ACUTE

PANCREATITIS

PROF. DR. SALİH PEKMEZCİ

 PATHOGENESIS
pancreatic enzymes and
activation of cascade systems
Proelastase, Kimotrypsinogen, Prekallikrein, C3,
Prophospholipase Plazminogen, Factor 12
trypsinogen

Enterokinase and
lisosomal katepsin
TRYPSİN

Kininogen
Elastase Kallikrein
Kimotrypsin C3a Kinin
Phospholipase Plasmin
Factor 12a
 MECHANISMS OF
PANCREATITIS

•OBSTRUCTION OF PANCREATIC DUCT

•COMMON CHANNEL HYPOTHESIS
•REFLUX OF ACTIVATED PANCREATIC
ENZYMES
•INCREASED DUCTAL PERMEABILITY
•OTHERS
 ETIOLOGY
• ALCOHOL
• GALLSTONES
• TRAUMA
• DUCTAL OBSTRUCTION
• INFECTION
• DRUGS
• METABOLIC DISTURBANCES
• ISCHEMIA
• HYPERPARATHYROIDISM
• IDIOPATIC
• OTHERS
 ETIOLOGY PATHOGENESIS OF ALCOHOL
INDUCED PANCREATITIS
• ALCOHOL
• GALLSTONE
• TRAUMA
• PARTIAL OBSTRUCTION IN
• DUCTAL
OBSTRUCTION
AMPULLA
• INFECTION • HYPERSECRETION OF PANCREAS
• DRUGS • PROTEIN PLUGS IN
• METABOLIC PANCREATIC DUCT
DISTURBANCES
• PANCREATIC ISCHEMIA
• ISCHEMIA
• OTHER
• IDIOPATIC
 THE PATHWAY OF ALCOHOL INDUCED
PANCREATITIS BY ISCHEMIA

ALCOHOL PANCREATIC ISCHEMIA

XANTHINE DEHYDROGENASE XANTHINE OXIDASE

metabolysme
ACETALDEHYDE FREE OXYGEN RAD
 ETIOLOGY RISK FACTORS IN BILIARY
PANCREATITIS
• ALCOHOL
• GALLSTONE • MULTIPLE SMALL GALLSTONES
IN GALLBLADDER
• TRAUMA
• LARGE CYSTIC DUCT
• DUCTAL
OBSTRUCTION
• CHOLEDOCOLITHIASIS
• LARGE CHOLEDOC-WIRSUNG
• INFECTION
ANGLE
• DRUGS
• COMMON CHANNEL > 5 MM
• METABOLIC
DISTURBANCES
• ISCHEMIA
• OTHER
 ETIOLOGY
COMMON CHANNEL IS
• ALCOHOL OBSERVED IN %90 OF
• GALLSTONE PATİENTS WITH BILIARY
• TRAUMA
PANCREATITIS, WHEREAS
• DUCTAL
ONLY IN %20 OF
OBSTRUCTION
PATIENTS WHO DID NOT
• INFECTION
PRESENT PANCREATITIS
• DRUGS
• METABOLIC
DISTURBANCES
• ISCHEMIA
• OTHER
 ETIOLOGY TRAUMA

