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Presented By: Ehsan Arefnia June 2012 Anatomy Retroperitoneal Organ Weighs 75 To 100 G 15 To 20 Cm Long Head Neck Body Tail 2 Physiology • Three General Functions: • Neutralizing the acid chyme entering the duodenum from the stomach • Synthesis and secretion of digestive enzymes after a meal • Systemic release of hormones that modulate metabolism of carbohydrates, proteins, and lipids 3 Acute Pancreatitis 4 Definition and Incidence • • • • Inflammatory disease with little or no fibrosis Initiated by several factors Develop additional complications 300,000 cases occur in the united states each year leading to over 3000 deaths 5 Etiology • Biliary tract disease • Alcohol • Drugs • 30 meds identified • AIDS therapy: didanosine, pentamidine • Anti-inflammatory: sulindac, salicylates • Antimicrobials: metronidazole, sulfonamides, tetracycline, nitrofurantoin • Diuretics: furosemide, thiazides • IBD: sulfasalazine, mesalamine • Immunosuppressives: azathioprine, 6mercaptopurine 6 Etiology: (GET SMASHED) G: Gallstone E: Ethanol T: Trauma S: Steroid M: Mump A: Alcoholism or Autoimmune S: Scorpion bits H: Hyperlipidemia E: ERCP D: Drugs 7 Differential Diagnosis •Pancreatitis •Acute Cholecystitis •MI •Cholangitis •Severe Pneumonia •Perforated Viscous •Intestinal Obstruction •Ruptured Aaa •Appendicitis •Diverticulitis •Caecal Perforation •Ruptured Ectopic •Bowel Ischemia 8 Clinical Presentation • Abdominal pain • Epigastric • Radiates to the back • Worse in supine position • • • • • Nausea and vomiting Tachycardia, Tachypnea, Hypotension, Hyperthermia Elevated Hematocrit Cullen's sign Grey Turner's sign 9 Grey Turner sign Cullen’s sign 10 Diagnosis: Biochemical • serum amylase • Nonspecific • Returns to normal in 3-5 days • Normal amylase does not exclude pancreatitis • Level of elevation does not predict disease severity • Urinary amylase • P-amylase • Serum Lipase • Serum Electrolytes • Hypocalcaemia (Poor prognosis) • Hyperglycemia (Poor prognosis) • Hypoalbuminemia • CBC • Increased Hb • Thrombocytosis • Leukocytosis • Liver Function Test • Serum Bilirubin elevated • Alkaline Phosphatase elevated • Aspartate Aminotransferase elevated 11 Assessment of Severity • Ranson Criteria • Biochemical Markers • Computed Tomography Scan 12 Ranson Criteria Criteria for acute gallstone pancreatitis • Admission • • • • • • During first 48 hours Age > 70 WBC > 18,000 Glucose > 220 LDH > 400 AST > 250 • • • • • Hematocrit drop > 10 points Serum calcium < 8 Base deficit > 5.0 Increase in BUN > 2 Fluid sequestration > 4L <2 pos sign: mortality rate is 0 3-5 pos sign: mortality rate is 10 to 20% >7 pos sign: mortality rate is >50% 13 50 year-old woman Stomach Liver V A R Kidney L Kidney Spleen 14 CT scans of normal kidneys and pancreas Gallstone-induced pancreatitis in 27 year-old woman Large, edematous, homogeneously attenuating pancreas (1) . Peripancreatic inflammatory changes (white arrows). There is no pancreatic necrosis. Calcified gallstones are seen in gallbladder (black arrow) 15 Pancreatic Necrosis 16 Treatment of Mild Pancreatitis • Pancreatic rest • Supportive care • fluid resuscitation – watch BP and urine output • Pain Control • NG tubes and H2 blockers or PPIs are usually not helpful • Refeeding (usually 3 to 7 days) If: • Bowel Sounds