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Download MBBS General Surgery PPT 2 Acute And Chronic Pancreatitis Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) General Surgery PPT 2 Acute And Chronic Pancreatitis Lecture Notes

This post was last modified on 07 April 2022


Acute and Chronic Pancreatitis

Acute pancreatitis
Acute pancreatitis

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Interstitial pancreatitis



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Necrotising pancreatitis

Interstitial pancreatitis
Necrotizing pancreatitis

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Etiology

Common Causes

? Gallstones

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? Alcohol

? Hypertriglyceridemia

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? ERCP

? Trauma

? Postoperative

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? Drugs (azathioprine, 6-mercaptopurine, sulfonamides, estrogens,

tetracycline, valproic acid, anti-HIV medications)

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? Sphincter of Oddi dysfunction
Etiology

Uncommon Causes

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? Vascular causes and vasculitis (ischemic-hypoperfusion states after

cardiac surgery)

? Connective tissue disorders

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? TTP

? Cancer of the pancreas

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? Hypercalcemia

? Periampullary diverticulum

? Pancreas divisum

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? Hereditary pancreatitis

? Cystic fibrosis

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? Renal failure

Etiology

? Rare Causes

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? Infections (mumps, coxsackievirus, cytomegalovirus, echovirus, parasites)

? Autoimmune (e.g., Sj?gren's syndrome)

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? Causes to Consider in Patients with Recurrent Bouts of Acute Pancreatitis without an Obvious

Etiology

? Occult disease of the biliary tree or pancreatic ducts, especial y microlithiasis, sludge

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? Drugs

? Hypertriglyceridemia

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? Pancreas divisum

? Pancreatic cancer

? Sphincter of Oddi dysfunction

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? Cystic fibrosis

? Idiopathic
Pathophysiology

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? In pancreatic parenchyma

Proteolytic

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? endotoxins, exotoxins, viral infections, ischemia,

enzymes

anoxia, lysosomal calcium, and direct trauma

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activated

? Activated proteolytic enzymes digest pancreatic and

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peri pancreatic tissues

Autodigestion ? also activate elastase and phospholipase A2


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Acute Pancreatitis

IL-1

TNF

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Other leucocyte

products

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IL-6

Oxygen radicals

IL-8

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Elastase

IFN-,

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N.O.

PAF

IL-10

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IL-2

Complications:

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?Vascular leakage

?Hypovolemia

?Shock

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?ARDS

?Acute renal tubular necrosis
Clinical features

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? Abdominal pain
? Nausea, vomiting, and abdominal distention
? Low-grade fever
? Tachycardia

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? Hypotension
? Jaundice
? Erythematous skin nodules
? Atelectasis, pleural effusion

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? Abdominal tenderness and muscle rigidity
? Diminished bowel sounds
? A faint blue discoloration around the umbilicus (Cullen's sign) may

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occur as the result of hemoperitoneum

? Blue-red-purple or green-brown discoloration of the flanks (Turner's

sign) reflects tissue catabolism of hemoglobin

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? Grey Turner sign

? Cullen's sign
Workup

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Laboratory Data

? serum amylase and lipase
? >threefold clinch the diagnosis

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? No correlation between the severity and the degree of elevation
? After three to seven days, values tend to return toward normal
? Pancreatic isoamylase and lipase levels may remain elevated for 7 to

14 days

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Markers of Severity within 24 Hours

? SIRS [temperature >38? or < 36?C, Pulse > 90, Tachypnea > 24, WBC > 12,000]

? Hemoconcentration (Hct >44%)

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? BISAP (bedside index of severity in acute pancreatitis)

? (B) Blood urea nitrogen (BUN) >22 mg%

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? (I) Impaired mental status

? (S) SIRS: 2/4 present

? (A) Age >60 years

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? (P) Pleural effusion

? Organ Failure

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? Cardiovascular: systolic BP <90 mmHg, heartrate >130

