Acute & Chronic
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Presented By: Ehsan Arefnia June 2012 PowerPoint PPT Presentation


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Acute & Chronic Pancreatitis. Presented By: Ehsan Arefnia June 2012. Anatomy. Retroperitoneal Organ Weighs 75 To 100 G 15 To 20 Cm Long Head Neck Body Tail. Physiology. Three General Functions: Neutralizing the acid chyme entering the duodenum from the stomach

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Presented By: Ehsan Arefnia June 2012

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Presented by ehsan arefnia june 2012

Acute & Chronic

Pancreatitis

Presented By: Ehsan Arefnia

June 2012


Anatomy

Anatomy

Retroperitoneal Organ

Weighs 75 To 100 G

15 To 20 Cm Long

Head

Neck

Body

Tail


Physiology

Physiology

  • Three General Functions:

  • Neutralizing the acid chyme entering the duodenum from the stomach

  • Synthesis and secretion of digestive enzymes after a meal

  • Systemic release of hormones that modulate metabolism of carbohydrates, proteins, and lipids


Acute pancreatitis

Acute Pancreatitis


Definition and incidence

Definition and Incidence

  • Inflammatory disease with little or no fibrosis

  • Initiated by several factors

  • Develop additional complications

  • 300,000 cases occur in the united states each year leading to over 3000 deaths


Etiology

Etiology

  • Biliary tract disease

  • Alcohol

  • Drugs

    • 30 meds identified

      • AIDS therapy: didanosine, pentamidine

      • Anti-inflammatory: sulindac, salicylates

      • Antimicrobials: metronidazole, sulfonamides, tetracycline, nitrofurantoin

      • Diuretics: furosemide, thiazides

      • IBD: sulfasalazine, mesalamine

      • Immunosuppressives: azathioprine, 6-mercaptopurine

      • Neuropsychiatric: valproic acid

      • Other: calcium, estrogen, tamoxifen, ACE-I

  • Hypertryglycerides

    • Greater than 1000 mg/dL

  • Trauma

    • External

      • pancreatic duct injury

    • Surgical

  • CABG, Organ transplant, ERCP, Billroth II, Splenectomy

  • Pancreatic duct obstruction

    • Neoplasms

    • Pancreas divisum

  • Ischemia

    • Hypoperfusion

    • Atheroembolic

    • Vasculitis

    • Ampullaryand duodenal lesions

  • Infections

    • Mumps, CMV, EBV, Coxaci, ECOV,HBV, Herpes

  • HIV

    • 35 to 800 times greater risk of AP c/w general pop.

  • Hypercalcemia

    • Most often secondary to hyperparathyroidism

  • Hereditary

  • Venom

    • Scorpion, spider, Gila Monster, lizard bites

  • Pregnancy

    • Third trimester until 6 weeks post partum

  • Chinese liver fluke

  • Cystic fibrosis


Etiology get smashed

Etiology: (GET SMASHED)

G: Gallstone

E: Ethanol

T: Trauma

S: Steroid

M: Mump

A: Alcoholism or Autoimmune

S: Scorpion bits

H: Hyperlipidemia

E: ERCP

D: Drugs


Differential diagnosis

Differential Diagnosis

  • Pancreatitis

  • Acute Cholecystitis

  • Cholangitis

  • Perforated Viscous

  • MI

  • Severe Pneumonia

  • Intestinal Obstruction

  • Ruptured Aaa

  • Diverticulitis

  • Bowel Ischemia

  • Appendicitis

  • Caecal Perforation

  • Ruptured Ectopic


Clinical presentation

Clinical Presentation

  • Abdominal pain

    • Epigastric

    • Radiates to the back

    • Worse in supine position

  • Nausea and vomiting

  • Tachycardia, Tachypnea, Hypotension, Hyperthermia

  • Elevated Hematocrit

  • Cullen's sign

  • Grey Turner's sign


Presented by ehsan arefnia june 2012

Grey Turner sign

Cullen’s sign


Diagnosis biochemical

serum amylase

Nonspecific

Returns to normal in 3-5 days

Normal amylase does not exclude pancreatitis

Level of elevation does not predict disease severity

Urinary amylase

P-amylase

Serum Lipase

Serum Electrolytes

Hypocalcaemia (Poor prognosis)

Hyperglycemia (Poor prognosis)

