Acute Pancreatitis

Hassan Mohammad AlShehri 2051040006

Pancreas
y Weight about 80g and is situated retroperitoneally y Divided into Head, Body and Tail y Of the pancreatic mass, 80-90% is composed of

exocrine tissue.

Pancreas
y Tail
y y y y

Adjacent to hilum of spleen Extends horizontally behind stomach lies within the curve of the duodenum Circular smooth muscle that surrounds both the common bile duct and the main pancreatic duct Site where the common bile duct and main pancreatic duct drain into duodenum

y Body y Head y Sphincter of Oddi

y Ampule of Vater
y

Pancreas
y The lobes of the pancreas are divided into subunits

of acinar tissue and the Islets of Langerhans

y Acini cells are involved in the production of 20 different

digestive enzymes which include amylase and lipase
y These enzymes are activated by Cholecystokinin(CCK),

which is produced by the intestinal mucosa

Acute Pancreatitis

Acute Pancreatitis
y An acute condition presenting with abdominal pain

and is usually associated with raised pancreatic enzyme levels as result of inflammatory disease of the pancreas.

Etiology
y I GET SMASHED y Idiopathic y Gallstones (or other obstructive lesions) y E thanol y Trauma y Steroids y Mumps (& other viruses: CMV, EBV) y Autoimmune (SLE, polyarteritis nodosa)
y Scorpion sting

(Trinidadian - Tityus trinitatis) y Hyper Ca, TG y ERCP (5-10% of pts undergoing procedure) y Drugs (thiazides, sulfonamides, ACE-I, NSAIDS, azathioprine)

Alcohol and gallstones account for 60-80% of cases

Etiology Anatomical Anomalies
y Pancreas Divisum y Failure of dorsal and ventral duct fusion (5-15% of population) y Annular pancreas y Any ductal anomalies y Sphincter of Oddi dysfunction y Always consider a primary malignancy as a possible

cause of new onset pancreatitis in old patients without other obvious risk factors

Signs & Symptoms
y Epigastric pain y Anorexia y Nausea & Vomiting y Tachycardia y Tachypnea y Absent or decreased bowel sounds in paralytic

ilius y +/- Fever; +/- Hypotension or shock
y Grey Turner sign y Cullen s sign

Signs & Symptoms Cont.
y Pain: y Steady & severe in nature; located in the epigastric or umbilical region(max within minutes!)
y Worsened by lying supine; may be relieved by flexing

knees or leaning forward
y May radiate to back 50%

Signs & Symptoms Cont.
y Pain . . y Sudden and may mimic perforated peptic ulce y Biliary colic or acute cholecystitis if pain maximal at right upper quadrant y Radiation to the chest can simulate MI, pneumonia or pleuritic pain.

Signs & Symptoms Cont.
y Vomiting/Nausea and retching y Vomiting usually frequent and persistent
y get worse by ingestion of food or fluid y Does not relieve the pain.

Grey Turner sign

Cullen's sign

y Grey Turner sign y Cullen s sign

Differential
y May include: y Biliary disease y Intestinal obstruction y Mesenteric Ischemia y MI (inferior) y AAA (Abdominal aortic aneurysm) y Perforated P.U

How to evaluate acute pancreatitis?!!

Criteria for evaluating Acute Pancreatitis
y Ranson s y Modified Glasgow y APACHE II(ICU scoring systems) y CT Severity Index (Balthazar Score)

Ranson s Criteria
y Admission y Age > 55 y WBC > 16,000 cells/mm3 y Glucose > 200 mg/dL y LDH >350 IU/L y AST > 250 IU/L
5% mortality risk with <2 signs 15-20% mortality risk with 3-4 signs 40% mortality risk with 5-6 signs 99% mortality risk with >7 signs

y During first 48 hours y Hematocrit drop > 10% y Serum calcium < 8mg/dL y Base deficit > 4.0 mEq/L y Increase in BUN > 5mg/dL y Fluid sequestration > 6L y Arterial PO2 < 60 mmHg

