ACUTE

PANCREATITIS
JULIA ABRAHAM
114 Batch
PANCREAS
◦ Situated in the retroperitoneum
◦ Head(30%),Body and Tail(70%), Neck and
Uncinate process
◦ Weighs approximately 80 g
◦ 80-90 percentage is composed of exocrine
acinar tissue which is organised into lobules
◦ Rest of the gland is composed of endocrine
cells known as islets of Langerhans.
VENOUS
DRAINAGE
CASE SCENARIO
◦ A 56 year old man, alcoholic, presented with
sudden severe epigastric pain and recurrent
episodes of vomiting. The pain was sharp,
constant, agonising in nature, radiated to the
back ,aggravated on lying down and mildly
improved on leaning forward. On examination,
the patient was in agony with pain , had
tachypnoea, tachycardia and hypotension.
Abdomen was mildly distended and tender .His
pancreatic enzymes were elevated. X ray shows
'sentinel loop'.
ACUTE PANCREATITIS
Definition:-
Acute pancreatitis is defined as an acute condition
presenting with abdominal pain, 3 fold or greater
rise in the serum levels of pancreatic enzymes
amylase or lipase, and /or characteristic findings of
pancreatic inflammation on contrast-enhanced CT.

Two types - mild or severe

MECHANISM OF INJURY
◦ Premature activation of pancreatic enzymes -
Autodigestion
◦ Anything that injures the acinar cell and
impairs the secretion zymogen granules,or
damages the duct epithelium and thus delays
enzymatic secretion,can trigger acute
pancreatitis.
Aetiology:-

• Gall stones most common(50-70%)

• Alcoholism(25%)
• Post ERCP(3%)
• Abdominal trauma
• Autoimmune pancreatitis
• Hereditary pancreatitis
• Ampullary tumor
• Drugs (Corticosteroids, azathioprine,
asparaginase, valproic acid, thiazides,
Oestrogen)
• Mumps
• Hyperparathyroidism
• Hypercalcaemia
• Malnutrition
• Scorpion bite
• Idiopathic
CLINICAL FEATURES
SYMPTOMS
Severe upper abdominal epigastric pain radiating
to the back. Relieved on sitting & bending
forward. Aggravated on lying down .pain is
constant.
• Nausea, repeated vomiting that is
profuse,projectile follows pain with retching
• Hiccups due to gastric distension or irritation of
the diaphragm.
SIGNS
• Febrile
• Tachypnoea
• Faint jaundice
• Features of shock—feeble pulse, tachycardia,
hypotension, cold extremities.
• Abdominal findings—tenderness in epigastrium,
upper abdominal guarding and distension of
abdomen, mass in epigastrium .
SIRS (Systemic Inflammatory
Response Syndrome)
• Heart rate >90/min
• Core temperature < 36°c or >38°c
• RR >20/min or pCO2 <32mmHg
• WBC count <4000 or >12000/ mm3
Cullen’s sign

Bluish ecchymotic
discolouration seen
around umbilicus
Grey Turner’s
sign

Bluish discolouration in
the flanks.
Both the signs are due to
seepage of blood along
the fascial plane
Fox sign

Discolouration
below the inguinal
ligament
INVESTIGATIONS
• Serum amylase raised 3 to 4 times.
• But a normal serum amylase do not rule out
the disease.
• Serum lipase test is more sensitive and specific
• Blood glucose - hyperglycemia
• Serum calcium - hypocalcemia
IMAGING
Plain x-ray shows

