Interstitial pancreatitis
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Necrotising pancreatitisInterstitial pancreatitis
Necrotizing pancreatitis
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EtiologyCommon 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 dysfunctionEtiology
Uncommon Causes
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? Vascular causes and vasculitis (ischemic-hypoperfusion states aftercardiac 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 failureEtiology
? 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 ObviousEtiology
? 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 tissuesAutodigestion ? also activate elastase and phospholipase A2
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Acute PancreatitisIL-1
TNF
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Other leucocyte
products
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IL-6Oxygen 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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ScoreA
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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1may show irregularity, enhancement may be
inhomogeneous but there is no peripancreatic
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inflammationC
Peripancreatic inflammation with intrinsic pancreatic
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2
abnormalities
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DIntrapancreatic 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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4retroperitoneum
Necrosis score based on contrast-enhanced CT
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Necrosis (%)
Score
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00
<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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swellingand
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-sectionalabdominal 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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ComplicationsLocal 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 classification1992)
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 complicationsTREATMENT
? 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 hypercoagulableChronic 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 pancreatitis5. 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 Mellitus50
? 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 bloodA. Enzymes
B. Pancreatic polypeptide
I . Measurement of pancreatic exocrine secretion
A. Direct measurements
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1. Enzymes2. Bicarbonate
B. Indirect measurement
1. Bentiromide test
2. Schil ing test
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3. Fecal fat, chymotrypsin, or elastase concentration4. [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 chronicpancreatitis. 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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57MRCP
? MRCP allows a noninvasive
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alternative to ERCP for imaging
the pancreatic duct.
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58EUS
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EUS is a minimally invasive test that allows simultaneous assessmentof 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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Management
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63
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 nauseaand 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 themost 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 tothe 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