Acute pancreatitis by sameen

By:

Dr. Sameen Jawed

House Surgeon

Civil Hospital Sukkur

•6 inches long, Retroperitoneal exo as well as endocrine gland•Head, neck, body & tail

•Dual Functions

•Exocrine-Trypsinogen, Chymotrypsinogen, Lipase, Amylase, Elastase, Esterase, Phospholipase A2, Lysophospholipase

•Endocrine-Insulin, Glucagon, Somatostatin

A group of reversible lesions characterized by inflammation of the pancreas

Male: female ratio is 1:3- in those with gallstones

6:1 in those with alcoholism

Non-traumatic(75%)Biliary tract diseasesAlcoholCa Pancreas Viral infection(EBV, CMV, mumps) Drugs(steroid, thiazide, furosemide) Scorpion bites Hyperlipidemia Hyperparathyroidism, Diabetes Mellitus, Porphyria Autoimmune diseases

Traumatic (5%) Operative trauma(Cardiopulmonary bypass, Billroth

type 2) Blunt/penetrating trauma Lab test(ERCP / angiography)

Idiopathic(20%)

(Morphological)Interstitial Edematous

Pancreatitis

Acute Necrotizing Pancreatitis

Parenchymal necrosis alone

Peripancreatic necrosis alone

Combined type

•(According to Severity)

•Mild Acute Pancreatitis

•Moderately Acute Pancreatitis

•Severe Acute Pancreatits

The most common symptoms and signs include:Severe epigastric painNausea, vomiting, diarrhea and loss of

appetiteFever/chillsHemodynamic instability, including shockIn severe case may present with tenderness,

guarding, rebound.Muscle Twitches, cramps & Spasm

Grey-Turner's signCullen's sign

Cullen’s sign – discolouration around umbilicus

Grey-Turner’s sign- discolouration in the flanks

Interstitial edema

Impaired blood flow

Ischaemia

Acinar cell injury

Interstitial inflammation oedema

GallstoneChronic alcoholism

Release of intracellular proenzymes and lysosomal hydrolases

Activation of enzymes

ACTIVATED ENZYMES

Delivery of proenzymes to lysosomal compartment

Intracellular activation of enzymes

Proteolysis(proteases)

Fat necrosis(lipase, phospholipase)

Haemorrhage(elastase)

Alcohol, drugstrauma, ischaemia,viruses

Metabolic injury(experimental)Alcohol, duct obstruction

DUCT OBSTRUCTION ACINAR CELL INJURYDEFECTIVE INTRACELLULAR TRANSPORT

Full blood countSerum Amylase & LipaseElectrolyte abnormalitiesElevated LDH in biliary diseaseBlood sugarUltrasound abdomenAbdominal CT scan & MRI

Renal failureEctopic pregnancyDiabetic ketoacidosisMesenteric ischaemia/infarction (but will

show bacterial contamination of peritoneal aspirate)

Small bowel perforation/obstructionRuptured or dissecting aortic aneurysmAtypical myocardial infarction

predicting the severity of acute pancreatitisAt admission age in years > 55 years white blood cell count > 16000 cells/mm3 blood glucose > 11 mmol/L (> 200 mg/dL) serum AST > 250 IU/L serum LDH > 350 IU/L At 48 hours Calcium (serum calcium < 2.0 mmol/L (< 8.0 mg/dL) Hematocrit fall > 10% Oxygen (hypoxemia PO2 < 60 mmHg) BUN increased by 1.8 or more mmol/L (5 or more mg/dL)

after IV fluid hydration Base deficit (negative base excess) > 4 mEq/L Sequestration of fluids > 6 L

If the score ≥ 3, severe pancreatitis likely If the score < 3, severe pancreatitis is unlikely

Hemorrhagic peritoneal fluidObesity Indicators of organ failureHypotension (SBP <90 mmHG) or tachycardia > 130

beat/minPO2 <60 mmHgOliguria (<50 mL/h) or increasing BUN and creatinineSerum calcium < 1.90 mmol/L (<8.0 mg/dL) serum albumin <33 g/L (<3.2.g/dL)>

