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Acute Pancreatitis LH
Acute Pancreatitis LH
1. https://emedicine.medscape.com/article/1948885-overview 2
Embryology
• Endodermal origin – forms from endodermic
foregut
• Begins with the formation of a ventral and a dorsal
pancreatic bud
• Dorsal bud forms the head, neck, body, and tail
• Ventral bud forms the uncinate process
2. https://en.wikipedia.org/wiki/Pancreas 3
Embryology
• Duodenum rotates to the right
• It carries with it the ventral pancreatic bud and
common bile duct (swings posteriorly)
• Upon reaching its final destination, the ventral bud
fuses with the dorsal bud, trapping the superior
mesenteric vessels in between.
3. http://cursoenarm.net/UPTODATE/contents/mobipreview.htm?26/21/26970 4
Embryology
• At this point of fusion, the main ducts of the ventral
and dorsal pancreatic buds fuse, forming the main
(Wirsung) pancreatic duct.
• The duct of the dorsal bud regresses, the proximal
part forming the accessory duct.
3. http://cursoenarm.net/UPTODATE/contents/mobipreview.htm?26/21/26970 5
Anatomy
6
Anatomy
• Head
Lies in the C-shaped curve of the duodenum
Uncinate process hooks behind the superior mesenteric
vesesls
Terminal CBD runs behind the upper half of the head of
pancreas before joining the main pancreatic duct of
Wirsung to form a common channel (ampulla), which
opens at the major papilla on the medial wall of the
second part of the duodenum.
2. https://en.wikipedia.org/wiki/Pancreas 7
Anatomy
• Neck
2.5 cm (1 in) long
Lies in front of the superior mesenteric artery and vein,
splenic vein and portal vein
Front upper surface supports the pylorus (the base) of
the stomach.
Grooved by the gastroduodenal artery on the right
2. https://en.wikipedia.org/wiki/Pancreas 8
Anatomy
• Body
Largest part of the pancreas
Lies behind the pylorus, along the transpyloric plane
Runs obliquely upwards to the left
• Tail
Reaches the splenic hilum in the splenorenal (lienorenal)
ligament
2. https://en.wikipedia.org/wiki/Pancreas 9
Blood supply
• The pancreas receives blood
from branches of both the
coeliac artery and superior
mesenteric artery.
• Neck, body and tail of the
pancreas are supplied by the
splenic artery through its
pancreatic branches
• Head of the pancreas is
supplied by the superior and
inferior pancreaticoduodenal
arteries.
2. https://en.wikipedia.org/wiki/Pancreas 10
Blood supply
• The body and neck of
the pancreas drain into
the splenic vein
• The head drains into
the superior
mesenteric and portal
veins.
2. https://en.wikipedia.org/wiki/Pancreas 11
Lymphatic drainage
• Head drains into
pancreaticoduodenal lymph
nodes and lymph nodes in the
hepatoduodenal ligament, pre
and postpyloric lymph nodes.
• Body and tail drain into
mesocolic lymph nodes (around
the middle colic artery) and
lymph nodes along the hepatic
and splenic arteries.
• Final drainage occurs into celiac,
superior mesenteric, and para-
aortic and aortocaval lymph
nodes.
1. https://emedicine.medscape.com/article/1948885-overview 12
Nerve supply
• Parasympathetic
supply from the
posterior vagal trunk
via celiac branch
• Sympathetic supply
from T6-T10 via the
thoracic splanchnic
nerves and the celiac
plexus.
1. https://emedicine.medscape.com/article/1948885-overview 13
Roles of the pancreas
• The pancreas is a composite gland containing both
exocrine and endocrine components.
1. https://emedicine.medscape.com/article/1948885-overview 14
Exocrine - external digestive role
• Acini, formed of acinar cells
around a central lumen, are
arranged in lobules.
• Each lobule has its own ductule,
and many ductules join to form
intralobular ducts, which then
form interlobular ducts that
drain into branches of the main
pancreatic duct.