? Pulmonary: Pao2 <60 mmHg

? Renal: serum creatinine >2.0 mg%

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? Gastrointestinal: bleeding >500 mL/24 hours

Severity

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? Risk Factors

? Age > 60 years

? Obesity, BMI > 30

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? Comorbid disease

? Markers during Hospitalization

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? Persistent organ failure

? Pancreatic necrosis

? Hospital-acquired infection

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Laboratory Data

? Leukocytosis (15,000?20,000 leukocytes per L)
? Hemoconcentration

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? with hematocrit values >44%

? and/or blood urea nitrogen (BUN) level >22 mg/Dl

? Hyperglycemia

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? decreased insulin release,

? increased glucagon release,

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? increased output of adrenal glucocorticoids and catecholamines.

? Hypocalcemia

Laboratory Data

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? Hyperbilirubinemia (>4.0 mg/dL) in 10%

? is transient

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? return to normal in four to seven days

? Serum alkaline phosphatase and aspartate aminotransferase levels

are also transiently elevated

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? Elevated serum lactic dehydrogenase levels (>500 U/dL)
? Hypertriglyceridemia occurs in 5?10%
? Hypoxemia (arterial Po2 60 mmHg), which may herald the onset of

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ARDS

? Electrocardiogram ST-segment and T-wave abnormalities simulating

myocardial ischemia.

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RADIOLOGY

? CXR

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? Sympathetic pleural effusion

? Atelectasis

? A.R.D.S.

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? AXR

? Sentinal loop

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? Colon cutoff sign

? Duodenal ileus

? Calcifications

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? Obscured psoas lines

? 79% will have radiological signs !!!
CT Findings and Grading of Acute Pancreatitis

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[CT Severity Index (Ctsi)]

Grade Findings

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Score

A

Normal pancreas: normal size, sharply defined, smooth

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0

contour, homogeneous enhancement, retroperitoneal
peripancreatic fat without enhancement

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B

Focal or diffuse enlargement of the pancreas, contour

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1

may show irregularity, enhancement may be

inhomogeneous but there is no peripancreatic

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inflammation

C

Peripancreatic inflammation with intrinsic pancreatic

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2

abnormalities

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D

Intrapancreatic or extrapancreatic fluid col ections

3

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E

Two or more large col ections or gas in the pancreas or

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4

retroperitoneum

Necrosis score based on contrast-enhanced CT

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Necrosis (%)

Score

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0

0

<33%

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2

33-50%

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4

>50%

6

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CT severity index equals unenhanced CT score

plus necrosis score; 6 = severe disease.

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CT Scan of acute pancreatitis

? CT shows
significant

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swelling
and
inflammation
of the
pancreas

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Diagnosis

? Requires two of the following:

? typical abdominal pain,

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? threefold or greater elevation in serum amylase

and/or lipase level,

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? and/or confirmatory findings on cross-sectional

abdominal imaging.

Differential diagnosis

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? (1) perforated viscus, especial y peptic ulcer

? (2) acute cholecystitis and biliary colic

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? (3) acute intestinal obstruction

? (4) mesenteric vascular occlusion

? (5) renal colic

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? (6) myocardial infarction

? (7) dissecting aortic aneurysm

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? (8) connective tissue disorders with vasculitis

? (9) pneumonia

? (10) diabetic ketoacidosis

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Complications

Local complications

? Necrosis

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? Sterile

? Infected

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? Walled-off necrosis

? Pancreatic fluid collections

? Pancreatic abscess

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? Pancreatic pseudocyst

? Pain

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? Rupture

? Hemorrhage

? Infection

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Local complications

? Obstruction of gastrointestinal tract (stomach, duodenum, colon)
? Pancreatic ascites

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? Disruption of main pancreatic duct

? Leaking pseudocyst

? Involvement of contiguous organs by necrotizing pancreatitis

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? Massive intraperitoneal hemorrhage

? Thrombosis of blood vessels (splenic vein, portal vein)

