Dr Kupe_ Acute Pancreatitis

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W E D N E S D A Y , F E B R U A R Y 2 3 , 2 0 1 1

Acute Pancreatitis

Definition

Acute inflammatory process of the pancreas with variable involvement of regional or remote tissues

Epidemiology

1–5/10,000

Predominant age:

- Acute pancreatitis: None

- Chronic pancreatitis: 35–45 years (usually related to alcohol)

Male = Female

Aetiology

I - idiopathic.(10%) Thought to be hypertensive sphincter or microlithiasis.

G - gallstone. (40%)

E - ethanol (alcohol) (35%)

T – trauma (usually in children), tumour

S - steroids

M - mumps (paramyxovirus) and other viruses (Epstein-Barr virus, CMV)

A - autoimmune disease (Polyarteritis nodosa, Systemic lupus erythematosus)-in pt <40

S - scorpion sting , snake bites

H - hypercalcemia, hyperlipidemia/hypertriglyceridemia and hypothermia

E - ERCP (4%) , emboli

D - drugs (SAND - steroids & sulfonamides, azathioprine, NSAIDS, diuretics such as furosemide and thiazides, &

didanosine) and duodenal ulcers

Pathophysiology

begins with injuries to acinar cells or impairment of zymogen granules secretion.

lysosomal and zymogen granule fuse, enabling trypsin production

trypsin triggers auto-digestion by zymogen activation cascade

secretory vesicles extrude into the interstitium, attracting inflammatory cells

Activated neutrophills release superoxide, proteolytic enzyme

Macrophages release cytokines (tumour necrosis factor alpha, IL-6, IL-8)

Mediators cause increased pancreatic vascular permeabilityà haemorrhage, edema, necrosis.

Presentation

epigastric/central abdomen dull, boring and steady pain, sudden onset, increasing severity. may radiate to back,

relieved by sitting forward

nausea, vomiting

fever, tachycardia, shock

jaundice (28%)

ileus, rigid abdomen, tenderness

periumbilical discoloration (Cullen’s sign) or in the flanks (Grey Turner’s sign) – due to methaemalbumin formed

01/03/2011 Dr Kupe: Acute Pancreatitis

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from digested blood tracks around the abdomen

*

Cullen’s sign

*

Grey Turner’s sign

Less common sign

Körte's sign (pain or resistance in the zone where the head of pancreas is located (in epigastrium, 6–

7 cm above the umbilicus)

Kamenchik's sign (pain with pressure under the xiphoid process)

Mayo-Robson's sign (pain while pressing at the top of the angle lateral to the Erector spinae muscles

and below the left 12th rib (left costovertebral angle(CVA))

Differential Diagnosis

Acute cholecystitis, organ rupture, AAA, PUD, any acute abdomen

Investigation

FBC an admission hematocrit > 47% may inidicate more severe disease

Leukocytosis may represent inflammation or infection

ABG if pt is dyspnoeic, monitor oxygenation, acid base status

CRP 24-48 hours after presentation

Calcium, magnesium,

cholesterol, and

triglycerides

search for an etiology of pancreatitis (hypercalcemia or hyperlipidemia) or

complications of pancreatitis (hypocalcemia resulting from saponification of fats

in the retroperitoneum).

Amylase ↑ amylase (>1000u/ml, falls after 2d)

may be normal (in 10% of cases)

Lipase rises 4 to 8 hours from the onset

lipase more sensitive & specific (falls after 7-14d)

LFT ALT >150 U/L suggests gallstone pancreatitis and a more fulminant disease

course.

Serum electrolytes,

BUN, creatinine,

glucose

electrolyte imbalances, renal insufficiency, and pancreatic endocrine

dysfunction

LDH, BUN, and

bicarbonate

Measured at admission and at 48h to determine Ranson Criteria

IgG4 evaluate for autoimmune pancreatitis



Abdomen U/S if suspect gallstone + AST↑,

FNA- for bacterial infection

Endoscopic U/S evaluating the cause of severe pancreatitis, particularly microlithiasis and biliary

sludge, and can help identify periampullary lesion

Abdominal CT

scanning

Indicated for severe pancreatitis

scan within the first 72h

Acute pancreatitis. Pancreatic necrosis. Note the nonenhancing pancreatic body anterior to the

splenic vein. Also present is peripancreatic fluid extending anteriorly from the pancreatic head.

MRI alternative for CT, in pt with contrast allergy or renal insufficiency.

Image: Focal pancreatitis involving pancreatic head. Pancreatic head is enlarged w ith adjacent

ill-defined peripancreatic inf lammation and f luid collections

ERCP Indication: severe acute gallstone pancreatitis that is not responding to

supportive therapy or with ascending cholangitis with worsening signs and

symptoms of obstruction,



This patient w ith acute gallstone

pancreatitis underw ent

endoscopic retrograde

cholangiopancreatography. The

cholangiogram show s no stones

in the common bile duct and

multiple small stones in the

gallbladder. The pancreatogram

show s narrow ing of the

pancreatic duct in the area of the

genu, the result of extrinsic

compression of the ductal

system by inf lammatory changes

in the pancreas.