Sentinel loop sign

Colon cut off
sign:
distension of
transverse colon with
collapse of
descending colon
RENAL HALO SIGN
• Ultrasound abdomen
• Contrast enhanced CT - gold standard
 If there is diagnostic uncertainty
 Severe acute pancreatitis, to distinguish
interstitial from necrotising pancreatitis
 with organ failure, signs of sepsis
 localised complication is suspected,- fluid
collection, psuedocyst or psuedoanuerysms
• Cross sectional MRI
ASSESSMENT OF SEVERITY
• APACHE II (Acute Physiology And Chronic
Health evaluation) Scoring system –
above 8 in severe pancreatitis
• C reactive protein >150mg/L at 48hrs.
Limitation– sensitivity of the assay decreases if
CRP levels are measured within 48hrs after
onset of symptoms.
ATLANTA CLASSIFICATION
• Mild acute pancreatitis-no organ failure, no
local or systemic complications
• Moderately severe acute pancreatitis-organ
failure that resolves within 48 hours, local or
systemic complications without persistent
organ failure
• Severe acute pancreatitis- persistent organ
failure >48 hrs, single organ failure, multiple
organ failure.
MANAGEMENT
• Admission(HDU/ICU)
• Analgesia
• Aggressive fluid rehydration
• Oxygenation
• Invasive monitoring of vital signs, central
venous pressure, urine output, blood gases
• Frequent monitoring of LFT, RFT, clotting
time , serum Ca, blood glucose
• Nasogastric drainage
• Antibiotic prophylaxis (Imipenem
/Cefuroxime / ciprofloxacin
+Metronidazole)
• Blood transfusion if Hb low/protein low.
• Nasogastric feeding
• CVP line – to monitor, fluid therapy, total
parenteral nutrition
• IV ranitidine 50 mg 6th hourly - to prevent
stress ulcers
• Supportive therapy for organ
failure—Inotropes, ventilatory
support, haemofiltration.
• ERCP within 72 hours for severe
gall stone pancreatitis or signs of
cholangitis
• Somatostatin/ octreotide – reduce
pancreatic secretion
LAPROSCOPIC
CHOLECYSTECTOMY
• Indicated for all patients with mild acute biliary
pancreatits
• Safe procedure that decreases recurrence
• Severe pancreatitis – conservative treatment for
atleast 6 weeks before surgery.
COMPLICATIONS
Systemic :
• Shock & arrhythmia
• Respiratory insufficiency-
• ARDS
• Pleural effusion
• Hypocalcemia
• Hyperglycemia & hyperlipidemia
• DIC
• Renal failure
Local complications:
•Acute fluid collection
•Sterile pancreatic necrosis
•Infected pancreatic necrosis
•Pancreatic abscess
•Psuedocyst
•Pancreatic ascites
•Pleural effusion
•Portal/ splenic vein thrombosis
•Pancreatic fistula
Local :
• Acute fluid collection(APFC)
1. sterile fluid collection, lacks fibrin wall or
granulation tissue
2. Treated by percutaneous aspiration under
ultrasound or CT guidance.

• Sterile and infected pancreatic necrosis

1. Diffuse or focal area of non viable
parenchyma – absence of parenchymal
enhancement on CT
with contrast.
2. Pancreatic necrosis is associated with lysis of
peripancreatic fat. This leads to ANC ( acute necrotic
collection)
3. ANC ( has no definable wall) WON (walled-off
necrosis)
4. Signs of sepsis- needle passed under CT guidance,
percutaneous drainage of fluid.
5. Pancreatic necrosectomy- infected pancreatic necrosis
Midline laprotomy– head involved, Retroperitoneal
approach – left flank incision with feeding jejunostomy
(body and tail involved), Gallstones-
cholecystectomy ,Closed continuous lavage(beger’s lavage),
Closed drainage, Open packing, Closure and relaparotomy
(Bradley)
PANCREATIC ABSCESS
• Circumscribed intra-abdominal collection of
pus usually in proximity to the pancreas.
• ANC or WON infected
• Percutaneous drainage with the widest possible
drains placed under standard imaging guidance
is the treatment.
• Antibiotics and supportive care
PANCREATIC ASCITES
• Chronic, generalized, peritoneal, enzyme rich
effusion usually associated with pancreatic duct
disruption.
• Paracentesis reveals turbid fluid with a high
amylase level.
• Adequate drainage with wide bore drains under
image guidance.
PLEURAL EFFUSION
Encapsulated collection of fluid in the plural cavity,
arising as a consequence of acute pancreatitis.
HAEMORRHAGE
Bleeding may occur into the gut, Into the
retroperitoneum or into the peritoneal cavity
Possible causes include bleeding into a pseudocyst
cavity, diffuse bleeding from a large raw surface or
a pseudoaneurysm.
PORTAL OR SPLENIC VEIN
THROMBOSIS
• Identified on CT scan
• Marked rise in platelet count
• Screened for pro coagulant tendencies
• Varices or portal hypertension manage
accordingly
PSEUDOCYST
• Collection of
amylase-rich
fluid enclosed in
a wall of fibrous
or granulation
tissue
• 4 weeks or more
from the onset of
acute pancreatitis
• single/ multiple
• identification- ultrasound or CT
• low CEA ,high amylase level
• cytology- inflammatory cells
• Resolve spontaneously- most cases
• if not resolved- percutaneous, surgical and
endoscopic draining approaches
• Percutaneous transgastric cystogastrostomy can
be done under image guidance ,double pigtail
drain placed with one end in cyst and other in
gastric lumen.
• Endoscopic drainage involves puncture of the
cyst through the stomach or duodenal wall
under EUS guidance and placement of tube
drain .
• Surgical drainage involves internally draining
the cyst into the gastric or Jejunal lumen.
PANCREATIC FISTULA
• Determine site
• Measure amylase level
• Management - correct fluid level
• Drain
• Parenteral or nasojejunal feed
• Octreotide
• Relieve pancreatic duct obstruction( ERCP
and Stent )
THANK YOU