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? Bowel infarction

? Obstructive jaundice

Systemic complications

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? Pulmonary

? Pleural effusion

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? Atelectasis

? Mediastinal abscess

? Pneumonitis

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? Acute respiratory distress syndrome

? Cardiovascular

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? Hypotension

? Hypovolemia

? Sudden death

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? Nonspecific ST-T changes in electrocardiogram simulating myocardial infarction



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Systemic complications

? Hematologic

? Disseminated intravascular coagulation

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? Gastrointestinal hemorrhage

? Peptic ulcer disease

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? Erosive gastritis

? Hemorrhagic pancreatic necrosis with erosion into major blood vessels

? Portal vein thrombosis, variceal hemorrhage

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? Renal

? Oliguria

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? Azotemia

? Renal artery and/or renal vein thrombosis

? Acute tubular necrosis

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Systemic complications

? Metabolic

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? Hyperglycemia

? Hypertriglyceridemia

? Hypocalcemia

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? Encephalopathy

? Sudden blindness (Purtscher's retinopathy)

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? Central nervous system

? Psychosis

? Fat emboli

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? Fat necrosis

? Subcutaneous tissues (erythematous nodules)

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? Bone

? Miscel aneous (mediastinum, pleura, nervous system)
HOW DO WE DETERMINE PROGNOSIS?

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? 80% Will recover without any complications
? 20% Will develop severe cardio-pulmonary complications or septic

complications

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? Prognostic assessment :

? Ranson

? Imrie

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? APACHE 2

? CRP

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? Classify into mild or severe acute pancreatitis ( Atlanta classification

1992)

Treatment

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? To limit severity of pancreatic inflammation

? To interrupt the pathogenesis of complications

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? To support the patient and treat complications
TREATMENT

? NON-OPERATIVE

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? To limit severity of pancreatic inflammation

? Inhibition of pancreatic secretion

? Nasogastric suction

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? Pharmacologic

? Hypothermia

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? Pancreatic irradiation

? Inhibition of pancreatic enzymes

? Corticosteroids

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? Prostaglandins

TREATMENT

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? To interrupt the pathogenesis of complications

? Antibiotics

? Antacids

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? Heparin

? Low molecular weight dextran

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? Vasopressin

? Peritoeal lavage
TREATMENT

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? To support the patient and treat complications

? Restoration and maintenance of intravascular volume

? Electrolyte replacement

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? Respiratory support

? Nutritional support

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? Analgesia

? Heparin

When to operate?

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? Diagnostic laparotomy

? To limit the severity of the pancreatic inflammation

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? Biliary procedures

? To interrupt the pathogenesis of complications

? Pancreatic drainage

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? Pancreatic resection

? Pancreatic debridement

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? Peritoneal lavage

? To support the patient and treat complications

? Drainage of pancreatic infection

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? Feeding jejunostomy

? To prevent recurrent pancreatitis
Summary of treatment

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? All patients

? Nasogastric suction

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? NPO

? Monitor and maintenance of intravascular volume

? Respiratory monitoring and support

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? Antibiotics(selective)

? Early laparotomy only fordiagnosis

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? Estimate prognosis by early signs

? Patients with severe pancreatitis

? Peritoneal lavage

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? Nutritional support

? Suspect and treat pancreatic sepsis

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? Heparin if hypercoagulable

Chronic Pancreatitis

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Definition and Prevalence

? Defined as chronic inflammatory condition that causes irreversible

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damage to pancreatic structure and function.

