Note - Acute Pancreatitis

Pancreatitis
o   Acute
o   Chronic – due to fibrosis within the gland
o   Acute on chronic
o   Injury to acinar cells / impairment of secretion of zymogen granules of Premature activation of
pancreatic enzymes à auto-digestion à Local effects (oedema, hemorrhage, necrosis), systemic
effects (hemodynamic instability, bactaraemia, ARDS, Pleural effusion, GI hemorrhage, renal
failure, DIC)

Acute Pancreatitis

·         Mortality – 10 -15 %
·         Mild – oedema, minimal organ dysfunction , Mortality rate – 1%
·         Severe – Pancreatic necrosis, SIR, multi organ failure, Mortality rate – 20-50%
·         3% of all abdominal pain
·         Peak – young men, older women
·         Causes
o   I – Idiopathic, iatrogenic, inborn (mutation of cationic trypsinogen gene à acute pancreatitis in teen
ages à  chronic pancreatitis in next two decades à pancreatic cancer in 70 Years of age)
o   G – Gall stones ( commonest cause in west)
o   E – Ethanol ( commonest cause in east)
o   T – Trauma ( commonest cause in children)
o   S – Steroids
o   M – Malnutrition, Mumps, CMV, EBV, Coxsackie B
o   A – Autoimmune (SLE,PAN)
o   S – Scorpion bite
o   H – Hyperlipidaemia, Hypercalcaemia, Hypothermia
o   E – ERCP – 1-3 %
o   D – Drugs
§  S – Steroids
§  A – Azathioprim
§  N – NSAIDS
§  D – Diuretics

Diagnosis/ investigations

·         Clinical
·         Biochemical
o   Serum amylase
§  Rises within 12 hours and remains elevated for 2-3 days
§  High up to 14 days
§  Three to four times above normal
§  Normal levels does not exclude the disease
o   Urine amylase
o   Serum lipase
§  Slightly more specific and sensitive than amylase
·         Radiological
o   Contrast enhanced CT
·         To find out complications
·         To find the etiology
·         To assess the fitness for surgery

Local Complications
·         Phlegmon – abscess or an inflammatory mass in the pancreas
·         Acute fluid collection
o   Sterile
o   Most resolves
o   Intervene only when large collections cause pressure effects – percutaneous aspiration under US or
CT guidance
o   Transgastric drainage under EUS guidance 
o   Can become a pseudocyst or a abscess if become infected
·         Sterile and infected pancreatic necrosis
o   Sterile – should not interfere
o   Infected necrosis – 50% mortality
o   If the patient is septic – CT or US guided aspiration of the fluid à if aspirate is purulent –
percutaneous drainage à send for microbiology à start antibiotics
o   If sepsis worsens à pancreatic necrosectomy
·         If head is involves à Midline laparotomy
·         If body and tail are involved à retroperitoneal approach through a left flank incision
·         Feeding jejunostomy
·         Cholecystectomy if gall stone pancreatitis
·         Also laparoscopic surgery is performed
o   Closed continuous lavage
o   Closed drainage
o   Open packing
o   Closure and relaparotomy
o   Nutritional support
·         Pancreatic abscess
o   Acute fluid collection or an infected pseudocyst
o   Percutaneous drainage
·         Pancreatic ascites
o   Turbid fluid
o   High amylase level
o   Drainage via wide bore draine
o   Suppress pancreatic secretion by parenteral and Nasojejunal feeding and ocreotide
o   ERCP – identify the duct disruption and placement of a stent
·         Pancreatic Effusion
o   Encapsulated collection of fluid in the pleural cavity
o   Percutaneous drainage under image guidance
·         Haemorrhage
o   Diagnosis by CT angiography and MR angiography
o   Treatment – embolisation or surgery
·         Portal or splenic vein thrombosis
·         Pseudocyst
o   Collection of amylase rich fluid enclosed in a wall of fibrous or granulation tissue
o   Forms after 4 or more weeks after an attack of acute pancreatitis, in chronic pancreatitis or after
trauma
o   More than half have communication with pancreatic duct
o   DD –
·         acute fluid collection
·         abscess
·         cystic neoplasm
o   EUS and aspiration of fluid
o   Fluid is tested for carcinoembryonic antigen level, amylase level and cytology
o   Can resolve spontaneously
o   Intervene only if symptoms, complications develops or have to distinguish from tumor
o   Complications
·         Infection
·         Rupture in to the gut or peritoneum
·         Enlargement causing pressure effect and pain
·         Erosion into a vessel
o   Drainage
·         Percutaneous transgastric cystgastrostomy
·         Endoscopic
·         Surgical

Systemic Complications

·         CVS – shock, arrhythmias

·         ARDS
·         Renal failure
·         DIC
·         Hypocalcaemia, hyperglycaemia, hyperlipidaemia
·         Ileus
·         Visual disturbances, confusion, irritability, encephalopathy
·         Subcutaneous fat necrosis, arthralgia