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pancretitis

Dr-Monther Abureden
General surgeon-MOH
Liver and kidney transplant surgeon

DEFINITIONS
Inflammation of
glandular parenchymal lead to injury
and destruction of acinar components
Acute: reversible
Chronic :
progressive

Acute Pancreatitis

CLASSIFICATION
Mild
Moderate
Sever 25%

Acute pancreatitis
Etiology:

1-Gallbladder stones
2-immoderate alcohol
consumption
3-hyperlipedemia
4-drug induce
5- infectious causes:
mumps,coxaki B
6-Post ERCP
7-Heredatery

pathophysiology
1-The critical step:
Pancreatic outflow
obstruction
2-Activation of pancreatic enzymes
3-Autodigestion
4-Release of cytotoxines
5-Activation of inflammatory response
6-Organ failure

The Pancreas

Diagnosis
pain,vomiting

Diagnosis
24 h
3x Normal levels of amylase
lipase
(10 140 U/L)

Abdominal Pain
Vomiting

( 50 150 U/Dl)

or

Acute Pancreatitis
phtsical examination

Cyanosis, Dyspnea
Bowel sounds decreased or absent
Low-grade fever, Leukocytosis
Hypotension, Tachycardia
Jaundice
Abnormal lung sounds - Crackles
Discoloration of abdominal wall Turners
or Cullens sign
SIGNS OF SHOCK

Prognosis Ransons
(Severe > 3)

Ransons Score

5 on Admission

Age > 55 y
Glucose >200 mgldl
WBC > 16000
LDH > 350 iu/l
AST > 250 iu/l

6 after 48 hours from presentation

Hct > 10% decrease


Calcium < 8 mg/dl
Base Deficit > 4 mEq/l
BUN > 8
Fluid Sequestration >= 6L
PaO2 < 60

APACHE II scale
age
temperature
mean arterial pressure
heart rate
PaO2
arterial pH
serum potassium
serum sodium
serum creatinine
hematocrit
white blood cell count
Glasgow Coma Scale score
chronic health status

Assesment of severity
25%Sever
1-CRP:
>130 mg/l(first 72h)=complicated
pancreatitis
2-Hematocrit:!!!!!!!!
bad sign: necrosis
bad sign:dehydrated
3-Ct scan

Complications
Local
Pancreatic fluid collection:
temporary,persistant
Pancreatic necrosis
Significant hemorrhage

Systemic
INFLAMMATORY PROCESS
Syestamatic Inflammatory Syndrome
Multiple Organ
Dysfunction:Respiratory,CVS,Renal
failur

Managments

Fluid
Pain killer
Abs
Nutrition
ERCP
Cholecystectomy

Fluid

Urine output,
H.R
BP,
CVP

Pain

NSAIDs
weak opioid
strong opioid
epidural anasthesia

Antibiotics

Nutrition
Early
Enteral feeding(no sepsis)

ERCP
cholangitis

Cholecystectomy

When to go for surgery


infected pancreatic necrosis

Chronic pancreatitis
Dynamic disease:
progressive loss of pancreatic
parenchyma caused by inflammation
and tissue destruction and subsequent
synthesis of fibrotic tissue

Causes
TIGARO
Toxic: Alcohol, Ca,lipid,smoking,uremia
Idiopathic
Genetic
Autoimmune
Radiation
Obstruction

Dynamic disease
Stage A:
Recurrent abdominal pain+_mild impairment
of pancreatic function
Stage B:
more frequent attaches ,more
sever+significant impairment in pancreatic
function
Stage C:
End stage .less sever less frequent
attachesBUT marked impairment of endocrine
and exocrine function

pathogenesis

???
Necrosis-fibrosis hypothesis
Protein plug hypothesis
Oxidative stress theory
Toxic metabolic theory
.

Diagnosis
History: recurrent attaches of
abdominal pain
Epigastric and radiating to the back
Weight loss:fear,malabsorbtion
Steatorrhea(late,90% lost)
Imaging

Imaging
plain x ray

ERCP
gold stander image
Dilated TortuosMultiple side branches

managemant
Conservative
Endoscopic
surgery

pain
1-stop Alcohol intake

2-Analgesia:NSAIDSOpioids
3-celiac plexus neurolysis

Pancreatic exocrine enzyme


supplement
Weight loss or
steatorrhea:mandatory

malnutreition

Frequent meals
protein: High
sugar :High
Fat: medium chain fatty acids?

Endoscopic treatment
Sone:extraction
Stricture:dilatation and stenting

surgery
Drainage procedures
Resection procedures

QUIZ

Standard supportive measures for


patients with mild pancreatitis include
the following:
A. Intravenous fluid and electrolyte
therapy.
B. Withholding of analgesics to allow
serial abdominal examinations
C. Subcutaneous octreotide therapy
D. Nasogastric decompression
E.prophylactic antibiotics

Which of the following is the most


popular single marker test for acute
pancreatitis severity used today?
1. Trypsinogen activation peptide
2. TNF- alpha
3. C Reactive Protein
4. Interleukin 6&8

Which of the following is associated


with gut atrophy?
1. NG feedings
2. Jejunal feedings
3. Parenteral feedings
4. Enteric feedings

Severity of acute pancreatitis


correlate with levels of all of the
following except
a) Glucose
b) Amylase
c) Transaminase
d) Calcium