Acute pancreatitisCase reports
Acute pancreatitisCase reports
Clinical problemsClinical problems
• Use of antibioticsUse of antibiotics? (? (P 1 & 2P 1 & 2))• Surgical treatment of AP Surgical treatment of AP ? (? (P 3 & 4P 3 & 4))
Clinical problemsClinical problems
• Use of antibioticsUse of antibiotics? (? (P 1 & 2P 1 & 2))• Surgical treatment of AP Surgical treatment of AP ? (? (P 3 & 4P 3 & 4))
Acute pancreatitisCase reports
Acute pancreatitisCase reports
Case 1Case 1Case 1Case 1
Acute pancreatitisCase 1 – Patient KDAcute pancreatitis
Case 1 – Patient KD
HistoryHistory
• M, M, 6363 y y• Obesity – BMI Obesity – BMI 30.330.3 kg/m kg/m22
• Gallbladder stones Gallbladder stones • No concomitant diseasesNo concomitant diseases• 1. episode of ABP1. episode of ABP• Time from onset Time from onset 33.533.5 h h
HistoryHistory
• M, M, 6363 y y• Obesity – BMI Obesity – BMI 30.330.3 kg/m kg/m22
• Gallbladder stones Gallbladder stones • No concomitant diseasesNo concomitant diseases• 1. episode of ABP1. episode of ABP• Time from onset Time from onset 33.533.5 h h
Acute pancreatitisCase 1 – Patient KDAcute pancreatitis
Case 1 – Patient KD
Lab data & prognostic assessmentLab data & prognostic assessment
• WBC (G/l)WBC (G/l) 13.6 13.6 -- 19.8 19.8 -- 14.414.4
• CRP (mg/l)CRP (mg/l) 5757 - - 167167 - ND - ND
• RNS (pts)RNS (pts) 55• AP-O (pts 0-1-2)AP-O (pts 0-1-2) 99 - 8 - 8 - 8 - 8• KCE (pts)KCE (pts) 44
Lab data & prognostic assessmentLab data & prognostic assessment
• WBC (G/l)WBC (G/l) 13.6 13.6 -- 19.8 19.8 -- 14.414.4
• CRP (mg/l)CRP (mg/l) 5757 - - 167167 - ND - ND
• RNS (pts)RNS (pts) 55• AP-O (pts 0-1-2)AP-O (pts 0-1-2) 99 - 8 - 8 - 8 - 8• KCE (pts)KCE (pts) 44
Acute pancreatitisCase 1 – Patient KDAcute pancreatitis
Case 1 – Patient KD
ERCP & CTERCP & CT
• ERCP (day 0)ERCP (day 0)CBD 5 mm, no stonesCBD 5 mm, no stonesNo ESNo ES
• CT (day 1)CT (day 1)Mild inflammatory infiltration close to body and tail ofMild inflammatory infiltration close to body and tail ofthe pancreas and in the left prerenal space, the pancreas and in the left prerenal space, no pancreatic necrosisno pancreatic necrosis(BLT (BLT CC, CTSI , CTSI 22))
ERCP & CTERCP & CT
• ERCP (day 0)ERCP (day 0)CBD 5 mm, no stonesCBD 5 mm, no stonesNo ESNo ES
• CT (day 1)CT (day 1)Mild inflammatory infiltration close to body and tail ofMild inflammatory infiltration close to body and tail ofthe pancreas and in the left prerenal space, the pancreas and in the left prerenal space, no pancreatic necrosisno pancreatic necrosis(BLT (BLT CC, CTSI , CTSI 22))
Acute pancreatitisCase 1 – Patient KDAcute pancreatitis
Case 1 – Patient KD
Acute pancreatitisCase reports
Acute pancreatitisCase reports
Case 2Case 2Case 2Case 2
Acute pancreatitisCase 2 – Patient MKAcute pancreatitis
Case 2 – Patient MK
HistoryHistory
• M,M, 2929 y y• Overweight – BMI Overweight – BMI 28.528.5 kg/m kg/m22