• Two main ducts, the main
pancreatic duct and the
accessory pancreatic duct, drain
pancreatic juice through the
ampulla of Vater into the
duodenum.
1. https://emedicine.medscape.com/article/1948885-overview 15
Exocrine - external digestive role
• Secretion of the pancreatic juice:
Digestive enzymes are stored in an inactive
form to prevent autodigestion
1. https://emedicine.medscape.com/article/1948885-overview 16
Endocrine – internal hormone role
• The endocrine cells of pancreas reside in
the islets of Langerhans (2% of pancreas
parenchyma)
• Consists of:
Insulin from beta cells (75%)
Glucagon from alpha cells (20%)
Somatostatin from delta cells
Pancreatic polypeptide from F cells
1. https://emedicine.medscape.com/article/1948885-overview 17
Acute pancreatitis
• Acute pancreatitis is an inflammatory
illness of the pancreas of various
severity.
• 2012 Revised Atlanta Classification of
acute pancreatitis
• Classification based on duration:
• Early (first week)
– Clinical parameters and SIRS
• Late (after the first week)
– Morphologic criteria based on CT findings
combined with clinical parameters
4. Klingensmith M.E. et al, The Washington Manual of Surgery 7th Edition. Wolters Kluwer. 2016; 388 - 404
18
Acute pancreatitis
• Mild acute pancreatitis
– No organ failure, local or systemic
complications
• Moderately severe acute pancreatitis
– Organ failure that resolves within 48 h
and/or
– Local or systemic complications without
persistent organ failure
• Severe acute pancreatitis
– Persistent organ failure > 48 h
5. Greenberg JA, Hsu J, Bawazeer M, Marshall J, Friedrich JO, Nathens A, et al. Clinical practice guideline:
management of acute pancreatitis. Canadian Journal of Surgery. 2016;59(2):128-40. 19
Acute pancreatitis
• Morphological classification:
• Interstitial edematous acute pancreatitis
(80%)
Acute inflammation of the pancreatic
parenchyma and peripancreatic tissues
Self limiting, milder, transient clinical
manifestations
• Necrotising acute pancreatitis (20%)
Inflammation and pancreatic parenchymal
necrosis
Higher morbidity and mortality
4. Klingensmith M.E. et al, The Washington Manual of Surgery 7th Edition. Wolters Kluwer. 2016; 388 - 404
20
Epidemiology in Malaysia
• Worldwide, the incidence of acute pancreatitis
ranges between 5 and 80 per 100,000 population,
with the highest incidence recorded in the United
States and Finland. [6]
• Females outnumbered males by a ratio of more
than 3:1 [7]
• Incidence peaks in the 40–60 years age group [8]
• The common factors associated with acute
pancreatitis were alcohol intake in males and
biliary disease in females. [8]
• 8.4% fell into the category of severe pancreatitis [6]
• Overall mortality rate was 2.1% [7]
6. https://emedicine.medscape.com/article/181364-overview#a5
7. Raj SM, Lopez D, Thambidorai CR, Kandasamy P, Toufeeq Khan TF, Mohamad H, et al. Acute pancreatitis in north-
eastern peninsular Malaysia: an unusual demographic and aetiological pattern. Singapore medical journal.
