Acute Pancreatitis

Shiwani Kamath

Acute Pancreatitis

• Inflammation of the gland parenchyma of the pancreas

• Acute condition presenting with abdominal pain and is usually associated with raised pancreatic enzyme levels in the blood or urine as a result of pancreatic inflammation

PathogenesisDefective intracellular transport and secretion of pancreatic zymogens

Pancreatic duct obstruction

Hyperstimulation of pancreas

Reflux of infected bile or duodenal contents into pancreatic duct

Proenzymes

Activated proteolytic enzymes

Acute Pancreatitis

(-) Pancreatic secretory trypsin inhibitors

Etiology

Common (90% of cases)– Gallstones– Alcohol– Post-ERCP– Idiopathic

Rare– Post-surgical– Trauma– Drugs– Metabolic– Pancreas divisum– Sphincter of Oddi dysfunction– Infection – Hereditary– Renal failure– Organ Transplantation– Severe hypothermia– Petrochemical exposure

Clinical FeaturesSymptoms

• Severe, constant upper abdominal pain – with increasing intensity over 15-20 minutes– radiating to back

• Nausea and vomiting

• Abdominal distension

Clinical FeaturesSigns

• Epigastric tenderness with guarding and rebound (later)

• Decreased/absent bowel sounds• Grey Turner’s Sign: Discoloration of the flanks• Cullen’s Sign: Discoloration of the periumbilical

region• Small, red, tender nodules on the skin of the legs• Abdominal distension – shifting dullness• Signs of pleural effusion

Clinical FeaturesCullen’s Sign

Clinical FeaturesTurner’s Sign

Complications Pancreatic

• Acute Fluid Collection• Pseudocyst• Abscess• Necrosis• Pancreatic Ascites and Effusion

ComplicationsSystemic and Other Systems

Systemic• Systemic inflammatory

response syndrome• Hypoxia• Hypergylcemia• Hypocalcemia• Reduced serum albumin

concentration• DIC

Gastrointestinal• Hemorrhage• Portal/Splenic Vein

Thrombosis• Erosion into colon• Duodenal Obstruction• Obstructive jaundice • Paralytic Ileus

Investigations• Serum amylase (N: 23-85 IU/L)• Serum lipase (N: 0 – 160 IU/L)• Ultrasound– Confirms diagnosis– Shows gallstones, biliary obstruction, pseudocyst

• Contrast enhanced CT– 6-10 days after admission– Decreased pancreatic enhancement – necrotizing– Gas within necrotic material – infection, abscess– Other organ involvement

Acute Pancreatitis

Normal Pancreas

CT Findings

Tail Indistinct

Intraperitoneal fluid

PANCPANCLIVERLIVER

CT FindingsSevere Pancreatitis

Peripancreatic edemaand inflammation

Necrosis(less enhancement)PANC

PANCLIVERLIVER

GBGB

• CBC: leucocytosis• Electrolyte abnormalities include hypokalemia,

hypocalcemia• Elevated LDH in biliary disease• Glycosuria ( 10% of cases)• Hyperglycaemia in severe cases• Serum phosphate• LFTs• RFTs• C – Reactive Protein - elevated

Routine

To rule out other conditionsi.e. perforated ulcer disease.

Nonspecific findings-cutoff colon sign gaseous distension seen in

proximal colon associated with narrowing of the splenic flexure

-Widening of the duodenal C loop caused by severe pancreatic head edema

Complications of lung such as pleural effusion, pulmonary edema and interstitial inflammation.

X ray

MANAGEMENT

• Establish the diagnosis• Assess severity• Early Treatment (Resuscitation)• Detection and Treatment of Complications• Treating Underlying Cause

MANAGEMENTSteps

• RANSON’S CRITERIA• MODIFIED GLASGOW CRITERIA• Acute Physiology and Chronic Health

Evaluation (APACHE II)

MANAGEMENTAssessment of Severity of Disease

• RANSON’S CRITERIA• MODIFIED GLASGOW CRITERIA• Acute Physiology and Chronic Health

Evaluation (APACHE II)

MANAGEMENTAssessment of Severity of Disease

Non-gallstone pancreatitis, the parameters are:At admission:•Age in years > 55 years•White blood cell count > 16000 cells/mm3

•Blood glucose> 10 mmol/L (> 200 mg/dL)•Serum AST > 250 U/L•Serum LDH > 700 U/L

Within 48 hours:•Serum calcium < 2.0 mmol/L (< 8.0 mg/dL)•Oxygen (hypoxemia PaO2 < 60 mmHg)•BUN increased by 1.8 or more mmol/L (5 or more mg/dL) after IV fluid hydration•Base deficit (negative base excess) > 4 mEq/L•Sequestration of fluids > 6 L

MANAGEMENTRanson’s Criteria

Gallstone pancreatitis, the parameters are:At admission:•Age in years > 70 years•White blood cell count > 18000 cells/mm3

•Blood glucose > 12.2 mmol/L (> 220 mg/dL)•Serum AST > 250 IU/L•Serum LDH > 400 IU/L

Within 48 hours:•Serum calcium < 2.0 mmol/L (< 8.0 mg/dL)•Oxygen (hypoxemia PaO2 < 60 mmHg)•BUN increased by 1.8 or more mmol/L (5 or more mg/dL) after IV fluid hydration•Base deficit (negative base excess) > 5 mEq/L•Sequestration of fluids > 4 L

MANAGEMENTRanson’s Criteria

MANAGEMENTGlasgow’s

alanine

MANAGEMENTAPACHE II

• Initial Assessment– Clinical Impression– BMI > 30– Pleural Effusion (on CX-ray)– APACHE II Score > 8

• 24 Hours After Admission– Clinical Impression– APACHE II Score > 8– Glasgow > 3– Persisting Organ Failure– CRP > 150 mg/L

• 48 Hours After Admission– Clinical Impression– Glasgow > 3– Persisting, Multiple, and Progressive Organ Failure– CRP > 150 mg/L

MANAGEMENTFactors Predicting Severity within 48 hours of admission

• Intravenous fluid administration • Analgesics• Anti-emetics• Recommended brief period of fasting• Frequent, non-invasive observation

MANAGEMENTConservative Measures

• Admission to HDU or ICU• Analgesia• Aggressive fluid rehydration• Oxygen• Monitor Vitals, central venous pressure, urine output, blood gases• Monitor hematological and biochemical parameters• Nasogastric drainage• Antibiotic prophylaxis (imipem, cefuroxime)• CT scan• ERCP• Supportive therapy for organ failure• Nasogastric feeding for nutritional support

MANAGEMENTSevere Acute Pancreatitis

• Cholecystectomy within 2 weeks following resolution of pancreatitis

• Necrotising pancreatitis/Pancreatic Abscess– Endoscopic/surgical necresectomy

• Pseudocyst– Drainage into stomach, duodenum or jejunum– Endoscopic/Surgical– After 6 weeks

MANAGEMENTSurgical Management of Severe Pancreatitis

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