Download MBBS (Bachelor of Medicine, Bachelor of Surgery) General Surgery PPT 2 Acute And Chronic Pancreatitis Lecture Notes
Acute and Chronic Pancreatitis
Acute pancreatitis
Acute pancreatitis
Interstitial pancreatitis
Necrotising pancreatitis
Interstitial pancreatitis
Necrotizing pancreatitis
Etiology
Common Causes
? Gallstones
? Alcohol
? Hypertriglyceridemia
? ERCP
? Trauma
? Postoperative
? Drugs (azathioprine, 6-mercaptopurine, sulfonamides, estrogens,
tetracycline, valproic acid, anti-HIV medications)
? Sphincter of Oddi dysfunction
Etiology
Uncommon Causes
? Vascular causes and vasculitis (ischemic-hypoperfusion states after
cardiac surgery)
? Connective tissue disorders
? TTP
? Cancer of the pancreas
? Hypercalcemia
? Periampullary diverticulum
? Pancreas divisum
? Hereditary pancreatitis
? Cystic fibrosis
? Renal failure
Etiology
? Rare Causes
? Infections (mumps, coxsackievirus, cytomegalovirus, echovirus, parasites)
? Autoimmune (e.g., Sj?gren's syndrome)
? 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
? Drugs
? Hypertriglyceridemia
? Pancreas divisum
? Pancreatic cancer
? Sphincter of Oddi dysfunction
? Cystic fibrosis
? Idiopathic
Pathophysiology
? In pancreatic parenchyma
Proteolytic
? endotoxins, exotoxins, viral infections, ischemia,
enzymes
anoxia, lysosomal calcium, and direct trauma
activated
? Activated proteolytic enzymes digest pancreatic and
peri pancreatic tissues
Autodigestion ? also activate elastase and phospholipase A2
Acute Pancreatitis
IL-1
TNF
Other leucocyte
products
IL-6
Oxygen radicals
IL-8
Elastase
IFN-,
N.O.
PAF
IL-10
IL-2
Complications:
?Vascular leakage
?Hypovolemia
?Shock
?ARDS
?Acute renal tubular necrosis
Clinical features
? Abdominal pain
? Nausea, vomiting, and abdominal distention
? Low-grade fever
? Tachycardia
? Hypotension
? Jaundice
? Erythematous skin nodules
? Atelectasis, pleural effusion
? Abdominal tenderness and muscle rigidity
? Diminished bowel sounds
? A faint blue discoloration around the umbilicus (Cullen's sign) may
occur as the result of hemoperitoneum
? Blue-red-purple or green-brown discoloration of the flanks (Turner's
sign) reflects tissue catabolism of hemoglobin
? Grey Turner sign
? Cullen's sign
Workup
Laboratory Data
? serum amylase and lipase
? >threefold clinch the diagnosis
? 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
Markers of Severity within 24 Hours
? SIRS [temperature >38? or < 36?C, Pulse > 90, Tachypnea > 24, WBC > 12,000]
? Hemoconcentration (Hct >44%)
? BISAP (bedside index of severity in acute pancreatitis)
? (B) Blood urea nitrogen (BUN) >22 mg%
? (I) Impaired mental status
? (S) SIRS: 2/4 present
? (A) Age >60 years
? (P) Pleural effusion
? Organ Failure
? Cardiovascular: systolic BP <90 mmHg, heartrate >130
? Pulmonary: Pao2 <60 mmHg
? Renal: serum creatinine >2.0 mg%
? Gastrointestinal: bleeding >500 mL/24 hours
Severity
? Risk Factors
? Age > 60 years
? Obesity, BMI > 30
? Comorbid disease
? Markers during Hospitalization
? Persistent organ failure
? Pancreatic necrosis
? Hospital-acquired infection
Laboratory Data
? Leukocytosis (15,000?20,000 leukocytes per L)
? Hemoconcentration
? with hematocrit values >44%
? and/or blood urea nitrogen (BUN) level >22 mg/Dl
? Hyperglycemia
? decreased insulin release,
? increased glucagon release,
? increased output of adrenal glucocorticoids and catecholamines.
? Hypocalcemia
Laboratory Data
? Hyperbilirubinemia (>4.0 mg/dL) in 10%
? is transient
? return to normal in four to seven days
? Serum alkaline phosphatase and aspartate aminotransferase levels
are also transiently elevated
? Elevated serum lactic dehydrogenase levels (>500 U/dL)
? Hypertriglyceridemia occurs in 5?10%
? Hypoxemia (arterial Po2 60 mmHg), which may herald the onset of
ARDS
? Electrocardiogram ST-segment and T-wave abnormalities simulating
myocardial ischemia.