• Gallbladder stonesGallbladder stones• No concomitant diseasesNo concomitant diseases• 1. episode of ABP1. episode of ABP• Time from onset Time from onset 46.546.5 h h
HistoryHistory
• M,M, 2929 y y• Overweight – BMI Overweight – BMI 28.528.5 kg/m kg/m22
• Gallbladder stonesGallbladder stones• No concomitant diseasesNo concomitant diseases• 1. episode of ABP1. episode of ABP• Time from onset Time from onset 46.546.5 h h
Acute pancreatitisCase 2 – Patient MKAcute pancreatitis
Case 2 – Patient MK
Lab data & prognostic assessmentLab data & prognostic assessment
• WBC (G/l)WBC (G/l) 20.9 20.9 -- 15.9 15.9 -- 15.015.0
• CRP (mg/l)CRP (mg/l) 7171 - - 9595 - - 166166
• RNS (pts)RNS (pts) 22• AP-O (pts 0-1-2)AP-O (pts 0-1-2) 4 - 2 - 54 - 2 - 5• KCE (pts)KCE (pts) 2 2
Lab data & prognostic assessmentLab data & prognostic assessment
• WBC (G/l)WBC (G/l) 20.9 20.9 -- 15.9 15.9 -- 15.015.0
• CRP (mg/l)CRP (mg/l) 7171 - - 9595 - - 166166
• RNS (pts)RNS (pts) 22• AP-O (pts 0-1-2)AP-O (pts 0-1-2) 4 - 2 - 54 - 2 - 5• KCE (pts)KCE (pts) 2 2
Acute pancreatitisCase 2 – Patient MKAcute pancreatitis
Case 2 – Patient MK
ERCP & CTERCP & CT
• ERCP (day 0)ERCP (day 0)CBD 12 mm, CBD 12 mm, impacted stone impacted stone + 4 other stones+ 4 other stonesSE done, stones removedSE done, stones removed
• TK (day 1)TK (day 1)Moderate inflammatory infiltrations in both prerenalModerate inflammatory infiltrations in both prerenalspaces, spaces, no pancreatic necrosis, no pancreatic necrosis, small amount of fluid small amount of fluid around the liver and mild bilateral hydrothoraxaround the liver and mild bilateral hydrothorax(BLT (BLT CC, CTSI , CTSI 22))
ERCP & CTERCP & CT
• ERCP (day 0)ERCP (day 0)CBD 12 mm, CBD 12 mm, impacted stone impacted stone + 4 other stones+ 4 other stonesSE done, stones removedSE done, stones removed
• TK (day 1)TK (day 1)Moderate inflammatory infiltrations in both prerenalModerate inflammatory infiltrations in both prerenalspaces, spaces, no pancreatic necrosis, no pancreatic necrosis, small amount of fluid small amount of fluid around the liver and mild bilateral hydrothoraxaround the liver and mild bilateral hydrothorax(BLT (BLT CC, CTSI , CTSI 22))
Acute pancreatitisCase 2 – Patient MKAcute pancreatitis
Case 2 – Patient MK
TKTKTKTK
Acute pancreatitisCase 2 – Patient MKAcute pancreatitis
Case 2 – Patient MK
Acute pancreatitisCases 1 & 2
Acute pancreatitisCases 1 & 2
• SIRS (+)SIRS (+)• Mild overweight / obesityMild overweight / obesity• BLT C, BLT C, no necrosisno necrosis, CTSI 2, CTSI 2• WBC WBC > 15 > 15 G/lG/l• CRP CRP > 150 > 150 mg/lmg/l
Should antibiotics be administered?Should antibiotics be administered?
Case 2 - MKCase 2 - MK• Very good prognosisVery good prognosis
Case 1 - KDCase 1 - KD• Moderate prognosisModerate prognosis
QuestionQuestion
Who should receive antibiotics?Who should receive antibiotics?
