Acute PancreatitisDiagnosis

• EtOH: history• Gallstones: abnormal LFTs & sonographY

• Hyperlipidemia: lipemic serum, Tri>1,000• Hypercalcemia: elevated Ca• Trauma: history• Medications: history

Abdominal Exam - Abdominal tenderness and rigidity - Bowel sounds decreased - Palpable upper abdominal mass Acute fluid

collections and pseudocysts

• Skin Exam - Erythematous skin Nodule (

Subcutaneous Fat Necrosis)

- Cullen's Sign (periumbilical discoloration) - Turner's Sign (flank discoloration) * due to

exudation of blood-stained fluid into the subcutaneous tissue, usually 72 h into the illness.

Acute PancreatitisClinical Manifestations

PANCREATIC

PERIPANCREATIC

Adjacent viscera:

SYSTEMIC

Mild: edema, inflammation, fat necrosisSevere: phlegmon, necrosis, hemorrhage, infection, abscess, fluid collections

Retroperitoneum, perirenal spaces, mesocolon, omentum, and mediastinum

ileus, obstruction, perforation

Cardiovascular: hypotensionPulmonary: pleural effusions, ARDSRenal: acute tubular necrosisHematologic: disseminated intravascular coag.Metabolic: hypocalcemia, hyperglycemia

Diagnosis: Biochemical - Serum Amylase elevated

• Nonspecific • Returns to normal in 48-72 hours • Normal amylase does not exclude

pancreatitis • Level of elevation does not predict disease

severity

- Serum Lipase elevated • Specific for pancreatic disease • Returns to normal in 7-14 days

Diagnosis: Biochemical • White Blood Cells increased to 15k-20k

• Hypertriglyceridemia (15%)

• liver Function Tests (ALP) (AST) ,elevated

• (LDH) elevated (Poor prognosis)

• Hyperglycemia

• Albumine(Poor prognosis)

- Serum Electrolytes • Hypocalcemia (25%)

• Another criteria often used to assess the severity of pancreatitis is the (APACHE-II) .

Acute Physiology And Chronic Health Evaluation

age and vital signs Specific laboratory parameters, Chronic health status The main advantage is the immediate assessment of the

severity of pancreatitis. A score of eight or more at admission is usually

considered indicative of severe disease

Predictors of Severity

• Why are they needed?- Appropriate triage & therapy- compare results of studies of the impact of

therapy• When are they needed?

- optimally, within the first 24 hours• Which is the best?

Ranson CriteriaAlcoholic Pancreatitis

AT ADMISSION1. Age > 55 years2. WBC > 16,0003. Glucose > 2004. AST > 250 IU/L5. LDH > 350 IU/L

WITHIN 48 HOURS1. HCT drop > 10%2. BUN > 53. Arterial PO2 < 60 mm Hg4. Base deficit > 4 mEq/L5. Serum Ca < 86. Fluid sequestration > 6L

NumberMortality

<21%

3-416%

5-640%

7-8100%

Glasgow CriteriaNon-alcoholic Pancreatitis

1. WBC > 15,0002. Glucose > 1803. BUN > 164. Arterial PO2 < 60 mm Hg5. Ca < 86. Albumin < 3.27. LDH > 600 U/L8. AST or ALT > 200 U/L

CT Severity Indexappearance normal enlarged inflamed 1 fluid

collection2 or more

collections

grade A B C D E

score 0 1 2 3 4

necrosis none < 33% 33-50% > 50%

score 0 2 4 6

score morbidity mortality

1-2 4% 0%

7-10 92% 17%

Balthazar et al. Radiology 1990.

Useful markers of severe disease.

• Pleural effusion• BMI (High body mass index) • Necrosis on contrast-enhanced CT-SCAN • CRP level greater than 150 mg/L at 48 h

• Infection of the necrotic tissue after the first week of illness is the major determinant of later outcome.

Pancreatic necrosis

CT-guided percutaneous fine-needle aspiration of the pancreatic tail

Pseudocyst

Pseudocyst

Pseudocyst

Pseudocyst

Pseudocyst

Pseudocyst

Acute pseudocyst

Pancreatic Cancer Pancreatic cancer is one of the most lethal malignancies.

An estimated 32,300 patients will die of pancreatic cancer in year 2006.

The tenth most common malignancy in the United State.

Despite recent advances,in pathology, molecular basis and treatment, the overall survival rate remains 4% for all stages and races.

Palliative care represents an important aspect of care in patient with pancreatic malignancy. Identifying and treating disease related symptomology are priorities.

Common problems include pain, intestinal obstruction, biliary obstruction, pancreatic insufficiency, anorexia-cachexia and depression.