• ALCOHOL A- POSTOPERATIVE OR POST-

• GALLSTONE ERCP
• TRAUMA B- FOLLOWING BLUNT OR
PENETRATING TRAUMA
• DUCTAL
OBSTRUCTION
• INFECTION
• DRUGS
• METABOLIC
DISTURBANCES
• ISCHEMIA
• OTHER
 ETIOLOGY
ETIOLOGY IN
• ALCOHOL
POSTOPERATIVE
• GALLSTONE
• TRAUMA
PANCREATITIS
• DUCTAL
OBSTRUCTION • DIRECT TRAUMA
• INFECTION
• ISCHEMIA
• DRUGS
• MICROEMBOLI AND TROMBUS
• METABOLIC
DISTURBANCES • DRUGS USED POSTOPERATIVELY
• ISCHEMIA (Azathioprine,steroids,
• OTHER calcium vs.)
 ETIOLOGY
ETIOLOGY IN
• ALCOHOL POST-ERCP
• GALLSTONE PANCREATITIS
• TRAUMA
• DUCTAL • OVER MANIPULATION
OBSTRUCTION • DIATHERMIA
• INFECTION • FORCED IRRIGATION OR
• DRUGS CONTRAST AGENT INFUSION
• METABOLIC
DISTURBANCES
• ISCHEMIA
• OTHER
 ETIOLOGY
DUCTAL OBSTRUCTION
• ALCOHOL
• GALLSTONE
• PANCREATIC TUMORS
• TRAUMA
• DUCTAL STRICTURE
• DUCTAL • PENETRATED DUODENAL ULCER
OBSTRUCTION
• AFFERENT LOOP SYNDROME
• INFECTION
• ANATOMICAL OR
• DRUGS PHYSIOLOGICAL ANOMALIES
• METABOLIC
DISTURBANCES
• ISCHEMIA
• OTHER
 VIRAL
ETIOLOGY Mumps, Coxsackie B, Enterovirus, EBV,
CMV, Hepatitis B, Hepatitis A,
Hepatitis C
• ALCOHOL
• GALLSTONE
BACTERIAL
• TRAUMA
Staphylococcus, E.Coli, Enterococcus,
• DUCTAL Enterobacteriae, Proteus, P.
OBSTRUCTION Aeruginosa, Spyrocets, C. dyphteria,
• INFECTION Legionella, Yersinia, Campylobacter,
Salmonella, Mycobacteria, Mycoplasma
• DRUGS
• METABOLIC
FUNGAL
DISTURBANCES
Aspergillosis, Actyomycosis
• ISCHEMIA
• OTHER
PARASYTES
 ETIOLOGY DRUGS ASSOCIATED WITH
PANCREATITIS

• ALCOHOL
ABSOLUTE RELATIONSHIP
• GALLSTONE
• TRAUMA
• AZOTHIOPRYNE
• DUCTAL
OBSTRUCTION • CHLOROTIAZIDE

• INFECTION • ESTROGENS

• DRUGS • FUROSEMIDE

• METABOLIC • SULFONAMIDES
DISTURBANCES • TETRACYCLINE
• ISCHEMIA • VELPROATE
• OTHER • PENTHAMIDINE AND DDL
 ETIOLOGY DRUGS ASSOCIATED WıTH
PANCREATITIS

• ALCOHOL POSSIBLE RELATIONSHIP

• GALLSTONE
• L-ASPARAGYNASE
• TRAUMA
• CORTICOSTEROIDS
• DUCTAL • ETACRYNIC ACID
OBSTRUCTION • PHENPHORMINE
• INFECTION
• DRUGS
• METABOLIC
DISTURBANCES
• ISCHEMIA
• OTHER
 ETIOLOGY THOUGHT TO BE RELATED WITH
PANCREATITIS

• ALCOHOL
• AMPHETAMINE
• GALLSTONE
• CHOLESTYRAMINE
• TRAUMA
• PROPOXYPHENE
• DUCTAL
OBSTRUCTION • INDOMETASYNE

• INFECTION • ISONIASYDE

• DRUGS • MERCAPTOPURINE

• METABOLIC • OPIADS
DISTURBANCES • RYFAMPISINE
• ISCHEMIA • SALISILATES
• OTHER • CIMETIDINE
 ETIOLOGY
METABOLIC DISTURBANCES
• ALCOHOL
• GALLSTONE • HYPERLIPIDEMIA
• TRAUMA
• HYPERCALCEMIA
• DUCTAL
OBSTRUCTION
• INFECTION
• DRUGS
• METABOLIC
DISTURBANCES
• ISCHEMIA
• OTHER
 ETIOLOGY
ISCHEMIA

• ALCOHOL
• EMBOLIZATION OF
• GALLSTONE PANCREATICODUODENAL ARTERY IN
• TRAUMA AORTOGRAPHY
• DUCTAL
OBSTRUCTION • STENOSIS OF TRUNCUS COELIACUS
• INFECTION
• DRUGS • RUPTURE OF ANEURYSM OF AORTA
• METABOLIC ABDOMINALIS
DISTURBANCES
• ISCHEMIA • MYOCARDIAL INFARCT
• OTHER
 ETIOLOGY
OTHERS

• ALCOHOL
• OTOIMMUN DISEASES
• GALLSTONE
• TRAUMA
• PROTEIN ANOMALIES
• DUCTAL
OBSTRUCTION
• SCORPION VENOM
• INFECTION
• DRUGS
• PREGNANCY
• METABOLIC
DISTURBANCES
• ISCHEMIA
• OTHER
 CLINICALPRESENTATION
• ABDOMINAL PAIN
• NAUSEA-VOMITMENT
• ANOREXIA
• FEVER
• ABDOMINAL MASS
• ILEUS
• JAUNDICE
PHYSICAL EXAMINATION