RADIOLOGY
? CXR
? Sympathetic pleural effusion
? Atelectasis
? A.R.D.S.
? AXR
? Sentinal loop
? Colon cutoff sign
? Duodenal ileus
? Calcifications
? Obscured psoas lines
? 79% will have radiological signs !!!
CT Findings and Grading of Acute Pancreatitis
[CT Severity Index (Ctsi)]
Grade Findings
Score
A
Normal pancreas: normal size, sharply defined, smooth
0
contour, homogeneous enhancement, retroperitoneal
peripancreatic fat without enhancement
B
Focal or diffuse enlargement of the pancreas, contour
1
may show irregularity, enhancement may be
inhomogeneous but there is no peripancreatic
inflammation
C
Peripancreatic inflammation with intrinsic pancreatic
2
abnormalities
D
Intrapancreatic or extrapancreatic fluid col ections
3
E
Two or more large col ections or gas in the pancreas or
4
retroperitoneum
Necrosis score based on contrast-enhanced CT
Necrosis (%)
Score
0
0
<33%
2
33-50%
4
>50%
6
CT severity index equals unenhanced CT score
plus necrosis score; 6 = severe disease.
CT Scan of acute pancreatitis
? CT shows
significant
swelling
and
inflammation
of the
pancreas
Diagnosis
? Requires two of the following:
? typical abdominal pain,
? threefold or greater elevation in serum amylase
and/or lipase level,
? and/or confirmatory findings on cross-sectional
abdominal imaging.
Differential diagnosis
? (1) perforated viscus, especial y peptic ulcer
? (2) acute cholecystitis and biliary colic
? (3) acute intestinal obstruction
? (4) mesenteric vascular occlusion
? (5) renal colic
? (6) myocardial infarction
? (7) dissecting aortic aneurysm
? (8) connective tissue disorders with vasculitis
? (9) pneumonia
? (10) diabetic ketoacidosis
Complications
Local complications
? Necrosis
? Sterile
? Infected
? Walled-off necrosis
? Pancreatic fluid collections
? Pancreatic abscess
? Pancreatic pseudocyst
? Pain
? Rupture
? Hemorrhage
? Infection
Local complications
? Obstruction of gastrointestinal tract (stomach, duodenum, colon)
? Pancreatic ascites
? Disruption of main pancreatic duct
? Leaking pseudocyst
? Involvement of contiguous organs by necrotizing pancreatitis
? Massive intraperitoneal hemorrhage
? Thrombosis of blood vessels (splenic vein, portal vein)
? Bowel infarction
? Obstructive jaundice
Systemic complications
? Pulmonary
? Pleural effusion
? Atelectasis
? Mediastinal abscess
? Pneumonitis
? Acute respiratory distress syndrome
? Cardiovascular
? Hypotension
? Hypovolemia
? Sudden death
? Nonspecific ST-T changes in electrocardiogram simulating myocardial infarction
Systemic complications
? Hematologic
? Disseminated intravascular coagulation
? Gastrointestinal hemorrhage
? Peptic ulcer disease
? Erosive gastritis
? Hemorrhagic pancreatic necrosis with erosion into major blood vessels
? Portal vein thrombosis, variceal hemorrhage
? Renal
? Oliguria
? Azotemia
? Renal artery and/or renal vein thrombosis
? Acute tubular necrosis
Systemic complications
? Metabolic
? Hyperglycemia
? Hypertriglyceridemia
? Hypocalcemia
? Encephalopathy
? Sudden blindness (Purtscher's retinopathy)
? Central nervous system
? Psychosis
? Fat emboli
? Fat necrosis
? Subcutaneous tissues (erythematous nodules)
? Bone
? Miscel aneous (mediastinum, pleura, nervous system)
HOW DO WE DETERMINE PROGNOSIS?
? 80% Will recover without any complications
? 20% Will develop severe cardio-pulmonary complications or septic
complications
? Prognostic assessment :
? Ranson
? Imrie
? APACHE 2
? CRP
? Classify into mild or severe acute pancreatitis ( Atlanta classification
1992)
Treatment
? To limit severity of pancreatic inflammation
? To interrupt the pathogenesis of complications
? To support the patient and treat complications
TREATMENT
? NON-OPERATIVE
? To limit severity of pancreatic inflammation
? Inhibition of pancreatic secretion
? Nasogastric suction
? Pharmacologic
? Hypothermia
? Pancreatic irradiation
? Inhibition of pancreatic enzymes
? Corticosteroids
? Prostaglandins
TREATMENT
? To interrupt the pathogenesis of complications
? Antibiotics
? Antacids
? Heparin
? Low molecular weight dextran
? Vasopressin
? Peritoeal lavage
TREATMENT
? To support the patient and treat complications
? Restoration and maintenance of intravascular volume
? Electrolyte replacement
? Respiratory support
? Nutritional support
? Analgesia
? Heparin
When to operate?