1.1.BothBoth
2.2.Patient 1Patient 1
3.3.Patient 2Patient 2
4.4.NoneNone
Acute pancreatitisCase 1 – Patient KDAcute pancreatitis
Case 1 – Patient KD
BacteriologyBacteriology
• Bile - Bile - positivepositiveEscherichia coliEscherichia coli(sensitive to Ciprofloxacin, Imipenem)(sensitive to Ciprofloxacin, Imipenem)
• Blood – Blood – negativenegative (1x) (1x)
BacteriologyBacteriology
• Bile - Bile - positivepositiveEscherichia coliEscherichia coli(sensitive to Ciprofloxacin, Imipenem)(sensitive to Ciprofloxacin, Imipenem)
• Blood – Blood – negativenegative (1x) (1x)
Acute pancreatitisCase 1 – Patient KDAcute pancreatitis
Case 1 – Patient KD
Acute pancreatitisCase 2 – Patient MKAcute pancreatitis
Case 2 – Patient MK
BacteriologyBacteriology
• Blood –Blood – 10 x negative 10 x negative
BacteriologyBacteriology
• Blood –Blood – 10 x negative 10 x negative
Acute pancreatitisCase 2 – Patient MKAcute pancreatitis
Case 2 – Patient MK
Acute pancreatitisCase 1 & 2
Acute pancreatitisCase 1 & 2
• Wide-spectrum antibiotics were used in both casesWide-spectrum antibiotics were used in both cases• No complications acc. to Atlanta criteriaNo complications acc. to Atlanta criteria• Probably mild necrosis of peripancreatic fatProbably mild necrosis of peripancreatic fat• Hospital stay 22 days in both casesHospital stay 22 days in both cases• Course mild / severe ?Course mild / severe ?
Acute pancreatitisCase reports
Acute pancreatitisCase reports
Case 3Case 3Case 3Case 3
Acute pancreatitisCase 3 – Patient AKAcute pancreatitisCase 3 – Patient AK
HistoryHistory
• M, M, 7979 y y• General condition severeGeneral condition severe
Hypertension 20 yHypertension 20 yParkinson’s disease?Parkinson’s disease?
• Suspicion of gallstonesSuspicion of gallstones• Probably 20 h from onset of abdominal painProbably 20 h from onset of abdominal pain• Very severe abdominal painVery severe abdominal pain
HistoryHistory
• M, M, 7979 y y• General condition severeGeneral condition severe
Hypertension 20 yHypertension 20 yParkinson’s disease?Parkinson’s disease?
• Suspicion of gallstonesSuspicion of gallstones• Probably 20 h from onset of abdominal painProbably 20 h from onset of abdominal pain• Very severe abdominal painVery severe abdominal pain
Acute pancreatitisCase 3 – Patient AKAcute pancreatitisCase 3 – Patient AK
OEOE
• DehydrationDehydration• HR HR 116116/min, RR /min, RR 3030/min/min• No peristalsisNo peristalsis• Rebound tenderness Rebound tenderness +-+-
OEOE
• DehydrationDehydration• HR HR 116116/min, RR /min, RR 3030/min/min• No peristalsisNo peristalsis• Rebound tenderness Rebound tenderness +-+-
Acute pancreatitisCase 3 – Patient AKAcute pancreatitisCase 3 – Patient AK
Angio-CT (day 0)Angio-CT (day 0)
• No mesenteric ischemiaNo mesenteric ischemia• Extensive atheromatosisExtensive atheromatosis• EExtensive inflammatory infiltration xtensive inflammatory infiltration
of peripancreatic fat, non-enhancement areaof peripancreatic fat, non-enhancement area(up to 1/3) in (up to 1/3) in bodybody and tail and tail
• BLT BLT CC, necrosis, necrosis < 1/3 < 1/3?, CTSI ?, CTSI 44
Angio-CT (day 0)Angio-CT (day 0)
• No mesenteric ischemiaNo mesenteric ischemia• Extensive atheromatosisExtensive atheromatosis• EExtensive inflammatory infiltration xtensive inflammatory infiltration