AXR Limited role in acute pancreatitis

detect free air in the abdomen, ‘sentinel loop’ of proximal jejunum (solitary air-

filled dilatation)

erect CXR exlude other causes, eg perforation.

Criteria for Severity

Several examples of scoring system:

Scoring System Criteria

Modified Glasgow

Criteria

Pa O2 <8kPa

Age >55

Neutrophils WCC> 15x 109/L

Calcium < 2mmol/L

Raised urea >16mmol/L

Enzymes: LDH>600iu/L, AST >200iu/L

Albumin<32g/L

Sugar : blood glucose >10 mmol/L

Ranson's Criteria Present on Admission - GA LAW

Glucose (blood) greater than 200 mg/dl

Age >55 years

LDH (serum) > 350 I.U./L

AST >250 I.U./L

WBC > 16,000/ul

Developing During the First 48 Hours: - C HOBBS

Calcium (serum) < 8 mg/dl

Hematocrit fall > 10%

Oxygen (arterial) saturation l< 60 mm Hg

BUN increase> 8 mg/dl.

Base deficit > 4 meq/L

Sequestration of fluid > 600 ml



Computed

Tomography

Severity Index

(CTSI)/

Balthazar score

Balthazar

Grade

Appearance on CT CT

Grade

Points

Grade A Normal CT 0 points

Grade B Focal or diffuse enlargement of the pancreas 1 point

Grade C Pancreatic gland abnormalities and

peripancreatic inflammation

2 points

Grade D Fluid collection in a single location 3 points

Grade E Two or more fluid collections and / or gas

bubbles in or adjacent to pancreas

4 points

Dx for severe pancreatitis : Ranson score >3, APACHE score >8, modified Glasgow score >3. Balthazar score –

proven to be more accurate

Management

Fluids (large 0.9% saline) to stabilize vital signs, urine flow >30mL/h, urinary catheter & consider

CVP monitoring

Nutrition Early initiation of enteral nutritional supplementation

TPN (2nd line)has been shown to reduce mortality rate

Antibiotics imipenem. (Controversial)

Analgesia pethidine or morphine(may cause sphincter of oddi to contract more but it is a better

analgesic, no CI)

Monitor Hourly pulse, BP, urine output, daily FBC, U&E, Ca, glucose, amylase, ABG

If worsening take to ICU. O2 if PaO2 ↓. Suspected abscess/necrosis(CT) à PTN +laparotomy &

debridement. Antibiotic controversial (imipenem)

ERCP if suspected CBD stone or clinical deterioration. Not in acute condition

Follow up Ensure alcohol incontinence

Within weeks to months after onset: check for signs of intra-abdominal infection,

pancreatic pseudocyst, intra-abdominal hemorrhage, colon perforation, obstruction or

fistulization, and multiorgan system failure.

CT-guide needle aspiration in the setting of necrotizing pancreatitis

Repeat CT/US to monitor complication (eg. pseudocyst)

Surgery for

infected

pancreatic

necrosis

indication: infected pancreatic necrosis, diagnostic uncertainty, complications.

Closed management - necrosectomy with closed continuous postoperative

lavage

Open management - necrosectomy with planned staged reoperations at

definite intervals (up to 20+ reoperations in some cases)



Management

for

pancreatic

pseudocyst

Definition Pseudocyst-peripancreatic fluid collections persisting for more

than 4 weeks are termed acute pseudocysts. Pseudocysts lack

an epithelial layer and, thus, are not considered true cyst.

Imaging

*

CT scan of a large symptomatic pancreatic pseudocyst abutting

the posterior wall of the stomach.

Investigation fluid in lesser sac, T↑, a mass + persistent ↑

amylase/LFT: 40% resolve spontaneously 6-12wk, supportive

mgt until thick wall has formed,drainage externally or into

stomach , biopsy to rule out malignancy.

Indication for

intervention

symptomatic (pain, bleeding, or infection)

larger than 7 cm and are rapidly expanding

Percutaneous

aspiration

for pt with very large fluid collection

Endoscopic

technique

by transpapillary or transmural techniques

The proximal end of the stent is placed into the cyst cavity

Success rate= 83%, complication rate = 12%

Transmural

enterocystostomy

for noncommunicating pseudocysts

Success rate= 85%, complication rate = 17%

Surgical cyst-

enterostomy

Internal pseudocyst enteric anastomosis

operative mortality rate of 3-5%

Pancreatitic

abscess

Pancreatic abscesses generally occur late in the course of pancreatitis. Many of these

respond to percutaneous catheter drainage and antibiotics. Those that do not respond

require surgical debridement and drainage.

Complications

Early Shock, ARDS, renal failure, Disseminated intravascular coagulation (DIC), sepsis,

SIRS, Ca2+↓

Late(>1wk) pseudocyst (most common)

Pancreatic necrosis

Infection (Within the first 1-3 weeks)

abscess



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Posted by Dr Kupe at 8:10 AM

Labels: Pancreatitic Diseases, Surgery

bleeding (eg: splenic artery), thrombosis

fistula, recurrent oedematous pancreatitis.

Prognosis

80% improve rapidly

20% have at leat one complication from which 1/3 die

Ranson scoring:

Ranson score of 0–2: Minimal mortality

Ranson score of 3–5: 10–20% mortality

Ranson score of >5: >50% mortality

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