Hypoalbuminemia

CBC

Increased Hb

Thrombocytosis

Leukocytosis

Liver Function Test

Serum Bilirubin elevated

Alkaline Phosphatase elevated

Aspartate Aminotransferase elevated

Diagnosis: Biochemical


Assessment of severity

Assessment of Severity

  • Ranson Criteria

  • Biochemical Markers

  • Computed Tomography Scan


Ranson criteria criteria for acute gallstone pancreatitis

Admission

Age > 70

WBC > 18,000

Glucose > 220

LDH > 400

AST > 250

During first 48 hours

Hematocrit drop > 10 points

Serum calcium < 8

Base deficit > 5.0

Increase in BUN > 2

Fluid sequestration > 4L

Ranson CriteriaCriteria for acute gallstone pancreatitis

<2 pos sign: mortality rate is 0

3-5 pos sign: mortality rate is 10 to 20%

>7pos sign: mortality rate is >50%


Presented by ehsan arefnia june 2012

50 year-old woman

Stomach

Pancreas

Liver

V

A

L Kidney

R Kidney

Spleen

CT scans of normal kidneys and pancreas


Presented by ehsan arefnia june 2012

Gallstone-induced pancreatitis in 27 year-old woman

Large, edematous, homogeneously attenuating pancreas (1). Peripancreatic inflammatory changes (white arrows). There is no pancreatic necrosis. Calcified gallstones are seen in gallbladder (black arrow)


Pancreatic necrosis

Pancreatic Necrosis


Treatment of mild pancreatitis

Treatment of Mild Pancreatitis

  • Pancreatic rest

  • Supportive care

    • fluid resuscitation – watch BP and urine output

    • Pain Control

    • NG tubes and H2 blockers or PPIs are usually not helpful

  • Refeeding(usually 3 to 7 days) If:

    • Bowel Sounds Present

    • Patient Is Hungry

    • Nearly Pain-free (Off IV Narcotics)

    • Amylase & Lipase Not Very Useful


Treatment of severe pancreatitis

Treatment of Severe Pancreatitis

  • Pancreatic Rest & Supportive Care

    • Fluid Resuscitation – may require 5-10 liters/day

    • Careful Pulmonary & Renal Monitoring – ICU

    • Maintain Hematocrit Of 26-30%

    • Pain Control – PCA pump

    • Correct Electrolyte Derangements (K+, Ca++, Mg++)

  • R/O necrosis

    • Contrasted CT scan at 48-72 hours

    • Prophylactic antibiotics if present

    • Surgical debridement if infected

  • Nutritional support

    • May be NPO for weeks

    • TPN vs. enteral support (TEN)


Complications

Complications

  • Local

    • Phlegmon, Abscess, Pseudocyst, Ascites

    • Involvement of adjacent organs, with hemorrhage, thrombosis, bowel infarction, obstructive jaundice, fistula formation, or mechanical obstruction

  • Systemic

    • A. Pulmonary: Pneumonia, atelectasis, ARDS, Pleural Effusion

    • B. Cardiovascular: Hypotension, Hypovolemia, Sudden Death, Nonspecific ST-T wave changes, Pericardial effusion

    • C. Hematologic :Hemoconcentration, DIC

    • D. GI: Hemorrhage, Peptic ulcer, Erosive gastritis, Portal vein or splenic vein thrombosis with varices

    • E. Renal: Oliguria, Azotemia, Renal artery/vein thrombosis

    • F. Metabolic :Hyperglycemia, Hypocalcemia, Hypertriglyceridemia, Encephalopathy, Sudden Blindness (Purtscher's retinopathy)

    • G. CNS: Psychosis, Fat Emboli, Alcohol withdrawal syndrome

    • H. Fat necrosis: Intra-abdominal saponification, Subcutaneous tissue necrosis


Acute pseudocyst

Acute Pseudocyst


Management

Management


Chronic pancreatitis

Chronic Pancreatitis


Definition and prevalence

Definition and Prevalence

  • Incurable, Chronic Inflammatory Condition

  • 5 To 27 Persons Per 100,000

  • Fibrosis

  • Alcohol


Etiology1

Etiology

  • Alcohol, 70%

  • Idiopathic (including tropical), 20%

  • Other, 10%

    • Hereditary

    • Hyperparathyroidism

    • Hypertriglyceridemia

    • Autoimmune pancreatitis

    • Obstruction

    • Trauma

    • Pancreas divisum


Signs and symptoms

Signs and Symptoms

  • Steady And Boring Pain

  • Not Colicky

  • Nausea Or Vomiting

  • Anorexia Is The Most Common

  • Malabsorption And Weight Loss

  • Apancreatic Diabetes


Laboratory studies

Laboratory Studies


Presented by ehsan arefnia june 2012

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


Treatment

Treatment

  • Analgesia

  • Enzyme Therapy

  • Antisecretory Therapy

  • Neurolytic Therapy

  • Endoscopic Management

  • Surgical Therapy


Complications1

Complications

  • Pseudocyst

  • Pancreatic Ascites

  • Pancreatic-Enteric Fistula

  • Head-of-Pancreas Mass

  • Splenic and Portal Vein Thrombosis


Management1

Management


References

References

  • Schwartz's Principles of Surgery, Ninth Edition

  • Sabiston Textbook of Surgery, 18th Edition.

  • WWW.UpToDate.COM

  • WWW.MDConsult.COM


Presented by ehsan arefnia june 2012

THANKE YOU

Questions, If any….??


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