Present • Patient Is Hungry • Nearly Pain-free (Off IV Narcotics) • Amylase & Lipase Not Very Useful 17 Treatment of Severe Pancreatitis • Pancreatic Rest & Supportive Care • Fluid Resuscitation – may require 5-10 liters/day • Careful Pulmonary & Renal Monitoring – ICU • Maintain Hematocrit Of 26-30% • Pain Control – PCA pump • Correct Electrolyte Derangements (K+, Ca++, Mg++) • R/O necrosis • Contrasted CT scan at 48-72 hours •Prophylactic antibiotics if present • Surgical debridement if infected • Nutritional support • May be NPO for weeks • TPN vs. enteral support (TEN) 18 Complications • Local • Phlegmon, Abscess, Pseudocyst, Ascites • Involvement of adjacent organs, with hemorrhage, thrombosis, bowel infarction, obstructive jaundice, fistula formation, or mechanical obstruction • Systemic • A. Pulmonary: Pneumonia, atelectasis, ARDS, Pleural Effusion • B. Cardiovascular: Hypotension, Hypovolemia, Sudden Death, Nonspecific ST-T wave changes, Pericardial effusion • C. Hematologic :Hemoconcentration, DIC • D. GI: Hemorrhage, Peptic ulcer, Erosive gastritis, Portal vein or splenic vein thrombosis with varices • E. Renal: Oliguria, Azotemia, Renal artery/vein thrombosis • F. Metabolic :Hyperglycemia, Hypocalcemia, Hypertriglyceridemia, Encephalopathy, Sudden Blindness (Purtscher's retinopathy) • G. CNS: Psychosis, Fat Emboli, Alcohol withdrawal syndrome • H. Fat necrosis: Intra-abdominal saponification, Subcutaneous tissue necrosis 19 Acute Pseudocyst 20 Management 21 Chronic Pancreatitis 22 Definition and Prevalence • • • • Incurable, Chronic Inflammatory Condition 5 To 27 Persons Per 100,000 Fibrosis Alcohol 23 Etiology • Alcohol, 70% • Idiopathic (including tropical), 20% • Other, 10% • Hereditary • Hyperparathyroidism • Hypertriglyceridemia • Autoimmune pancreatitis • Obstruction • Trauma • Pancreas divisum 24 Signs and Symptoms • • • • • • Steady And Boring Pain Not Colicky Nausea Or Vomiting Anorexia Is The Most Common Malabsorption And Weight Loss Apancreatic Diabetes 25 Laboratory Studies Tests for Chronic Pancreatitis I. Measurement of pancreatic products in blood A. Enzymes B. Pancreatic polypeptide II. Measurement of pancreatic exocrine secretion A. Direct measurements 1. Enzymes 2. Bicarbonate B. Indirect measurement 1. Bentiromide test 2. Schilling test 3. Fecal fat, chymotrypsin, or elastase concentration 4. [14C]-olein absorption III. Imaging techniques A. Plain film radiography of abdomen B. Ultrasonography C. Computed tomography D. Endoscopic retrograde cholangiopancreatography E. Magnetic resonance cholangiopancreatography F. Endoscopic ultrasonography 26 Pancreatic calcifications. CT scan showing multiple, calcified, intraductal stones in a patient with hereditary chronic pancreatitis Endoscopic retrograde cholangiopancreatography in chronic pancreatitis. The pancreatic duct and its side branches are irregularly dilated 27 Treatment • • • • • • Analgesia Enzyme Therapy Antisecretory Therapy Neurolytic Therapy Endoscopic Management Surgical Therapy 28 Complications • • • • • Pseudocyst Pancreatic Ascites Pancreatic-Enteric Fistula Head-of-Pancreas Mass Splenic and Portal Vein Thrombosis 29 Management 30 References • • • • Schwartz's Principles of Surgery, Ninth Edition Sabiston Textbook of Surgery, 18th Edition. WWW.UpToDate.COM WWW.MDConsult.COM 31 32