MRCP
Endoscopic Ultrasound,
MRCP: CBD stones detection, assessment
of pancreatic parenchyma. Not widely
available.
ERCP: CBD stones identification &
removal.
Urgent ERCP in severe acute gallstone
pancreatitis & signs of ongoing biliary
obstruction & cholangitis.
ERCP
Goals of Treatment
Aggressive supportive care
Decrease inflammation
Limit superinfection
Identify and treat complications
(of pancreatitis & its treatment)
Treat cause if possible
Conservative
Management
Gain IV access, obtain blood sample, rapid
fluid resuscitation & electrolytes replacement.
Keep the patient NPO
Give analgesics.
Give Anti-emetics.
NGT insertion to relieve vomiting.
Urinary catheterization
Monitor the vital signs.
Injection Ranitidine 50 mg IV 8 hourly, or
Omeprazole 40 mg IV BD.
Somatostatin or octreotide (pancreatic
secretions inhibitors).
Respiratory support: oxygen supplementation,
or Venti mask
ICU admission if severe acute pancreatitis.
Role of Antibiotics
Prophylactic antibiotics have shown No
decrease in mortality in severe acute
pancreatitis.
Antibiotics are justified if:
1. Gas in retroperitoneal space
2. Needle aspiration of necrotic material confirms
infection
3. Sepsis
4. CRP of 120 mg/L
5. Peri-pancreatic fluid collection
6. Organ dysfunction
Operative Management
Surgery has no immediate role in acute
pancreatitis.
Aggressive surgical pancreatic debridement
(Necrosectomy) should be undertaken soon
after confirmation of the presence of
infected necrosis.
Pseudocyst: Cystogastrostomy,
Cystodudenostomy, Roux-en-Y
cystojejunostomy.
Complications
Complications
Systemic Complications:
Cardiovascular: Shock, Arrhythmias, Pericardial
effusion
Pulmonary: Basal atelactasis, pleural effusion, ARDS
Renal: ATN, Renal failure
Haematological: DIC
Metabolic: Hypocalcemia, Hyperglycemia,
Hyperlipidemia
GIT: Ileus
Neurological: Confusion, Irritability, Encephalopathy
Miscellaneous: Subcutaneous fat necrosis,
Arthralgia
Pancreatic
Pseudocyst:
Wall formed by granulation
tissue & fibrosis
typically presents as
abdominal pain, abdominal
mass, & persistent
hyperamylasemia in a
patient with prior
pancreatitis.
Transgastric Endoscopic
Pseudocyst Drainage
Mortality
Mild acute pancreatitis: Mortality
rate of 1%
Severe pancreatitis: Mortality
rate of 75-90%
Overall mortality rate of 15-20%