Presented by: Dr. Rana Chowdhury.

Acute and Chronic Pancreatitis.

Pancreas: A large gland behind the stomach that

secretes digestive enzymes into the duodenum.

Acute Pancreatitis:

Acute abdominal pain usually associated with raised pancreatic enzyme level in the blood or urine as a result of inflammatory disease of pancreas.

Acute Pancreatitis: Pathogenesis: Intracellular activation of trypsinogen to

trypsin by numerous stimuli. Activation, intestinal liberation and auto

digestion of Pancreas by own enzymes. Heredetery defect in chromosome – 7.

Acute Pancreatitis: causes: Billiary stone (50 – 70%) . Alcoholism (25%) . Trauma (Surgical, Post ERCP, Blunt

trauma etc.) Drugs, Metabolic disorders. Infections, like mumps, mycoplasma

etc. Idiopathic.

Acute Pancreatitis:

symptoms:

Epigastric pain.

Nausea, Vomiting.

Fever.

Acute Pancreatitis: Signs: Tachypnoea, Tachycardia, Hypotension. Patient may be in shock. Bleeding into Fascial plan produce - Gray Turner’s sign. - Culler’s sign. Icteric in gall stone pancreatitis. Small red tender nodule on leg.

Gray Turner’s sign

Acute Pancreatitis: Signs on abdominal examination: Abdomen distended due to paralytic

ileus. Tender epigastrium. Muscle guard in epigastric region. Bowel sound may be absent.

Acute Pancreatitis: Diagnosis

• Serum Amylase (within 24 hours) • Urine Amylase (after 24 hours) • Ultrasonograph of whole abdomen • Serum lipase level • Serum Calcium level • Plain X ray abdomen: sentinel loop;

colon cut off sign, renal halo (oedema around kidney) sign.

Acute Pancreatitis: management: Conservative: Immediate hospitalization. Bed rest. Antispasmodic, analgesic. Nothing per os, NG Suction, I/V fluid. Non invasive monitoring. Oral feeding after 7 days in mild & 14

days in severe case.

Acute Pancreatitis: management: Conservative: [contd.] HDU/ ICU in severe cases, with narcotic

for analgesia, invasive monitoring with ABG analysis, Catheterization, CVP etc.

Surgery indicated in case of: Diagnostic dilemma. Acute haemorrhaegic pancreatitis. Necrotizing pancreatitis.

Acute Pancreatitis: management: Surgery indicated in case of : [contd.] Gall stone disease. If patient does not respond to

conservative treatment. ERCP: Pancreatitis due stone impact in ampula

of vater. Abnormal LFT.

Acute Pancreatitis: prognosis: Ranson score:

Acute Pancreatitis: prognosis: Glasgow scale: On admission: Within 48 hours: Age > 55 years, Serum Calcium < 2

mmol/ L WBC Count > 15 X 109 / L Serum Albumin < 32

gm/ L Blood glucose > 10 mmol / L LDH > 600 units/ L Serum urea > 16 mmol / L AST/ ALT > 600 units/ L Arterial O2 saturation < 8 kPa

The Apache II scoring system:

Acute Pancreatitis: complications: Local:• Acute fluid collection. • Sterile pancreatic necrosis. • Infective pancreatic necrosis. • Pancreatic abscess. • Pseudocyst. • Pancreatic ascitis. • Pleural effusion.

Acute Pancreatitis: complications: Systemic: • Shock, Arrythmia. • ARDS. • Renal failure. • DIC. • Hypocalcaemia, Hypoglycemia. • Visual disturbance, Confusion. • Subcutaneous fat necrosis.

Chronic Pancreatitis: Chronic pancreatitis is a chronic

inflammatory disease in which there is irreversible progressive destruction of pancreatic tissue.

Male female ratio = 4 : 1 Mean age of onset is above 40 years.

Chronic Pancreatitis: Etiology: • High alcohol consumption in 60-70%

cases. • Pancreatic duct obstruction, resulting

from stricture formation after a) Trauma; b) Acute pancreatitis; c) Occlusion of duct by neoplasia or stone. • Congenital anomalies: pancreas divisum.

Chronic Pancreatitis: clinical features: • Pain: site of pain depends on the main

focus of disease. • Nausea, vomiting. • Exocrine and endocrine pancreatic

insufficiency. • Over and above, almost all

complications of acute pancreatitis may be present in chronic pancreatitis.

Chronic Pancreatitis: Diagnosis: • Plain X ray abdomen may show

pancreatic calcification. • CT scan or MRI can show outline of the

gland, the main area of damage and possibilities of surgical correction.

• MRCP will identify presence of Billiary obstruction & state of pancreatic duct.

• ERCP is most elucidating for the duct anatomy.

Chronic Pancreatitis: Treatment: Medical treatment: Low fat and high protein diet. Pancreatic enzyme supplimentation. Stop the patient from alcoholism &

smoking. Eliminate obstructive factors. Escalate analgesia. For intractable pain, consider CT guided

coeliac axis block.

Chronic Pancreatitis: Prognosis: • Chronic pancreatitis is difficult to treat

and often recurs. • Permanent exocrine or endocrine

dysfunction. • Development of pancreatic cancer.

• Bailey & Love’s – Short practice of surgery.

• Current surgical diagnosis & treatment – Gerard M. Doherty.

• Essential Surgical Practice – Sir Alfred Cuschieri.

Thank You.