ACUTE PANCREATITIS

ACUTEPANCREATITISM. IQBAL RIVAIANATOMY

INCIDENCE3% of all cases of abdominal pain (in UK)

Worldwide: 5 to 50 per 100.000

Occur at any age

Peak in young men and older womenPancreatic Ducts become obstructedHypersecretion of the exocrine enzymes of pancreas

These enzymes enter the bile duct, where they are activated and with bile back up into the pancreatic duct Pancreatitis

PATOPHYSIOLOGY4AETIOLOGYPOSSIBLE CAUSES OF ACUTE PANCREATITISGallstonesAlcoholismPost ERCPAbdominal traumaFollowing billiary, upper GI or cardiothoracic surgeryAmpullary tumorHyperparathyroidismHypercalcemiaPancreas divisumAutoimmune pancreatitisidiopathicAETIOLOGYIt is essential to establish the aetiologyInvestigate thoroughly before labelling it as idiopathicAfter acute episode resolves, remember further management of underlying aetiologyIf aetiology is gallstones, cholecystectomy is desirable during the same admissionCLINICAL PRESENTATIONANAMNESISAbdominal pain (develops very quickly)Pain is severe, constant and refractory to analgesicsPain experienced first in the epigastrium, upper quadrant, or diffusePain radiates to the back, or to the chestNauseaRepeated vomitingCLINICAL PRESENTATIONPHYSICAL EXAMINATIONGeneral appearance: severely illTachypnoeTachycardiaHypotensionMild icterusGrey Turners signCullens signMuscle guarding in upper abdomen9

910Cullens sign

1011Grey Turners sign

11INVESTIGATIONSAnamnesisPhysical examinationElevated serum amylase level three to four times above normalSerum lipase (more sensitive and spesific than amylase)Contrast-enhanced Abdominal CT ScanASSESMENT OF SEVERITY

ASSESMENT OF SEVERITYIMAGINGAbdominal radiographs for differential diagnosisUltrasonography to detect gallstones, rule out acute cholecystitis, or common bile duct is dilated

Contrast-enhanced CT, if:If there is diagnostic uncertaintySevere acute pancreatitisIn patients with organ failure, signs of sepsis or progressive clinical deteriorationWhen a localised complication is suspected: fluid collection, pseudocyst or a pseudoaneurysm

MRCPERCP16CE-CTEnlargement of the pancreas(focal/diffuse) Irregular enhancementShaggy Pancreatic contourThickening of fascial planesfluid collections.Intraperitoneal / retroperitonealRetroperitoneal air

RADIOLOGY1617U/SDiagnosis of gallstones F/U of pseudocysts. Dx pseudoaneurysmsEAUS vs. EUS

RADIOLOGY17MRCP

MANAGEMENTAdmission to ICUAnalgesiaAggressive fluid rehydrationOxygenation Invasive monitoring of vital signs, CVP, urine output, blood gasesFrequent monitoring of haematological and biochemical parametersNasogastric drainage

MANAGEMENTAntibiotic prophylaxisCT scan essential if organ failure, clinical deterioration or signs of sepsis developERCP within 72 hours for severe gallstone pancreatitis or signs of cholangitisSupportive therapy for organ failure if it developsIf nutritional support is required, consider enteral feedingCOMPLICATIONS OF ACUTE PANCREATITIS

COMPLICATIONS OF ACUTE PANCREATITIS23

PLEURAL EFFUSION2324

PSEUDOCYST PANCREAS24ACUTE PANCREATITISCOLLABORATIVE CAREObjectives includeRelief of painPrevention or alleviation of shock of pancreatic secretionsFluid/electrolyte balanceRemoval of the precipitating cause

Conservative therapy Supportive careAggressive hydrationPain managementIV morphineCombined with antispasmodic agentManagement of metabolic complicationsMinimizing stimulation

ACUTE PANCREATITISCOLLABORATIVE CAREConservative therapy (contd)Shock Plasma or plasma volume expanders (dextran or albumin)Fluid/electrolyte imbalanceLactated Ringers solutionOngoing hypotensionVasoactive drugs: Dopamine (Intropin) Systemic vascular resistance

ACUTE PANCREATITISCOLLABORATIVE CAREConservative therapy (contd)Suppression of pancreatic enzymesNPONG suctionPrevent infectionsPeritoneal lavage or dialysisRemove kinin and phospholipase A exudate

ACUTE PANCREATITISCOLLABORATIVE CARESurgical therapy indicated if Presence of gallstonesUncertain diagnosisUnresponsive to conservative therapyAbscess, pseudocyst, or severe peritonitis

ACUTE PANCREATITISCOLLABORATIVE CARESurgical therapy (contd)ERCPEndoscopic sphincterotomyLaparoscopic cholecystectomy

ACUTE PANCREATITISCOLLABORATIVE CAREERCP

ERCP

LAPAROSCOPY

Drug therapyIV morphineNitroglycerin or papaverineAntispasmodics Carbonic anhydrase inhibitorAntacidsHistamine (H2) receptor

ACUTE PANCREATITISCOLLABORATIVE CARENutritional therapyNPO status initially to reduce pancreatic secretionIV lipidsMonitor triglyceridesSmall, frequent feedingsHigh-carbohydrate, low-fat, high-protein dietBland diet

ACUTE PANCREATITISCOLLABORATIVE CARENutritional therapy (contd)Supplemental fat-soluble vitaminsSupplemental commercial liquid preparationsParenteral nutritionNo caffeine or alcohol

ACUTE PANCREATITISCOLLABORATIVE CARE