• LOCALIZED/GENERALIZED ABDOMINAL
TENDERNESS
• ABDOMINAL DISTENTION
• FEVER
• TACHYCARDIA
• HYPOTENSION
• GREY-TURNER VE CULLEN SIGNS
• CONFUSION, PSYCHOSE AND COMA
 DIAGNOSIS
BIOCHEMICAL MARKERS

• SERUM AMYLASE AND ISOFORMES

• URINE AMYLASE
• AMYLASE-CREATININE CLEARANCE RATIO
• SERUM LIPASE AND ISOFORMES
• TRYPSINE
• PHOSPHOLIPASE-A
 AMYLASE CONTAINING TISSUES

• PANCREAS P-ISOAMYLASE

• SALIVARY GLANDS
• TUBA
• OVER
• ENDOMETRIUM
• PROSTATE S-ISOAMYLASE
• BREAST
• LUNG
• LIVER
• SMALL BOWEL
 DISEASES ASSOCIATED WITH
HYPERAMYLASEMIA
INTRAABDOMINAL CAUSES

• PANCREATIC DISEASES
ACUTE PANCREATITIS, CHRONIC PANCREATITIS, TRAUMA
CARCINOMA, PSEUDOCYST, PANCREATIC ASCITES, ABCESS

• NON-PANCREATIC DISEASES
BILIARY DISEASES, BOWEL OBSTRUCTIONS, MESENTERIC
INFARCT, PERFORATED PEPTIC ULCER,PERITONITIS,
AFFERENT LOOP SYNDROME, ACUTE APPENDICITIS RUPTURE
OF ECTOPICAL PREGNANCY, SALPENGITIS, RUPTURATED
ANEURYSM OF AORTA
 DISEASES ASSOCIATED WITH
HYPERAMYLASEMIA
EXTRAABDOMINAL CAUSES

• DISEASES OF SALIVARY GLANDS, MUMPS, PAROTITIS,

TRAUMA, PAROTIS STONES, RADIATION SIALADENITIS

• AMYLASE CLEARANCE DEFECTS: RENAL FAILURE,

MACROAMYLASEMIA

• OTHER: PNUEMONIA, PANCREATIC PLEURAL EFFUSION,

MEDIASTINAL PSEUDOCYST, CEREBRAL TRAUMA, SEVERE
BURNS, DIABETIC KETOACIDOSIS, PREGNANCY, DRUGS
AMYLASE-CREATININE CLEARANCE RATIO =

URINE AMYLASE X SERUM CREATININE X 100

SERUM AMYLASE URINE CREATININE

 OTHER LABORATORY
EXAMINATIONS
• WHOLE BLOOD COUNT
• SGOT, SGPT
• ALKALINE PHOSPHATASE
• BILIRUBINE
• BLOOD GLUCOSE
• BLOOD UREA AND CREATININE
• SERUM ELECTROLYTES
• DIAGNOSTIC PERITONEAL LAVAGE
 IMAGING

• PLAIN X-RAY (THORAX AND ABDOMEN)

• ABDOMINAL ULTRASONOGRAPHY
• COMPUTERIZED TOMOGRAPHY
• MAGNETIC RESONANCE IMAGING
• ERCP
 SCORING SYSTEMS IN ACUTE
PANCREATITIS