1995;36(4):371-4. 21
8. P T, G H. Comparative study of acute pancreatitis in different ethnic populations in a Malaysian public hospital2008.
Pathophysiology
22
Etiology
23
History
• Abdominal pain
– Usually epigastric, sudden in
onset, dull in nature, radiating to
the back, relieved by bending
forward
• Nausea, vomiting, anorexia
• Fever
• Jaundice
• History of previous biliary colic,
binge alcohol consumption, ECRP,
family history of
hypertriglyceridemia/
autoimmune disease
4. Klingensmith M.E. et al, The Washington Manual of Surgery 7th Edition. Wolters Kluwer. 2016; 388 – 404
6. https://emedicine.medscape.com/article/181364-overview#a5 24
Clinical Presentation
• Tachycardia, hypotension
(hypovolemia)
• Abdominal tenderness, guarding,
distension, silent abdomen
• Febrile
• Jaundice
• Severe systemic effects
– Hypoxemia, renal failure,
hypocalcemia, hyperglycemia,
respiratory failure
• Gray-Turner sign (flank ecchymosis
– reddish brown)
• Cullen sign (periumbilical
ecchymosis - bluish)
• Fox sign (thigh ecchymosis – bluish)
• Purtscher retinopathy (temporary
or permanent blindness) *rare*
4. Klingensmith M.E. et al, The Washington Manual of Surgery 7th Edition. Wolters Kluwer. 2016; 388 – 404
6. https://emedicine.medscape.com/article/181364-overview#a5 25
Diagnosis
The diagnosis of acute pancreatitis is made
by fulfilling two of the following three
criteria:
• Abdominal pain (acute onset of a
persistent, severe, epigastric pain often
radiating to the back)
• Lipase/amylase elevation >3 times the
upper limit of normal
• Characteristic imaging features on
contrast-enhanced CT, MRI, or
ultrasound
9. https://gi.org/guideline/acute-pancreatitis/ 26
Blood investigations
Blood test Abnormality Explanation
4. Klingensmith M.E. et al, The Washington Manual of Surgery 7th Edition. Wolters Kluwer. 2016; 388 – 404 27
Blood investigations
Blood test Abnormality Explanation
4. Klingensmith M.E. et al, The Washington Manual of Surgery 7th Edition. Wolters Kluwer. 2016; 388 – 404 28
Radiological investigations
Ultrasound
• Pancreas not visualised in 40% due to overlying bowel gas
and body hiatus. [4]
• Ultrasonography should be performed in all patients at
baseline to evaluate the biliary tract to determine if the
patient has gallstones and/or a stone in the common bile
duct. [5]
• Ultrasonography can also identify gallbladder wall
thickening and edema, gallbladder sludge, pericholecystic
fluid and a sonographic Murphy sign, consistent with
acute cholecystitis.
• When these signs are present, the positive predictive
value of ultrasonography in the diagnosis of acute
cholecystitis is greater than 90%, and additional studies
are rarely needed.
4. Klingensmith M.E. et al, The Washington Manual of Surgery 7th Edition. Wolters Kluwer. 2016; 388 – 404
5. Greenberg JA, Hsu J, Bawazeer M, Marshall J, Friedrich JO, Nathens A, et al. Clinical practice guideline:
29
management of acute pancreatitis. Canadian Journal of Surgery. 2016;59(2):128-40.
Radiological investigations
Ultrasound
9. http://wuxifhff.com/ultrasound-abdomen-anatomy/ultrasound-abdomen-anatomy-with-full-of-ultrasound-abdomen-
30
anatomy/
Radiological investigations
Ultrasound
9. http://wuxifhff.com/ultrasound-abdomen-anatomy/ultrasound-abdomen-anatomy-with-full-of-ultrasound-abdomen-
31
anatomy/
Radiological investigations
Computed tomography (CT)
• Gold standard (sensitivity 90%, specificity 100%)
• Should be performed selectively when:
1) a patient presents with substantial abdominal pain and a
broad differential diagnosis that includes acute pancreatitis
2) in patients with suspected local complications of acute
pancreatitis (e.g., peritonitis, signs of shock, suggestive
ultrasound findings)
3) Patients with clinical deterioration or failed to improve with
medical management
• Computed tomography for the assessment of local
complications is most useful 48–72 hours after the onset of
symptoms rather than at the time of admission.
• Unless contraindicated (e.g., renal dysfunction), intravenous
contrast should be given in order to assess for pancreatic
necrosis once patients are adequately fluid resuscitated and
normovolemia is restored.
