Transcript Acute and chronic pancreatitis

Jasim Al-Abbad, MBBCh, FRCSC
Assistant Professor
General Surgery
Colon and Rectal Surgery
[email protected]

inflammation of the gland parenchyma of the
pancreas

Acute vs. Chronic

The incidence of acute pancreatitis is increasing

> 300,000 hospital admissions annually in USA

10 – 20 % of patients develop life-threatening form

Direct cost > 2 billion USD
N Engl J Med 2006; 354:2142-2150
Gastroenterol Clin N Am 41 (2012) 1–8

Mortality rate reach up to 30% with severe
pancreatitis

Mortality is due to:
◦ Multi-system organ failure (1st 2 weeks)
◦ Septic complications (after 2 weeks)
World J Gastroenterol 2007; 13:5043-5051










Gallstones
Alcohol
Hypertriglyceridemia
Hypercalcemia
Post ERCP
Trauma
Pancreatic duct obstruction
Infections
Drugs
Hereditary

The overall incidence in patients with symptomatic
gallstones 3 – 8 %

Small gallstones are associated with an increased risk

2 theories:
◦ Obstructive
 Pancreatic duct obstruction  excessive pressure  pancreatic injury
◦ Reflux
 Stone in ampulla of Vater  bile reflux into pancreas  direct necrosis
Adv Surg 2006; 40:265-284
N Engl J Med 2006; 354:2142-2150








Abdominal pain
Nausea / vomiting
Low grade fever
Dehydration
Epigastric tenderness
Jaundice
Grey Turner
Cullen's signs

History / physical examination

Biochemical workup
◦
◦
◦
◦

CBC
RFT
LFT
Amylase, lipase
Imaging

It rises within 6 to 12 hours of onset

Remains elevated for three to five days

There is no correlation between the magnitude
of serum amylase elevation and severity of
pancreatitis

Causes of hyper-amylasemia:










Acute cholecystitis
Bowel obstruction
Mesenteric ischemia
Trauma
Ketoacidosis
Ruptured ectopic pregnancy
Parotitis
Renal failure
Salpingitis
Cirrhosis

More specific than amylase

Longer half life

The elevation of ALT levels in the serum in the
context of acute pancreatitis has a positive
predictive value of 95% in the diagnosis of acute
biliary pancreatitis
Adv Surg 2006; 40:265-284

Plain x-rays

Ultrasound

CT scan

MRCP

ERCP

EUS

Early recognition of severe disease is crucial to
optimize care and improve outcome

Many scoring systems developed

Developed in 1974

Score based on 11 parameters

Mortality
◦ 0 to 3 % when the score <3
◦ 11 to 15 % when the score ≥3
◦ 40 % when the score ≥6
On admission
Age
> 55
WBC count
> 16,000 /mm3
Blood glucose
> 11.1 mmol/L
AST
> 250 U/L
LDH
> 350 U/L
48 hours
Hematocrit
Drop by >10%
BUN
Increase by >1.8 mmol/L
Serum Calcium
< 2 mmol/L
pO2
< 60 mmHg
Base deficit
> 4 mEq/L
Fluid sequestration
> 6 Liters

It needs 48hrs to calculate

Meta-analysis of 110 clinical studies found
Ranson's score to have a poor predictive power
Crit Care Med. 1999;27(10):2272

12 physiologic measurements

It provides a general measure of the severity of
disease

A score of ≥8 defines severe pancreatitis

Balthazar score

Based on CT findings
Grade
Findings
Score
A
Normal pancrease
0
B
Focal or diffuse enlargment of the pancreas
1
C
Peripancreatic inflammation
2
D
1 fluid collection
3
E
2 or more fluid collections
4
Pancreatic necrosis
None
0
≤ 30 %
2
30 – 50 %
4
> 50 %
6
Mortality
0-3 = 3%
4-6 = 6%
7-10= 17%
Radiology 1990; 174:331

Acute phase reactants made by the liver

Levels correlates with disease activity

Level ≥ 150 mg/mL defines severe pancreatitis
Br J Surg. 1989;76(2):177
Organ failure
• Shock (SBP <90mmHg)
• Pulmonary insuffciency (PaO2 <60 mmHg)
• Renal failure (creatinine > 2mg/dL)
• GI bleeding (>500 mL/24hr)
Systemic
complications
• DIC (Platelet count ≤ 100,000)
• Fibrinogen <1 g/L
• Fibrin split products > 80 µg/dL
• Metabolic disturbance (calcium < 7.5 mg/dL)
Local
complications
• Necrosis
• Abscess
• Pseudocyst