Prognosis CT Severity Index
y CT Grade
Normal Focal or diffuse enlargement Intrinsic change and peripancreatic inflammation y Single fluid collection y Multiple collections of fluid or gas
y y y

0 points 1 point 2 points 3 points 4 points 0 points 2 points 4 points 6 points

y Necrosis Score
y y y y

None 1/3 of pancreas 1/2 of pancreas > 1/2 of pancrease

y Severe = Score > 6 (CT Grade + Necrosis)

Acute Hemorrhagic pancreatitis

Investigations

Investigations
y CBC y RFT y LFT y ELECTROLYTES
o WBC

hematocrit o BUN o AST, ALT Ca

y o amylase Nonspecific !!!
y Amylase levels > 3x normal very suggestive of

pancreatitis
y

May be normal in chronic pancreatitis!!!

y Enzyme level { severity y False (-): acute on chronic (EtOH); HyperTG y False (+): renal failure, other abdominal or salivary gland

process, acidemia

y o lipase
y More sensitive & specific than amylase

Imaging
y Plain X-ray: y It is not diagnostic Signs: y Sentinel loop y Colon cut-off sign y It may show a pleural

effusion

y US :
y To rule out acute cholycystitis y The pancreas is swollen y CBD dilated y Pseudocyst

y Esophageal US:
y Indicated in obese patient

y CT scan
y contrast-enhanced CT scan Is the best single imaging

investigation Indication: a. if there is diagnosis uncertainty b. In patient with sever acute pancreatitis, to distinguish interstitial from necrotizing pancreatitis c. In patient with organ failure d. When a localized complication is suspected

y signs: y Enlarged pancreas y Peripancreatic inflamation y Fluid collection y Pseudocysts y hemorrhageic

y MRCP
y Can help in detecting stones in the

CBD y Directly assessing the pancreatic parenchyma y Better visualization of fluid collections

ERCP

Management
y Supportive
y 1- NPO y NG suction for patients with ileus or emesis y 2- Aggressive volume repletion with IVF y Keep an eye on fluid balance/sequestration and electrolyte disturbances

y 3- Narcotic analgesics
y y

usually necessary for pain relief textbooks say Meperidine

y 4- Urgent ERCP and biliary sphincterotomy
y within 72 hours improves outcome of severe gallstone

pancreatitis y Reduced biliary sepsis, not actual improvement of pancreatic inflammation

complication
y Acute fluid collection: y Occur early and located in or near the pancreas y No intervention is necessary unless a large collection cause pressure symptom y Pancreatic abscess: y If the fluid collection get infected y ttt: y Percutaneous aspirated under US or CT guidance

y Pancreatic effusion: y Encapsulated collection of fluid in the pleural cavity y Pancreatic ascites: y Chronic generalized peritoneal enzyme rich effusion y Paracentesis will show turbid fluid with high amylase level y ttt: y Adequate drainage

y Hemorrhage: y Bleeding into pseudocyst cavity, or bleeding from pseudoaneurysm y Recurrent bleeding is common y Pseudocyst: y Collection of amylase rich fluid enclosed in a wall of fibrous tissue

y Pancreatic necrosis: y Diffuse or focal area of non viable parenchyma that is typically associated peripancreatic fat necrosis. y Distinguishing between infected

and sterile pancreatic necrosis is an ongoing clinical challenge.

Infected : - Uniformly fatal without intervention(100%), - Necrosectomy soon after confirmation of infected necrosis Sterile : - Mortality 10%, benefit of surgery remain unproved, - Frequently indicated for surgical debridement

Systemic complication:
y Pulmonary

Atelactasis y Pleural effusions y ARDS y Cardiovascular y Cardiogenic shock y Neurologic y Pancreatic encephalopathy y Metabolic y Metabolic acidosis y Hypocalcemia y Altered glucose metabolism
y

y Bailey & love y http://emedicine.medscape.com y http://imaging.consult.com