of peripancreatic fat, non-enhancement areaof peripancreatic fat, non-enhancement area(up to 1/3) in (up to 1/3) in bodybody and tail and tail
• BLT BLT CC, necrosis, necrosis < 1/3 < 1/3?, CTSI ?, CTSI 44
Acute pancreatitisCase 3 – Patient AKAcute pancreatitisCase 3 – Patient AK
Angio-CT (day 0)Angio-CT (day 0)Angio-CT (day 0)Angio-CT (day 0)
Acute pancreatitisCase 3 – Patient AKAcute pancreatitisCase 3 – Patient AK
ERCP (day 1)ERCP (day 1)
• Extensive swelling of D2 of moderate severity,Extensive swelling of D2 of moderate severity,bluish discoloration of mucosa, severe duodenopathybluish discoloration of mucosa, severe duodenopathy
• Papilla very small and tightPapilla very small and tight• No deep CBD cannulation despite No deep CBD cannulation despite pre-cutpre-cut• CDB narrow (< 4 mm)CDB narrow (< 4 mm)
ERCP (day 1)ERCP (day 1)
• Extensive swelling of D2 of moderate severity,Extensive swelling of D2 of moderate severity,bluish discoloration of mucosa, severe duodenopathybluish discoloration of mucosa, severe duodenopathy
• Papilla very small and tightPapilla very small and tight• No deep CBD cannulation despite No deep CBD cannulation despite pre-cutpre-cut• CDB narrow (< 4 mm)CDB narrow (< 4 mm)
Acute pancreatitisCase 3 – Patient AKAcute pancreatitisCase 3 – Patient AK
Lab dataLab data
• WBC (G/l)WBC (G/l) 10.810.8 -- 20.1 20.1 -- 15.3 15.3• PLTS (G/l)PLTS (G/l) 151151 - - 8787 – – 7272• HCT (%)HCT (%) 5050 - - 5353 - 48 - 48• paO2 (mm Hg)paO2 (mm Hg) 101 - 101 - 6565 - - 5252
• Cre (mg/dl)Cre (mg/dl) 1.1 - 0.9 - 1.1 - 0.9 - 1.61.6• AT III (%)AT III (%) ND - ND – ND - ND – 4242• CRPCRP ND!ND!
Lab dataLab data
• WBC (G/l)WBC (G/l) 10.810.8 -- 20.1 20.1 -- 15.3 15.3• PLTS (G/l)PLTS (G/l) 151151 - - 8787 – – 7272• HCT (%)HCT (%) 5050 - - 5353 - 48 - 48• paO2 (mm Hg)paO2 (mm Hg) 101 - 101 - 6565 - - 5252
• Cre (mg/dl)Cre (mg/dl) 1.1 - 0.9 - 1.1 - 0.9 - 1.61.6• AT III (%)AT III (%) ND - ND – ND - ND – 4242• CRPCRP ND!ND!
Acute pancreatitisCase 3 – Patient AKAcute pancreatitisCase 3 – Patient AK
Prognostic assessmentPrognostic assessment
• RNS (pts)RNS (pts) 66• AP-II (pts 0-1-2)AP-II (pts 0-1-2) 1717 - - 1818 - - 17 17 (death risk (death risk 8585%)%)• AP III J (pts 0-1-2)AP III J (pts 0-1-2) 5050 - - 6565 - - 5757 (death risk (death risk 6767%)%)• KCE (pts)KCE (pts) 77 • OFS (Bernard, pts 0-2)OFS (Bernard, pts 0-2) 1 - 1 - 6 6 (death risk (death risk 8585%)%)
Prognostic assessmentPrognostic assessment
• RNS (pts)RNS (pts) 66• AP-II (pts 0-1-2)AP-II (pts 0-1-2) 1717 - - 1818 - - 17 17 (death risk (death risk 8585%)%)• AP III J (pts 0-1-2)AP III J (pts 0-1-2) 5050 - - 6565 - - 5757 (death risk (death risk 6767%)%)• KCE (pts)KCE (pts) 77 • OFS (Bernard, pts 0-2)OFS (Bernard, pts 0-2) 1 - 1 - 6 6 (death risk (death risk 8585%)%)
Acute pancreatitisCase 3 – Patient AKAcute pancreatitisCase 3 – Patient AK
CT (day 2)CT (day 2)• Mild progressionMild progression• BLT E, necrosis BLT E, necrosis < < 1/3, CTSI 61/3, CTSI 6
CT (day 2)CT (day 2)• Mild progressionMild progression• BLT E, necrosis BLT E, necrosis < < 1/3, CTSI 61/3, CTSI 6
Acute pancreatitisCase 3 – Patient AKAcute pancreatitisCase 3 – Patient AK
CT (day 2)CT (day 2)CT (day 2)CT (day 2)
Acute pancreatitisCase 3 – Patient AKAcute pancreatitisCase 3 – Patient AK