? Incurable
? 5 To 27 Persons Per 100,000

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Etiology

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? Alcohol, 70%
? Idiopathic (including tropical), 20%
? Other, 10%

? Hereditary

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? Hyperparathyroidism

? Hypertriglyceridemia

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? Autoimmune pancreatitis

? Obstruction

? Trauma

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? Pancreas divisum

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Classification:

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1.Calcific pancreatitis

2. Obstruction pancreatitis
3. Inflammatory pancreatitis

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4. Auto immune pancreatitis
5. Asymptomatic fibrosis
6. Tropical pancreatitis
7. Hereditary pancreatitis
8. Idiopathic pancreatitis

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Signs and Symptoms

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? Steady and Boring Pain
? Not Colicky
? Nausea /Vomiting
? Anorexia- Most Common
? Malabsorption And Weight Loss

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? Diabetes Mellitus

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? Classic triad " pancreatic calcification , steatorrhea , and diabetes

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mellitus"

? Found in <1/3
? secretin stimulation test (abnormal when 60% or more of pancreatic

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exocrine function has been lost)

? decreased serum trypsinogen (<20ng/ml) or a fecal elastase level of

<100ug/mg of stool strongly suggests severe pancreatic insufficiency

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Laboratory Studies

Tests for Chronic Pancreatitis

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I. Measurement of pancreatic products in blood
A. Enzymes
B. Pancreatic polypeptide
I . Measurement of pancreatic exocrine secretion
A. Direct measurements

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1. Enzymes
2. Bicarbonate
B. Indirect measurement
1. Bentiromide test
2. Schil ing test

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3. Fecal fat, chymotrypsin, or elastase concentration
4. [14C]-olein absorption

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Imaging techniques

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? A. Plain film radiography of abdomen
? B. Ultrasonography
? C. Computed tomography
? D. ERCP

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? E. MRCP
? F. EUS

? Plain films :

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? Pancreatic calcifications : 30%

? most common with alcoholic

pancreatitis

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Pancreatic calcifications. CT scan showing

multiple, calcified, intraductal stones in a

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patient with hereditary chronic pancreatitis

Endoscopic retrograde

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cholangiopancreatography in chronic

pancreatitis. The pancreatic duct and its

side branches are irregularly dilated

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CT features

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? Pancreatic atrophy,

calcifications, and main

pancreatic duct dilation

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ERCP

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? ERCP is a highly sensitive

radiographic test for CP

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MRCP

? MRCP allows a noninvasive

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alternative to ERCP for imaging

the pancreatic duct.

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EUS

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EUS is a minimally invasive test that allows simultaneous assessment

of ductal and parenchymal structure

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Treatment
? Analgesia
? Enzyme Therapy
? Antisecretory Therapy

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? Neurolytic Therapy
? Endoscopic Management
? Surgical Therapy

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Complications
? Pseudocyst
? Pancreatic Ascites

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? Pancreatic-Enteric Fistula
? Head-of-Pancreas Mass
? Splenic and Portal Vein Thrombosis

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62


Management

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A 45-year-old man presents to the emergency room complaining of severe

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epigastric pain that radiates to his back and left scapula. He has had severe nausea

and vomiting associated with the pain for 3 days. Nothing seems to relieve his pain.

He drinks about a fifth of bourbon a day. He has not had a bowel movement in

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several days. He also complains of a very dry mouth. He is afebrile and

normotensive with a heart rate of 110 beats/min. He is mildly tender on abdominal

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examination. His serum amylase level is 650 IU/L. Which of the following is the

most appropriate initial step in the management of this patient?

(A) Exploratory laparotomy and pancreatic d?bridement

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(B) Discharge and close follow up as outpatient

(C) Obtain an abdominopelvic computed tomography (CT) scan

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(D) Perform esophagogastroduodenoscopy (EGD)

(E) Admit for intravenous (IV) hydration and withhold oral feeding
A 48-year-old, alcoholic male has been hospitalized over the last 20 years

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more than 30 times for episodes of acute pancreatitis. He now presents to

the emergency department complaining of mid-back pain and horribly

malodorous and frequent soft stools. He describes that the stools float in the

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toilet. He also explains that he has lost 30 lb over the last 6 months. Which of

the fol owing therapeutic measures is the best option to improve this

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patient's health maintenance?

(A) Total pancreatectomy

(B) Oral pancreatic enzyme replacement

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(C) Total parenteral nutrition

(D) Octreotide therapy

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(E) High-fat diet