• RANSON CRITERIA
• IMRIE CRITERIA
• APACHE II (acute physiologic and
chronic health enquiry)
• MRCS (medical research council
sepsis)
• SAP (simplified acute physiologic)
 RANSON CRITERIA
(GALLSTONE PANCREATITIS)
ADMISSION IN THE FIRST 48 HOURS
• AGE >70 • DECREASED LEVEL OF
• LEUCOCYTE >18000/mm3 HEMATOCRIT BY %10
• BLOOD GLUCOSE • INCREASED LEVEL OF BUN
>220mg/dl >2mg/dl
• SERUM LDH >400 IU/dl • DECREASED SERUM
• AST >250 U/dl CALCIUM VALUE BELOW <8
mg/dl
• BASE DEFICIT >5 mEq/L
• ESTIMATED FLUID LOSS
>4 L
 RANSON CRITERIA
(NON-GALLSTONE PANCREATITIS)
ADMISION IN THE FIRST48 HOURS
• AGE >55
• DECREASED LEVEL OF
• LEUCOCYTE >16000/mm3
HEMATOCRIT BY %10
• BLOOD GLUCOSE
>200mg/dl • INCREASED LEVEL OF BUN
• SERUM LDH >350 IU/dl >5mg/dl
• AST >250 U/dl • DECREASED SERUM
CALCIUM <8 mg/dl
• BASE DEFICIT >4 mEq/L
• ESTIMATED FLUID LOSS
>6 L
• ARTERIAL PaO2 <60 torr
 ASSESSMENT OF THE SEVERITY OF
PANCREATITIS
BIOCHEMICAL MARKERS
• NEUTROPHIL ELASTASE
• ACUTE PHASE PROTEINS
• TAP (tripsinogen activation peptide)
• PANCREATITIS RELATED PROTEIN (PAP)
• COMPLEMENT
• IL-6
• TNF (tumor necrosis factor)
• RIBONUCLEASE
• ANTI-PROTEASES
• PHOSPHOLIPASE-A
• METHEMALBUMIN
 ASSESSMENT OF THE SEVERITY OF
PANCREATITIS
RADIOLOGICAL EVALUATION

• ULTRASONOGRAPHY
• CONTRAST ENHANCED CT
• ERCP
• ANGIOGRAPHY
 COMPLICATIONS

LOCAL COMPLICATIONS

• BLEEDING
• PSEUDOCYST
• ABCESS
• PHLEGMON
• NECROSIS
• PANCREATIC ASCITES
 COMPLICATIONS

SYSTEMIC COMPLICATIONS

• RESPIRATORY FAILURE
• CARDIOVASCULAR COMPLICATIONS
• HEPATOBILIARY COMPLICATIONS
• GASTROINTESTINAL COMPLICATIONS
• RENAL FAILURE
• MULTI-ORGAN FAILURE
• METABOLIC DISTURBANCES
• LESIONS OF SKIN AND BONE
 TREATMENT

• SUPPORTIVE TREATMENT
• SUPPRESSION OF EXOCRINE SECRETION OF PANCREAS
• INHIBITION OF PANCREATIC ENZYMES
• PROTECTION OF PANCREAS FROM FREE OXYGEN
RADICALS
• ELIMINATION OF TOXIC AGENTS IN PERITONEAL
CAVITY
 TREATMENT

SUPPORTIVE TREATMENT

• FLUID RESUSCITATION
• ELECTROLYTE REPLACEMENT
• ANALGESIA
• NUTRITIONAL SUPPORT
• ANTIBIOTICS
• RESPIRATORY SUPPORT
 TREATMENT

SUPPRESSION OF EXOCRINE SECRETION OF

PANCREAS

• NASOGASTRIC SUCTION
• H2 RECEPTOR ANTAGONISTS
• ANTIACIDS
• ANTICHOLINERGICS
• GLUCAGON
• CALCITONIN
• SOMATOSTATIN
 TREATMENT

INHIBITION OF PANCREATIC ENZYMES

• INHIBITORS OF PROTEASES
• APROTININE
• GABEXATE
• CHAMOSTATE
• FRESH FROZEN PLASMA
• ANTIFIBRINOLITICS
• CHLOROQUINE
 TREATMENT

PROTECTION OF PANCREAS FROM

FREE OXYGEN
RADICALS

• CLEANSING AGENTS OF FREE OXYGEN RADICALS

• XANTHINE OXYDASE INHIBITORS
• ISOVOLEMIC HEMODILUTION
 TREATMENT

ELIMINATION OF TOXIC AGENTS

• PERITONEAL DIALYSIS
 Abdominal pain
history
physical examination
serum enzyme levels
Acute pancreatitis

CRP, LDH, BT

edematous pancreatitis Necrotizing pancreatitis

daily follow-up until the

symptoms disappear ICU

daily
CRP, LDH response + response -

Ultrasonography
Biliary pancreatitis
Medical treatment CT
ERCP/papillotomy (No complication,
Elective biliary surgery Focal necrosis -<%50) Sepsis parameters

FNA - Culture

Surgery
 TREATMENT
SURGERY

•Necrosectomy in necrotizing
pancreatitis
•Cholecystectomy
•ERCP
•Surgery in complications
(pseudocyst, ascites vs.)
 TREATMENT
SURGERY

NECROSECTOMY

•Necrosis infected / sterile ?