4. Klingensmith M.E. et al, The Washington Manual of Surgery 7th Edition. Wolters Kluwer. 2016; 388 – 404
5. Greenberg JA, Hsu J, Bawazeer M, Marshall J, Friedrich JO, Nathens A, et al. Clinical practice guideline:
32
management of acute pancreatitis. Canadian Journal of Surgery. 2016;59(2):128-40.
Radiological investigations
Computed tomography (CT)
CT findings include:
• Parenchymal enlargement and edema
• Necrosis
• Blurring of fat planes
• Peripancreatic fluid collections
• Bowel distention
• Mesenteric edema
• Left pleural effusion and atelectasis
4. Klingensmith M.E. et al, The Washington Manual of Surgery 7th Edition. Wolters Kluwer. 2016; 388 – 404
5. Greenberg JA, Hsu J, Bawazeer M, Marshall J, Friedrich JO, Nathens A, et al. Clinical practice guideline:
33
management of acute pancreatitis. Canadian Journal of Surgery. 2016;59(2):128-40.
Radiological investigations
Acute pancreatitis
4. Klingensmith M.E. et al, The Washington Manual of Surgery 7th Edition. Wolters Kluwer. 2016; 388 – 404
5. Greenberg JA, Hsu J, Bawazeer M, Marshall J, Friedrich JO, Nathens A, et al. Clinical practice guideline:
34
management of acute pancreatitis. Canadian Journal of Surgery. 2016;59(2):128-40.
Radiological investigations
Computed tomography (CT)
Necrotising pancreatitis
4. Klingensmith M.E. et al, The Washington Manual of Surgery 7th Edition. Wolters Kluwer. 2016; 388 – 404
5. Greenberg JA, Hsu J, Bawazeer M, Marshall J, Friedrich JO, Nathens A, et al. Clinical practice guideline:
35
management of acute pancreatitis. Canadian Journal of Surgery. 2016;59(2):128-40.
Radiological investigations
Computed tomography (CT)
Necrotising pancreatitis
4. Klingensmith M.E. et al, The Washington Manual of Surgery 7th Edition. Wolters Kluwer. 2016; 388 – 404
5. Greenberg JA, Hsu J, Bawazeer M, Marshall J, Friedrich JO, Nathens A, et al. Clinical practice guideline:
36
management of acute pancreatitis. Canadian Journal of Surgery. 2016;59(2):128-40.
Radiological investigations
Magnetic resonance imaging (MRI)
• Sensitivity 83%, specificity 91%
• Safe, non invasive
• Useful substitute for CT scan in patients
allergic to contrast or in acute renal failure
• Magnetic resonance
cholangiopancreatography (MRCP) superior
than normal MRI scan in visualising:
– Cholelithiasis
– Choledocholithiasis
– Anomalies of pancreatic and common bile ducts
4. Klingensmith M.E. et al, The Washington Manual of Surgery 7th Edition. Wolters Kluwer. 2016; 388 – 404
5. Greenberg JA, Hsu J, Bawazeer M, Marshall J, Friedrich JO, Nathens A, et al. Clinical practice guideline:
37
management of acute pancreatitis. Canadian Journal of Surgery. 2016;59(2):128-40.
Radiological investigations
4. Klingensmith M.E. et al, The Washington Manual of Surgery 7th Edition. Wolters Kluwer. 2016; 388 – 404
5. Greenberg JA, Hsu J, Bawazeer M, Marshall J, Friedrich JO, Nathens A, et al. Clinical practice guideline:
38
management of acute pancreatitis. Canadian Journal of Surgery. 2016;59(2):128-40.
Endoscopic Retrograde Cholangiopancreatography (ERCP)
• Indications:
Patients with suspected biliary pancreatitis
and possible cholangitis who are not clinically
improving within 24H after admission
Endoscopic sphincterotomy and stone extraction
Patients with no identifiable cause to rule out
occult CBD stones, strictures or neoplasm
Suspected pancreatic ductal disruption eg.
traumatic pancreatitis
• In unstable patients with severe acute
gallstone pancreatitis, bile duct obstruction or
cholangitis, placement of a percutaneous
transhepatic gallbladder drainage tube
should be considered if ERCP is not safely
feasible.