? Diagnostic laparotomy
? To limit the severity of the pancreatic inflammation
? Biliary procedures
? To interrupt the pathogenesis of complications
? Pancreatic drainage
? Pancreatic resection
? Pancreatic debridement
? Peritoneal lavage
? To support the patient and treat complications
? Drainage of pancreatic infection
? Feeding jejunostomy
? To prevent recurrent pancreatitis
Summary of treatment
? All patients
? Nasogastric suction
? NPO
? Monitor and maintenance of intravascular volume
? Respiratory monitoring and support
? Antibiotics(selective)
? Early laparotomy only fordiagnosis
? Estimate prognosis by early signs
? Patients with severe pancreatitis
? Peritoneal lavage
? Nutritional support
? Suspect and treat pancreatic sepsis
? Heparin if hypercoagulable
Chronic Pancreatitis
46
Definition and Prevalence
? Defined as chronic inflammatory condition that causes irreversible
damage to pancreatic structure and function.
? Incurable
? 5 To 27 Persons Per 100,000
47
Etiology
? Alcohol, 70%
? Idiopathic (including tropical), 20%
? Other, 10%
? Hereditary
? Hyperparathyroidism
? Hypertriglyceridemia
? Autoimmune pancreatitis
? Obstruction
? Trauma
? Pancreas divisum
48
Classification:
1.Calcific pancreatitis
2. Obstruction pancreatitis
3. Inflammatory pancreatitis
4. Auto immune pancreatitis
5. Asymptomatic fibrosis
6. Tropical pancreatitis
7. Hereditary pancreatitis
8. Idiopathic pancreatitis
49
Signs and Symptoms
? Steady and Boring Pain
? Not Colicky
? Nausea /Vomiting
? Anorexia- Most Common
? Malabsorption And Weight Loss
? Diabetes Mellitus
50
? Classic triad " pancreatic calcification , steatorrhea , and diabetes
mellitus"
? Found in <1/3
? secretin stimulation test (abnormal when 60% or more of pancreatic
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
Laboratory Studies
Tests for Chronic Pancreatitis
I. Measurement of pancreatic products in blood
A. Enzymes
B. Pancreatic polypeptide
I . Measurement of pancreatic exocrine secretion
A. Direct measurements
1. Enzymes
2. Bicarbonate
B. Indirect measurement
1. Bentiromide test
2. Schil ing test
3. Fecal fat, chymotrypsin, or elastase concentration
4. [14C]-olein absorption
52
Imaging techniques
? A. Plain film radiography of abdomen
? B. Ultrasonography
? C. Computed tomography
? D. ERCP
? E. MRCP
? F. EUS
? Plain films :
? Pancreatic calcifications : 30%
? most common with alcoholic
pancreatitis
Pancreatic calcifications. CT scan showing
multiple, calcified, intraductal stones in a
patient with hereditary chronic pancreatitis
Endoscopic retrograde
cholangiopancreatography in chronic
pancreatitis. The pancreatic duct and its
side branches are irregularly dilated
55
CT features
? Pancreatic atrophy,
calcifications, and main
pancreatic duct dilation
56
ERCP
? ERCP is a highly sensitive
radiographic test for CP
57
MRCP
? MRCP allows a noninvasive
alternative to ERCP for imaging
the pancreatic duct.
58
EUS
EUS is a minimally invasive test that allows simultaneous assessment
of ductal and parenchymal structure
59
Treatment
? Analgesia
? Enzyme Therapy
? Antisecretory Therapy
? Neurolytic Therapy
? Endoscopic Management
? Surgical Therapy
60
Complications
? Pseudocyst
? Pancreatic Ascites
? Pancreatic-Enteric Fistula
? Head-of-Pancreas Mass
? Splenic and Portal Vein Thrombosis
61
62
Management
63
A 45-year-old man presents to the emergency room complaining of severe
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
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
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
(B) Discharge and close follow up as outpatient
(C) Obtain an abdominopelvic computed tomography (CT) scan
(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
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
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
patient's health maintenance?
(A) Total pancreatectomy
(B) Oral pancreatic enzyme replacement
(C) Total parenteral nutrition
(D) Octreotide therapy
(E) High-fat diet
This post was last modified on 07 April 2022