Acute Pancreatitis

1. Acute Pancreatitis โดย พญ. กนิษฐา โชคสวัสดิ์

2. Pancreatitis • Inflammation of the pancreatic parenchyma • Acute or Chronic •Acute pancreatitis =A transient inflammation that resolves with or without complications • Chronic pancreatitis =Continuous inflammation resulting in progressive anatomic and functional damage to the pancreas

3. Acute Pancreatitis • Etiology •Gallstones (45%) • Alcohol abuse (35%) • Others (10%) • Idiopathic (10%) ** Males (alcohol) > Females (choledocholithiasis)

7. Acute Pancreatitis • Pathophysiology • Activation of digestive zymogens inside acinar cells  Acinar cell injury  • inflammatory cell recruitment + activation, • generation + release of cytokines & other mediators

8. Acute Pancreatitis • Clinical Presentation • Mid epigastric abdominal pain • Steady, boring pain • Radiation to the left upper back • Anorexia, nausea ± vomiting ± diarrhea • Low grade fever • Inflammation or secondary infection • Presentations associated with complications • Shock • Multi-system failure

9. Acute Pancreatitis • Exam Findings • Abdominal tenderness • Fever (76%) • Abdominal guarding (68%) • Abdominal distension (65%) • Tachycardia (65%) • Hypoactive bowel sounds • Jaundice (28%) • Dyspnea (10%) • Hemodynamic changes (10%) • Melena or hematemesis (5%) • Cullen’s sign • Grey-Turner sign • Left pleural effusion

10. Acute Pancreatitis • Cullen’s sign • Grey-Turner sign

11. Investigation

12. 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 Serum Electrolytes Hypocalcemia (25%) Hyperglycemia Complete Blood Count (CBC) White Blood Cells increased to 15k-20k Lipids Elevated Hypertriglyceridemia Liver Function Tests Serum Bilirubin elevated ALT elevated AST Hypoalbuminemia (Poor prognosis) Lactate Dehydrogenase (LDH) elevated (Poor prognosis) Diagnosis: Biochemical

14. Diagnosis • Ultrasound - Most useful initial test for gallstone etiology • Dynamic contrast-enhanced CT (CECT) - the imaging modality of choice for diagnosis, staging, and detection of complications of acute pancreatitis.

15. Severity assessment

16. APACHE II SCORE

17. On admission Age > 55 yrs WCC > 16,000 LDH > 600 U/l AST >120 U/l Glucose > 10 mmol/l Within 48 hours Haematocrit fall >10% Urea rise >0.9 mmol/l Calcium < 2 mmol pO2 < 60 mmHg Base deficit > 4 Fluid sequestration > 6L Ranson's criteria

18. Ranson criteria - prognosis • Mortality correlates with number of criteria 0-2 1% 3-4 15% 5-6 40% 7-8 100%

19. CT Severity index • serial CT scans are important for following the progression of the disease and for detecting additional complications. • In Balthazar’s series

21. Complication

22. Acute Pancreatitis • Mild • Severe • Overall mortality 10 -15% - severe disease as high as 30%

23. Severe Acute Pancreatitis - Definition 1. Organ failure • Shock, pulmonary insufficiency, renal failure, GI bleeding 2. Local complications • Pseudocyst, abscess, pancreatic necrosis 3. >= 3 Ranson criteria Overall mortality 30% , Early (MOFS), late (infection)

24. Local Complications • Peri-pancreatic fluid collections • 57% of patients • Initially ill-defined • Usually managed conservatively • Pseudocysts • Pancreatic necrosis

25. Acute pseudocyst

26. Pancreatic necrosis

27. Peripancreatic and retroperitoneal edema

28. Treatment

29. Treatment of acute pancreatitis • Supportive  Eliminating of oral intake Intravenous hydration Parenteral analgesia NG suction : ileus or severe vomiting Collection of electrolyte and glucose abnormalities vascular, respiratory and renal support Removal of factors : drug or alcohol

30. Surgical • Kelly and Wagner • Pt who underwent surgery earlier(<48hrs) had higher mortality and morbidity rates than those who underwent surgery later(>48hrs) • This finding was even more pronounced in those with severe pancreatitis

31. Surgical • Stone et al. • No deference in mortality between Pt randomly assigned to early biliary surgery (<72hr) and those assigned to late surgery(3mo after admission)

32. Surgery • The traditional indication for surgery  acute abdomen • removal of impact stone from the CBD(emergency or elective) • Drainage of pancreatic fluid collections • Debridement of necrotic tissue

33. Antibiotics • Three early controlled trials • Ampicillin did not change the course of mild acute alcoholic pancreatitis • Imipenem reduced the incidence of pancreatitis sepsis in pt with necrotizing pancreatitis

34. Cimetidine Atropine Calcitonin Glucagon Somatostatin Fluororacil  not been shown to change the course of the disease Inhibiting pancreatic secretion

35. Summary • No specific treatment for acute pancreatitis • Supportive therapy • Vigorous intravenous hydration • Parenteral analgesia • Collection of electrolyte and glucose abnormalities and vascular, respiratory and renal support

36. Summary • The use of antiproteases and inhibitor of pancreatic secretion cannot be recommended • Immediate endoscopic removal of impacted stones in pt with severe disease appears to reduce morbidity

37. Summary • Controlled studies are needed to demonstrate whether debridement of sterile necrotic tissue improve outcome • Infected necrotic tissue and infected collections of fluid are best treated by surgical debridement