• Pancreatic duct stents and/or postprocedure
rectal NSAID suppositories should be utilized
to prevent severe post-ERCP pancreatitis in
high-risk patients
4. Klingensmith M.E. et al, The Washington Manual of Surgery 7th Edition. Wolters Kluwer. 2016; 388 – 404
5. Greenberg JA, Hsu J, Bawazeer M, Marshall J, Friedrich JO, Nathens A, et al. Clinical practice guideline: management of acute 39
pancreatitis. Canadian Journal of Surgery. 2016;59(2):128-40.
Endoscopic Retrograde
Cholangiopancreatography (ERCP)
4. Klingensmith M.E. et al, The Washington Manual of Surgery 7th Edition. Wolters Kluwer. 2016; 388 – 404
5. Greenberg JA, Hsu J, Bawazeer M, Marshall J, Friedrich JO, Nathens A, et al. Clinical practice guideline:
40
management of acute pancreatitis. Canadian Journal of Surgery. 2016;59(2):128-40.
Prognosis
• Predicting risk of developing severe outcomes is
crucial due to high mortality in fulminant acute
pancreatitis and benefits of early aggressive
supportive care
• Parameters in predicting prognosis and severity
of acute pancreatitis:
Ranson’s scoring
BISAP scoring
Glasgow scoring
CT Severity Index (CTSI)
Acute Physiology and Chronic Health Evaluation
(APACHE II)
Multiple Organ Dysfunction Score (MODS) and
Sequential Organ Failure Assessment (SOFA)
4. Klingensmith M.E. et al, The Washington Manual of Surgery 7th Edition. Wolters Kluwer. 2016; 388 – 404 41
Ranson’s scoring
• Assessing prognosis in early acute pancreatitis
on admission and initial 48H
• Limitation:
– Cannot be completed until 48 hours following
admission, which may lead to missing an early
therapeutic window and increased mortality
• Interpretation of severity:
Score ≥ 3: severe pancreatitis likely
• Interpretation for mortality:
0-2 criteria: <1%
3-4 criteria: 15%
5-6 criteria: 50%
>6 criteria: 70-90%
42
4. Klingensmith M.E. et al, The Washington Manual of Surgery 7th Edition. Wolters Kluwer. 2016; 388 – 404
Ranson’s scoring
On Admission
G
Blood glucose >200mg/dL or >11 mmol/L
A Age > 55 years
L Serum lactate dehydrogenase >350 IU/L
A Aspartate aminotransferase >250 IU/L
W White blood cell count > 16,000/µL
Initial 48 hours
C Serum calcium <8 mg/dL or 2.0 mmol/L
H Hematocrit decrease > 10%
O Arterial PO2 <60mmHg
11. https://www.ahcmedia.com/articles/62466-pancreatitis 44
Bedside Index for Severity in Acute
Pancreatitis (BISAP) scoring
<3: Low
risk of
mortality
≥3: High
risk of
mortality
11. https://www.ahcmedia.com/articles/62466-pancreatitis 45
Glasgow scoring
2. https://en.wikipedia.org/wiki/Pancreas 46
Glasgow scoring
Parameters Readings
2. https://en.wikipedia.org/wiki/Pancreas 47
Modified CT Severity Index (CTSI)
4. Klingensmith M.E. et al, The Washington Manual of Surgery 7th Edition. Wolters Kluwer. 2016; 388 – 404 48
Modified CT Severity Index (CTSI)
4. Klingensmith M.E. et al, The Washington Manual of Surgery 7th Edition. Wolters Kluwer. 2016; 388 – 404 49
Acute Physiology and Chronic Health
Evaluation II
• Assess disease severity in ICU patients >16 years
old (not specific to acute pancreatitis)
• Advantage:
Calculated within the first 24 hours and daily
thereafter allowing continual assessment
• Limitations:
Limited ability to distinguish between interstitial and
necrotizing acute pancreatitis
Cumbersome and difficult to calculate
• Interpretation:
Score <8: <4%
Score ≥8: 11-18%
Scoring increase during first 48H: Mild
Scoring decrease during first 48H: Severe
4. Klingensmith M.E. et al, The Washington Manual of Surgery 7th Edition. Wolters Kluwer. 2016; 388 – 404
5. Greenberg JA, Hsu J, Bawazeer M, Marshall J, Friedrich JO, Nathens A, et al. Clinical practice guideline: 50
management of acute pancreatitis. Canadian Journal of Surgery. 2016;59(2):128-40.