Clinical courseClinical course
• No improvement within 48 hoursNo improvement within 48 hours• Rapidly evolving multiorgan failureRapidly evolving multiorgan failure• Patient transferred to ICUPatient transferred to ICU• Surgical consultationSurgical consultation
Clinical courseClinical course
• No improvement within 48 hoursNo improvement within 48 hours• Rapidly evolving multiorgan failureRapidly evolving multiorgan failure• Patient transferred to ICUPatient transferred to ICU• Surgical consultationSurgical consultation
Acute pancreatitisCase reports
Acute pancreatitisCase reports
Case 4Case 4Case 4Case 4
Acute pancreatitisCase 4 – Patient MLAcute pancreatitis
Case 4 – Patient ML
HistoryHistory
• F, F, 50 y50 y• No concomitant diseasesNo concomitant diseases• Mild obesity, BMI Mild obesity, BMI 31.631.6 kg/m2 kg/m2• 10 months befor10 months beforee single episode of biliary colic single episode of biliary colic
No gallbladder stonesNo gallbladder stones• 1. episode of ABP1. episode of ABP• Time from onset 8 hTime from onset 8 h
HistoryHistory
• F, F, 50 y50 y• No concomitant diseasesNo concomitant diseases• Mild obesity, BMI Mild obesity, BMI 31.631.6 kg/m2 kg/m2• 10 months befor10 months beforee single episode of biliary colic single episode of biliary colic
No gallbladder stonesNo gallbladder stones• 1. episode of ABP1. episode of ABP• Time from onset 8 hTime from onset 8 h
Acute pancreatitisCase 4 – Patient MLAcute pancreatitis
Case 4 – Patient ML
OEOE
• ObesityObesity• JaundiceJaundice• Epigastric tendernessEpigastric tenderness
OEOE
• ObesityObesity• JaundiceJaundice• Epigastric tendernessEpigastric tenderness
Acute pancreatitisCase 4 – Patient MLAcute pancreatitis
Case 4 – Patient ML
ERCP (day 0)ERCP (day 0)
• Duodenum and papilla normalDuodenum and papilla normalCDB 10 mm, no stonesCDB 10 mm, no stonesNo ESNo ESMicroscopic bile analysis: CMC+, CaBG+++Microscopic bile analysis: CMC+, CaBG+++
ERCP (day 0)ERCP (day 0)
• Duodenum and papilla normalDuodenum and papilla normalCDB 10 mm, no stonesCDB 10 mm, no stonesNo ESNo ESMicroscopic bile analysis: CMC+, CaBG+++Microscopic bile analysis: CMC+, CaBG+++
Acute pancreatitisCase 4 – Patient MLAcute pancreatitis
Case 4 – Patient ML
Lab dataLab data
• WBC (G/l)WBC (G/l) 17.1 17.1 -- 15.3 15.3 -- 13.7 13.7• HGB (g/dl)HGB (g/dl) 14.3 - ND - 14.7 14.3 - ND - 14.7 - - 8.08.0 (d7) (d7)• paO2 (mm Hg)paO2 (mm Hg) 7373• TP (mg/dl)TP (mg/dl) 7.1 - 7.1 - 6.26.2 - - 5.05.0• CRPCRP (mg/l) (mg/l) 1010 -- 68 68 -- 200 200 -- 298 298
(d7)(d7)
Lab dataLab data
• WBC (G/l)WBC (G/l) 17.1 17.1 -- 15.3 15.3 -- 13.7 13.7• HGB (g/dl)HGB (g/dl) 14.3 - ND - 14.7 14.3 - ND - 14.7 - - 8.08.0 (d7) (d7)• paO2 (mm Hg)paO2 (mm Hg) 7373• TP (mg/dl)TP (mg/dl) 7.1 - 7.1 - 6.26.2 - - 5.05.0• CRPCRP (mg/l) (mg/l) 1010 -- 68 68 -- 200 200 -- 298 298
(d7)(d7)
Acute pancreatitisCase 4 – Patient MLAcute pancreatitis
Case 4 – Patient ML
Prognostic assessmentPrognostic assessment
• RNS (pts)RNS (pts) 66• AP-O (pts 0-1-2)AP-O (pts 0-1-2) 88 - - 99 - - 66• AP III J (pts 0-1-2)AP III J (pts 0-1-2) 23 - 22 - 1923 - 22 - 19• KCE (pts)KCE (pts) 77 • OFS (Bernard, pts 0-2)OFS (Bernard, pts 0-2) 0 - 10 - 1
Prognostic assessmentPrognostic assessment