•Presence of sepsis
 TREATMENT
SURGERY
NECROSECTOMY

3. Laparotomy
• packing
• closed lavage - drainage
2. CT-guided percutaneous
necrosectomy
 TREATMENT
SURGERY

CHOLECYSTECTOMY

Laparoscopic or open (during the

same hospitalization period, if
possible)

Biliary drainage is best

accomplished by ERCP
 TREATMENT
SURGERY
Treatment of pancreatic pseudocyst:
1.Conservative management
2.Percutaneous drainage (radiological)
3.Endoscopic (stenting vs.)
4.Surgical (cystogastrostomy or
cystoduodenoostomy or cystojejunostomy)
• Laparotomy
• Laparoscopy
 TREATMENT
SURGERY

Pancreatic ascites

1. Endoscopic (pancreatic stent)

2. Surgical (drainage to
jejunum,resection)
 CHRONIC
PANCREATITIS
 DEFINITION

Irreversible damage to the

pancreas and the development of
histologic evidence of
inflammation and fibrosis and
destruction of exocrine (acinar
cell) and endocrine (islets of
Langerhans) tissue
 HISTOPATHOLOGY
• Pancreas is normal at the initial
period of the disease
• As the disease progresses pancreas
become wide and stiff
• There are narrow and wide segments into
the pancreatic ducts; the ducts become
dilated and curled in time
• Calcified stones may be present into
the pancreatic ducts
 ETIOLOGY

• Alcohol
• Pancreatic duct obstruction
(trauma, acute pancreatitis,
tumor etc.)
• Hereditary pancreatitis
• İnfantil malnütrisyon
• İdyopatik
 Classification of Chronic Pancreatitis
• Alcoholic
• Tropical
Tropical calcific pancreatitis
Fibrocalculous pancreatic diabetes
• Genetic
Hereditary pancreatitis
Cystic fibrosis
Others?
• Metabolic
Hypercalcemia
Hypertriglyceridemia, acquired or inherited
(e.g.,apoprotein C-II deficiency, lipoprotein lipase
deficiency)
Obstructive
• Benign pancreatic duct obstruction
Traumatic stricture
Stricture after necrotizing pancreatitis
Stenosis of sphincter of Oddi
Pancreas divisum (with inadequate accessory papilla)
Sphincter of Oddi dysfunction?
Malignant pancreatic duct stricture
Pancreatic, ampullary, or duodenal carcinoma
• Autoimmune
Isolated autoimmune chronic pancreatitis
Associated with autoimmune diseases (Sjögren’s syndrome,
primary biliary cirrhosis, primary sclerosing
cholangitis)
• Idiopathic
Early-onset
Late-onset
• Asymptomatic pancreatic fibrosis
Chronic alcoholic patients
Aged individuals
 CLINICAL PRESENTATION

• Abdominal pain
• Nausea - vomiting
• Weight loss
• Infections
• Steatorrhea
• Diabetes
 DIAGNOSIS

• Laboratory: serum amylase and

other laboratory examinations of
pancreatic function – direct ve
indirect)
• Imaging: (Plain abdominal X-ray,
CT, MRCP, ERCP)
• Biopsy
 TREATMENT
• Cessation of alcohol
• Low fat diet
• Pancreatic enzyme supplements
• Morphine and tobacco should be avoided
• Analgesics
• Endoscopic interventions
(sphincterotomy, stone removal, stent
therapy vs.)
• Surgery
 TREATMENT
surgery
Ampullary operations
• Transduodenal sphincteroplasty
• Septoplasty of pancreatic duct
Denervation operations
• Alcohol injection
Drainage procedures
• Puestow procedure
Resection
• Whipple procedure
• Beger procedure
• Total pancreatectomy
 Complications
• Pancreatic Pseudocyst
• Bleeding
Pseudocyst Wall, Pseudoaneurysms, Variceal
Bleeding from Splenic Vein Thrombosis
• Common Bile Duct Obstruction
• Duodenal Obstruction
• Pancreatic Fistula
External Pancreatic Fistula, Internal Pancreatic
Fistulas
• Cancer
• Dysmotility