The International Symposium on Acute Pancreatitis (1992)

Severe pancreatitis is defined by the presence of any evidence of
organ failure or a local complication.
Arch Surg 1993; 128:586-590

Regardless of the cause or the severity of the disease

Aggressive fluid resuscitation

Pain control

Oral feeding may not be possible

Enteral feeding vs. TPN

Data controversial

No benefit for pancreatitis without necrosis

Imipenem reduces pancreatic infections with
proven necrosis
Cochrane Database Syst Rev. 2010

Routine use of ERCP is not indicated

ERCP is indicated for:
◦ Cholangitis
◦ Persistent bile duct obstruction (obstructive jaundice)

30% of patients with acute biliary pancreatitis will have
recurrent disease, in the absence of definitive treatment

For mild pancreatitis:

For severe pancreatitis:
◦ Early laparoscopic cholecystectomy (during the initial admission)
is a safe procedure that decreases recurrence of the disease
◦ Early surgery may increase the morbidity and length of stay
◦ Laparoscopic cholecystectomy should be delayed for at least 6
weeks
Adv Surg 2006; 40:265-284
Acute Fluid Collections
 Occur during the early stages of severe pancreatitis in 30% to 50% of
patients
 No wall of granulation or fibrous tissue, and more than half regress
spontaneously.
Pancreatic Necrosis
 Areas of nonviable pancreatic tissue
 either sterile or infected
Pancreatic Pseudocyst
 collections of pancreatic fluid enclosed by a non-epithelialized wall
composed of fibrous and granulation tissue
 Not present before 4 to 6 weeks after the onset of an attack
Pancreatic Abscess
 Collections of pus, usually in proximity to the pancreas
Sabiston, David C., and Courtney M. Townsend. Sabiston Textbook of Surgery: The Biological Basis
of Modern Surgical Practice. Philadelphia: Saunders/Elsevier, 2008. Print.





Persistent inflammation
Irreversible fibrosis
Atrophy of the pancreatic parenchyma
Chronic pain
Endocrine and exocrine insufficiency
Brunicardi, F. Charles., and Seymour I. Schwartz. Schwartz's Principles of Surgery. New
York: McGraw-Hill, Health Pub. Division, 2010. Print.
Brunicardi, F. Charles., and Seymour I. Schwartz. Schwartz's Principles of Surgery.
New York: McGraw-Hill, Health Pub. Division, 2010. Print.

Alcohol (70 - 80%)

Genetics (hereditary, CF gene mutation)

Hyperparathyroidisim

Hypertriglyceridemia

Autoimmune pancreatitis

Ductal obstruction (trauma, stones, tumors, ?pancreas divisum)

Smoking

Idiopathic

Abdominal Pain

Pancreatic insufficiency
◦ Fat malabsorption
◦ Apancreatic diabetes

Blood tests:
◦
◦
◦
◦

CBC
RFT
LFT
Serum amylase and lipase levels usually normal
Functional tests
 Fecal fat content
 Fecal elastase-1 level

Imaging:




CT scan
MRCP
EUS
ERCP
Sabiston, David C., and Courtney M. Townsend. Sabiston Textbook of Surgery: The Biological Basis of
Modern Surgical Practice. Philadelphia: Saunders/Elsevier, 2008. Print.
Medical Treatment
 Multidisciplinary team

Stop drinking and smoking

Pain control

Pancreatic enzyme replacement
Endoscopic Treatment
 ERCP with duct dilatation ± stent
Surgical Treatment
 Resection procedures
 Drainage procedures
Souba, Wiley W. ACS Surgery: Principles and Practice. Hamilton, Ont.: B C Decker,
2007. Print.

Biliary strictures (jaundice / cholangitis)

Duodenal obstruction

Splenic / portal vein thrombosis

Pseudocyst
Brunicardi, F. Charles., and Seymour I. Schwartz. Schwartz's Principles of Surgery.
New York: McGraw-Hill, Health Pub. Division, 2010. Print.