• RNS (pts)RNS (pts) 66• AP-O (pts 0-1-2)AP-O (pts 0-1-2) 88 - - 99 - - 66• AP III J (pts 0-1-2)AP III J (pts 0-1-2) 23 - 22 - 1923 - 22 - 19• KCE (pts)KCE (pts) 77 • OFS (Bernard, pts 0-2)OFS (Bernard, pts 0-2) 0 - 10 - 1
Acute pancreatitisCase 4 – Patient MLAcute pancreatitis
Case 4 – Patient ML
CT (day 2)CT (day 2)
• Enlarged pancreatic head, homogenous enhancement,Enlarged pancreatic head, homogenous enhancement,no necrosisno necrosis
• Fluid collections at both prerenal spaces, in spleen hilum,Fluid collections at both prerenal spaces, in spleen hilum,between small bowel loopsbetween small bowel loops
• BLT E, CTSI 4BLT E, CTSI 4
CT (day 2)CT (day 2)
• Enlarged pancreatic head, homogenous enhancement,Enlarged pancreatic head, homogenous enhancement,no necrosisno necrosis
• Fluid collections at both prerenal spaces, in spleen hilum,Fluid collections at both prerenal spaces, in spleen hilum,between small bowel loopsbetween small bowel loops
• BLT E, CTSI 4BLT E, CTSI 4
Acute pancreatitisCase 4 – Patient MLAcute pancreatitis
Case 4 – Patient ML
Clinical courseClinical course• InteIntennsive conventional management, antibioticssive conventional management, antibiotics• SIRS symptoms between days 10 and 16SIRS symptoms between days 10 and 16• Control CT (d12) – progression, CTSI 4 Control CT (d12) – progression, CTSI 4 • Control CT (d26) – Control CT (d26) – progression, no pancreatic necrosis,progression, no pancreatic necrosis,
but extensive necrosis of peripancreatic fatbut extensive necrosis of peripancreatic fat• Second period of fever from day 32, ↑ WBC i CRPSecond period of fever from day 32, ↑ WBC i CRP• US – fluid collection, bacteriology – US – fluid collection, bacteriology – Str. faecalisStr. faecalis• Surgical consultation (d43)Surgical consultation (d43)
Clinical courseClinical course• InteIntennsive conventional management, antibioticssive conventional management, antibiotics• SIRS symptoms between days 10 and 16SIRS symptoms between days 10 and 16• Control CT (d12) – progression, CTSI 4 Control CT (d12) – progression, CTSI 4 • Control CT (d26) – Control CT (d26) – progression, no pancreatic necrosis,progression, no pancreatic necrosis,
but extensive necrosis of peripancreatic fatbut extensive necrosis of peripancreatic fat• Second period of fever from day 32, ↑ WBC i CRPSecond period of fever from day 32, ↑ WBC i CRP• US – fluid collection, bacteriology – US – fluid collection, bacteriology – Str. faecalisStr. faecalis• Surgical consultation (d43)Surgical consultation (d43)
Acute pancreatitisCase 4 – Patient MLAcute pancreatitis
Case 4 – Patient ML
CT (days 2, 12 i 26)CT (days 2, 12 i 26)CT (days 2, 12 i 26)CT (days 2, 12 i 26)
Acute pancreatitisCase 4 – Patient MLAcute pancreatitis
Case 4 – Patient ML
CT (days 2, 12 i 26)CT (days 2, 12 i 26)CT (days 2, 12 i 26)CT (days 2, 12 i 26)
Acute pancreatitisCases 3 & 4
Acute pancreatitisCases 3 & 4
Case 4 – MLCase 4 – ML
• Day 43Day 43• Infected necrosisInfected necrosis• No MOFNo MOF• Moderate prognosisModerate prognosis
Case 4 – MLCase 4 – ML
• Day 43Day 43• Infected necrosisInfected necrosis• No MOFNo MOF• Moderate prognosisModerate prognosis
Case 3 – AKCase 3 – AK
• Day 3Day 3• Sterile necrosisSterile necrosis• ↑ ↑ MOFMOF• Bad prognosisBad prognosis
Who should be operated on?Who should be operated on?