Acute Physiology and Chronic Health
Evaluation II
• Rectal temperature
• Mean arterial pressure
• Heart rate
• Respiratory rate
• A-a gradient or PaO2
• Arterial pH or HCO3-
• Sodium
• Potassium
• Creatinine
• Haematocrit
• WBC
• Glasgow coma scale
• Age
• Comorbidity
4. Klingensmith M.E. et al, The Washington Manual of Surgery 7th Edition. Wolters Kluwer. 2016; 388 – 404
5. Greenberg JA, Hsu J, Bawazeer M, Marshall J, Friedrich JO, Nathens A, et al. Clinical practice guideline: 51
management of acute pancreatitis. Canadian Journal of Surgery. 2016;59(2):128-40.
Prognosis
4. Klingensmith M.E. et al, The Washington Manual of Surgery 7th Edition. Wolters Kluwer. 2016; 388 – 404
5. Greenberg JA, Hsu J, Bawazeer M, Marshall J, Friedrich JO, Nathens A, et al. Clinical practice guideline: 52
management of acute pancreatitis. Canadian Journal of Surgery. 2016;59(2):128-40.
Local Complications
Interstitial Necrotising
53
4. Klingensmith M.E. et al, The Washington Manual of Surgery 7th Edition. Wolters Kluwer. 2016; 388 – 404
Local Complications
54
4. Klingensmith M.E. et al, The Washington Manual of Surgery 7th Edition. Wolters Kluwer. 2016; 388 – 404
Local Complications
55
4. Klingensmith M.E. et al, The Washington Manual of Surgery 7th Edition. Wolters Kluwer. 2016; 388 – 404
Local Complications
• Pseudocyst
56
4. Klingensmith M.E. et al, The Washington Manual of Surgery 7th Edition. Wolters Kluwer. 2016; 388 – 404
Local Complications
57
4. Klingensmith M.E. et al, The Washington Manual of Surgery 7th Edition. Wolters Kluwer. 2016; 388 – 404
Local Complications
Infected pancreatic necrosis
58
4. Klingensmith M.E. et al, The Washington Manual of Surgery 7th Edition. Wolters Kluwer. 2016; 388 – 404
Local Complications
• Walled-off necrosis
59
4. Klingensmith M.E. et al, The Washington Manual of Surgery 7th Edition. Wolters Kluwer. 2016; 388 – 404
Local Complications
Vascular complications:
• Rare complication, most common in necrotising
• Haemorrhage:
– resulting from erosion of blood vessels and tissue
necrosis
• Pseudoaneurysm:
– autodigestion of arterial walls by pancreatic enzymes
results in pulsatile mass that is lined by fibrous tissue
and maintains communication with parent artery
• Splenic vein thrombosis
• Portal vein thrombosis
60
4. Klingensmith M.E. et al, The Washington Manual of Surgery 7th Edition. Wolters Kluwer. 2016; 388 – 404
Systemic Complications
61
Management
• Supportive care
• Interventional and surgical
• Treatment of gallstone pancreatitis
62
Initial assessment and risk stratification
64
Supportive Care
Gastric rest with nutritional support
• Nasogastric decompression
– Decrease neurohormonal stimulation of
pancreatic secretion
• Early nutritional support
– Catabolic
– Started once nausea, vomiting, abdominal pain
resolved
• Mild acute pancreatitis
Initiation of feeding with a low-fat solid diet
• Severe acute pancreatitis
• Early enteral feeding preferred
Lower rates of infection
Lower rates of surgical intervention
Shorter length of stay
65
Supportive Care
Analgesics
• Pain relief
66
Supportive Care
67
Supportive Care
Antibiotics
• Routine use of antibiotics is not
recommended
Some randomised trials demonstrate
significantly lower rates of septic
complications in patients receiving
antibiotics
Meta-analysis demonstrated no
difference in mortality, infected
necrosis, or overall infections with
antibiotic therapy
68
Supportive Care
Antibiotics
• Indications
Extrapancreatic infections (eg. cholangitis)
Catheter-acquired infections
Bacteremia
Urinary tract infection
Pneumonia
• When infection is suspected, treat with
broad-spectrum antibiotics that cover
– Gram-negative bacteria
– Common hospital-acquired pathogens
(depending on length of hospitalization)
69
Supportive Care
Antibiotics
• Infected necrosis should be considered
in patients with pancreatic or
extrapancreatic necrosis who
deteriorate or fail to improve after 7–
10 days of hospitalization.