• Score 0 to 2 : 2% mortality Score 3 to 4 : 15% mortality • Score 5 to 6 : 40% mortality Score 7 to 8 : 100%

mortality

On Admission: Age>55 years Arterial oxygenation saturation (PaO2)<8

Kpa(60mmhg) Total leucocyte count>15000/mm3 Serum Urea>16 m.mol/L Blood Glucose>10 m.mol/L (200mg/dl) Within 48 hrs: Serum Calcium<2 m.mol/l Serum Albumin<3.2 mg/dl LDH>600 IU/L AST/ALT>600 IU/L Score >= 3 indicates Acute Severe Pancreatitis Score < 3 indicates Acute Mild Pancreatitiss

Balthazar GradeBalthazar Grade Appearance on CT CT Grade Points Grade A Normal CT 0 points Grade B Focal or diffuse enlargement of the pancreas 1

point Grade C Pancreatic gland abnormalities and peripancreatic inflammation

2points Grade D Fluid collection in a single location 3

points Grade E Two or more fluid collections and / or gas bubbles in or adjacent 4

points to pancreas Necrosis ScoreNecrosis Percentage Points No necrosis 0 points 0 to 30% necrosis 2 points 30 to 50% necrosis 4 points Over 50% necrosis 6 points

Score > 4 Severe Pancreatitis Score < 2 Mild disease

The numerical CTSI (Computed Tomography Severity Index) has a maximum of ten points, it is the sum of the Balthazar grade points and pancreatic necrosis grade points

Score > 2 or more defines presence of organ dysfuntion

ImmediateShockSIRS/DIVCARDSOrgan Failure

LatePancreatic pseudocystPancreatic abscessPancreatic necrosisProgressive jaundicePersistent duodenal ileusPancreatic ascites & Pleural

effusion

Cavity surrounding outside of pancreas filled with necrotic products and liquid secretions

Abdominal painPalpable epigastric mass Nausea, vomiting, and anorexiaElevated serum amylaseResolves SponatneouslyInternal or External drainage

A large pus-containing cavity within pancreasUsually after the 4-6 weeks of PancreatitisResults from extensive necrosisUpper abdominal painAbdominal massHigh feverLeukocytosis

Treated Surgically

Relief of painPrevention or alleviation of shock Decrease respiratory failure↓ of pancreatic secretionsMaintain Fluid/electrolyte balanceAntiemetic if necessaryAntibiotic prophylaxisDetermine & treat specific etiology

IV Pethidine, IV Buprenorphine IV Benzodiazepines

Antispasmodic agent Bentyl Pro-Banthine

Spasmolytics – Nitroglycerine

Positioning – sitting up and leaning forward

BloodPlasma ExpandersAlbuminRinger Lactate Solution250–500 ml per hour of isotonic crystalloid

solution during first 12-24 hrsBolus of 1 litre in Severe casesAssesment within 6 hrs is essential till 24-48

hrs

Oxygen InhalationMonitoring O2 SaturationSemi-fowlers position

Keeping NPON.G SuctionAntacids, H2 Receptor Anatagonists, Anti

Spasmodics

Particularly Paralytic IleusFrequent vomiting

CalciumMagnessiumGlucoseAll should be corrected if derranged

Broad-spectrum antibioticsciprofloxacin, ofloxacin, imipenem, and

pefloxacinMetronidazole

Enteral Nutrition is superior to Parenteral NutritionIn mild cases: Immediate oral feeding Low fat solid diet

In Severe cases: Nasogastric feeding Nasojejunal feeding

Energy 25 to 35 kcal/kg/dayprotein 1.2 to 1.5 g/kg/daycarbohydrates 3 to 6 g/kg/day lipids 2 g/kg/day.

Surgical therapy – If related to gallstones

ERCPEndoscopic sphincterotomyLaparoscopic cholecystectomy

Necrosectomy for Infected Necrosis

Avoid AlcoholAvoid Culprit Drugs