QuestionQuestion
Who should be operated on?Who should be operated on?
1.1.Both patientsBoth patients
2.2.Patient 3Patient 3
3.3.Patient 4Patient 4
4.4.NoneNone
Acute pancreatitisCase 3 – Patient AKAcute pancreatitisCase 3 – Patient AK
SurgerySurgery• Day 2 of hospitalizationDay 2 of hospitalization• 2000 ml brown fluid in the abdominal cavity2000 ml brown fluid in the abdominal cavity• Extensive pancreatic necrosis (black pancreas)Extensive pancreatic necrosis (black pancreas)
Necrosectomy. Setonage. LaparostomyNecrosectomy. Setonage. Laparostomy• Cardiac arrest at the end of the procedure, deathCardiac arrest at the end of the procedure, death• Autopsy:Autopsy:
Necrosis haemorrhagica pancreatis et telae adiposae.Necrosis haemorrhagica pancreatis et telae adiposae.Inflammatio purulenta cum necrosi d. choledochi.Inflammatio purulenta cum necrosi d. choledochi.
SurgerySurgery• Day 2 of hospitalizationDay 2 of hospitalization• 2000 ml brown fluid in the abdominal cavity2000 ml brown fluid in the abdominal cavity• Extensive pancreatic necrosis (black pancreas)Extensive pancreatic necrosis (black pancreas)
Necrosectomy. Setonage. LaparostomyNecrosectomy. Setonage. Laparostomy• Cardiac arrest at the end of the procedure, deathCardiac arrest at the end of the procedure, death• Autopsy:Autopsy:
Necrosis haemorrhagica pancreatis et telae adiposae.Necrosis haemorrhagica pancreatis et telae adiposae.Inflammatio purulenta cum necrosi d. choledochi.Inflammatio purulenta cum necrosi d. choledochi.
Acute pancreatitisCase 4 – Patient MLAcute pancreatitis
Case 4 – Patient ML
SurgerySurgery
• DayDay 49 49 of hospitalization of hospitalization• Extensive fat necrosisExtensive fat necrosis• Abscess (500 ml) in lesser sacAbscess (500 ml) in lesser sac
• Fat necrosis from right iliac fossa to diaphragmatic hiatusFat necrosis from right iliac fossa to diaphragmatic hiatus• Necrosectomy, setonage, laparostomyNecrosectomy, setonage, laparostomy
SurgerySurgery
• DayDay 49 49 of hospitalization of hospitalization• Extensive fat necrosisExtensive fat necrosis• Abscess (500 ml) in lesser sacAbscess (500 ml) in lesser sac
• Fat necrosis from right iliac fossa to diaphragmatic hiatusFat necrosis from right iliac fossa to diaphragmatic hiatus• Necrosectomy, setonage, laparostomyNecrosectomy, setonage, laparostomy
Acute pancreatitisCase 4 – Patient MLAcute pancreatitis
Case 4 – Patient ML
Surgery (2)Surgery (2)
• MuMulltiple exchangetiple exchangess of setones ( of setones (1111))days 51 to 68days 51 to 68
• Wound abscess in the epigastriumWound abscess in the epigastrium6 drainage procedures from day 103 to 1316 drainage procedures from day 103 to 131
• Gradual improvementGradual improvement• Discharge on day Discharge on day 146146
Surgery (2)Surgery (2)
• MuMulltiple exchangetiple exchangess of setones ( of setones (1111))days 51 to 68days 51 to 68
• Wound abscess in the epigastriumWound abscess in the epigastrium6 drainage procedures from day 103 to 1316 drainage procedures from day 103 to 131
• Gradual improvementGradual improvement• Discharge on day Discharge on day 146146
Acute pancreatitisIndications for surgery
Acute pancreatitisIndications for surgery
• Infected necrosisInfected necrosis• Local complications of pancreatitisLocal complications of pancreatitis