• Treatment:
CT-guided fine needle aspiration (FNA)
Empiric use of antibiotics such as
carbapenems, quinolones, and
metronidazole
70
Interventional and surgical
Indications:
• Clinical deterioration
• Sepsis
• Hypotension
• Necrotising pancreatitis
Debridement (18-20 days after onset of attack
to allow sequestration of necrosis)
Cholecystectomy (deferred until active
inflammation subsides and fluid collections
resolve or stabilize)
• Gastrointestinal obstruction due to
collections
Percutaneous or endoscopic drainage
Necrosectomy by endoscopic or minimally
invasive or open surgery 71
Interventional and surgical
72
Interventional and surgical
73
Treatment of gallstone pancreatitis
• Mild acute pancreatitis
Laparoscopic cholecystectomy with operative
cholangiogram on the index admission or soon
thereafter in healthy patients.
Delay has resulted in the occurrence of a second
attack, which may be more severe.
• Severe gallstone pancreatitis
Cholecystectomy should be performed when
general and local conditions permit
Operative cholangiography is needed to rule out
persistent choledocholithiasis
• Patients unfit for surgery
Endoscopic sphincterotomy may protect against
further attacks of pancreatitis.
74
References
1. https://emedicine.medscape.com/article/1948885-overview
2. https://en.wikipedia.org/wiki/Pancreas
3. http://cursoenarm.net/UPTODATE/contents/mobipreview.htm?26/21/26970
4. Klingensmith M.E. et al, The Washington Manual of Surgery 7th Edition. Wolters Kluwer.
2016; 388 – 404
5. Greenberg JA, Hsu J, Bawazeer M, Marshall J, Friedrich JO, Nathens A, et al. Clinical
practice guideline: management of acute pancreatitis. Canadian Journal of Surgery.
2016;59(2):128-40.
6. https://emedicine.medscape.com/article/181364-overview#a5
7. Raj SM, Lopez D, Thambidorai CR, Kandasamy P, Toufeeq Khan TF, Mohamad H, et al.
Acute pancreatitis in north-eastern peninsular Malaysia: an unusual demographic and
aetiological pattern. Singapore medical journal. 1995;36(4):371-4.
8. P T, G H. Comparative study of acute pancreatitis in different ethnic populations in a
Malaysian public hospital2008.
9. http://wuxifhff.com/ultrasound-abdomen-anatomy/ultrasound-abdomen-anatomy-
with-full-of-ultrasound-abdomen-anatomy/
10. Chen L, Lu G, Zhou Q, Zhan Q. Evaluation of the BISAP Score in Predicting Severity and
Prognoses of Acute Pancreatitis in Chinese Patients. International Surgery. 2013;98(1):6-
12.
11. https://www.ahcmedia.com/articles/62466-pancreatitis
12. https://gi.org/guideline/acute-pancreatitis/
75
THANK YOU
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