• Sterile necrosisSterile necrosis
• Infected necrosisInfected necrosis• Local complications of pancreatitisLocal complications of pancreatitis
• Sterile necrosisSterile necrosis
No swellingNo swelling Minor swelling,limited to peripapillaryarea
Minor swelling,limited to peripapillaryarea
Severe swellingwith extensiveinvolvementof D2, bluishdiscoloration
Severe swellingwith extensiveinvolvementof D2, bluishdiscoloration
Moderateswelling withextensive involvementof D2
Moderateswelling withextensive involvementof D2
DGE MUSK 2000-2005DGE MUSK 2000-2005
Duodenal swellingDuodenal swelling
DGE MUSK 2000-2005DGE MUSK 2000-2005
Duodenal swellingDuodenal swelling
DGE MUSK 2000-2005DGE MUSK 2000-2005
Normal duodenumNormal duodenum Deformed duodenal loopD2 deformed and narrowed
Deformed duodenal loopD2 deformed and narrowed
Duodenal swellingDuodenal swelling
DGE & DPATMUSK
2000-2005
DGE & DPATMUSK
2000-2005Mucosal hyperemiaMucosal hyperemia
Edema of submucosal layerEdema of submucosal layer
Duodenal swellingDuodenal swelling
Normal duodenumNormal duodenum Marked thickening of D2 wallMarked thickening of D2 wall
DGE & DRAD MUSK, Helimed 2000-2005DGE & DRAD MUSK, Helimed 2000-2005
20 mm20 mm
Duodenal swellingDuodenal swelling
DGE & DRAD MUSK, Helimed 2000-2005DGE & DRAD MUSK, Helimed 2000-2005
D2 swellinglimited toperipapillaryarea
D2 swellinglimited toperipapillaryarea
D2 swellinglimited toantero-medialwall
D2 swellinglimited toantero-medialwall
Duodenal swellingDuodenal swelling
DGE & DRAD MUSK, Helimed 2000-2005DGE & DRAD MUSK, Helimed 2000-2005
Severe swellingwith circularD2 involvement;lumen barely visiblein the most severe cases
Severe swellingwith circularD2 involvement;lumen barely visiblein the most severe cases
Duodenal swellingDuodenal swelling
n (851)%
Age (y)Sex (% F)BMI (kg/m2)SE failure (%)
n (851)%
Age (y)Sex (% F)BMI (kg/m2)SE failure (%)
N69081%
57.273
28.94
N69081%
57.273
28.94
MLD405%
62.153
30.613
MLD405%
62.153
30.613
MOD88
10%
60.759
31.917
MOD88
10%
60.759
31.917
SEV334%
65.149
32.370
SEV334%
65.149
32.370
p
0.00770.00010.00000.0000
p
0.00770.00010.00000.0000
Duodenopathy gradeDuodenopathy grade
Marek et al., Gut 2005 (abstract)Marek et al., Gut 2005 (abstract)
Duodenal swellingDuodenal swelling
n (851)%
CRPmax48 mg/LIL-6max48 pg/mLWBCmax48 G/LAP-Ocum48 (score)CTSI72h (score)
n (851)%
CRPmax48 mg/LIL-6max48 pg/mLWBCmax48 G/LAP-Ocum48 (score)CTSI72h (score)
N69081%
12312010.5 9.6 1.7
N69081%
12312010.5 9.6 1.7
MLD405%
16314411.812.2 2.3
MLD405%
16314411.812.2 2.3
MOD88
10%
23226714.912.8 3.5
MOD88
10%
23226714.912.8 3.5
SEV334%
29925914.618.8 4.9
SEV334%
29925914.618.8 4.9
p
0.00000.00000.00000.00000.0000
p
0.00000.00000.00000.00000.0000
Marek et al., Gut 2005 (abstract)Marek et al., Gut 2005 (abstract)
Duodenopathy gradeDuodenopathy grade
Duodenal swellingDuodenal swelling
n (851)%
% severe% surgery% mortality
SGS-10
n (851)%
% severe% surgery% mortality
SGS-10
N69081%
31 4 2
3.9
N69081%
31 4 2
3.9
MLD405%
48 5 3
4.9
MLD405%
48 5 3
4.9
MOD88
10%
7216 8
6.0
MOD88
10%
7216 8
6.0
SEV334%
944236
7.9
SEV334%
944236
7.9
p
0.00000.00000.0000
0.0000
p
0.00000.00000.0000
0.0000
Duodenopathy gradeDuodenopathy grade
Marek et al., Gut 2005 (abstract)Marek et al., Gut 2005 (abstract)
Duodenal swellingDuodenal swelling