acute pancreatitis. anatomy acute pancreatitis -acute pancreatitis (ap) are characterized by...
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ACUTE PANCREATITIS
ANATOMY
ACUTE PANCREATITIS
-Acute pancreatitis (AP) are characterized by edematous lesions, eventually necrosis and bleeding inside and in peripancreatic area.
A. Pathology: - 2 types of AP
• 1. Edematous AP• congestion and edema of the pancreas. • swelling • normal/mild inflammation of the retroperitoneum
• 2. Necrotic pancreatitis
• Severe +++.• Important swelling of the pancreas, bleeding multiples areas
and hematomas till the complete distruction of the gland. • Involvement of all retroperitoneum, fatty necrosis- white
spots• Plasmal escape – peripancreatic and retroperitoneal spaces + ascites
ETIOLOGY: 2 MAIN CAUSES1. GALLSTONES2. ALCOHOL
1. GALLSTONES
• 2. ALCOHOL
• 3. Rare etiology• Less than 10%
• Postoperative and postraumatic AP– Billiary ,pancreatic, gastric surgery– Kidney transplantation– Post- ERCP
• Pancreatic tumors• Infections
– Leptospirosis– Ascaridiosis
• Metabolical factors– Hypercalcemia– Hypertriglyceridemia
• Drug induced– Corticotherapy– Chlorothiazide, Isothiazide– Immunosupressors– Oral Contraceptives
• Auto-immune AP• Idiopathic factors
• C. PATHOPHYSIOLOGY
3 mechanisms STOP the autodigestion of the pancreas
1.enzymes - preserved as zymogenes separates from other proteins2.enzymes sont secreted – inactive forms3.inhibitors of proteolitic enzymes in the pancreatic tissu and pancreatic juice
• AP= enzimatic autodigestion of the pancreas--- trypsinogen activation in trypsine in the pancreatic cells .
• Trypsine --- cascade activation of proenzymes from zymogens granules – pancreatic acinar cell distruction
• SIRS --- proinflammatory cytokines(Il-1, TNF) in the pancreatic tissu and other organs (kidney, liver, lung) SEVERE SYSTEMIC EVENTS
PATHOPHYSIOLOGY
D. CLINICAL SIGNS• ABDOMINAL PAIN Describe it!!!• Nausea and vomiting• Abdominal distension- paralitic ileus • +/ tachycardia, low/ high temperature, hypotension, tachypnea-
severe forms• Oliguria• Jaundice• Ascites
!! Pain intensity vs poverty of clinical signs
• 50 %- symptoms are not specific Differential dg:• Acute cholecystitis• Mesenteric infarction• Bowel obstruction• Ruptured abdominal aortic aneurism • Respiratory distress• Oligo-anuria • Peritonitis
E. DIAGNOSTIC
• 1. Blood tests• HIGH levels of amylase and lipase (≥ 3 N) ESSENTIAL BUT NOT SPECIFIC!!• CRP > 15 mg/100 ml – SEVERE AP.
2. IMAGING DG • Plain abdominal X- Ray- localised ileus- sentinel loop, free
air, calcifications• Abdominal US- swelling , diffuse hypoechogenity - Eventually the cause - gallstones
CT SCAN
• SEVERITY EVALUATION criteria
• Balthasar score- severity and extent of necrosis, peripancreatic fluid collection
• Correlation with morbidity and mortality
MRCP
• Non-invasive• Safer• Faster THAN ERCP but less sensitive
WHEN Suspicion of bile ductobstruction
MRI - severity of AP - no iodine contrast - bile obstruction
• F. COMPLICATIONS• PANCREATIC NECROSIS• PSEUDOCYST• PANCREATIC ABCESS
PSEUDOCYST- necrosis organising - Wirsung disruption - after aprox 4 w evolution of AP
PANCREATIC ABCESS- pseudocyst infection/ infection of necrotic areas
OTHER COMPLICATIONS
Venous thrombosis ( splenic, portal, SMV ) Pleural effusion Ascites Fatty necrosis- cutaneus
• G. PROGNOSIS• Good – Edematous AP – mortality< 2%• Bad – Necrotic forms of AP- high mortality Severity prediction RANSON scale- if > 3 crt- AP severe if > 7- 100% mortality AP induced by alcohol
RANSON scale
Admission After 48 H
Age > 55 yearsLeucocytes/mm³ > 16.000Glycemia > 200 mg%LDH > 1.5 NSGOT > 6 N
Hematocrit reduced with 10%Urea raised with 5 mg %Calcemia < 8 mg%PaO2 < 60 mm HgBase deficit > 4 mEq/lLiquid sechestration > 6 l
!!! Admission: High levels of CPR – bad prognosisOther severity scales- Glasgow, Apache III
TREATMENT
• MEDICAL- NPO- NGT ?- IVF- PPI - PAIN CONTROL- ANTIBIOTICS- ????
• SURGICAL- Indications !!!WHEN WE HAVE THEPROOF OF INFECTIONChoosing of the moment!!
• ERCP with sphyncterotomyINDICATIONS- gallstones in bile duct
SURGICAL TREATMENT
• Surgical infected necrose debridement
• Drainage• +/- Laparostomy
SURGICAL TREATMENT- PSEUDOCYSTS
INDICATIONS:• IF > 7 cm• Rapidly growing• Bleeding• Compression • Disruption• Pain• Infection
PSEUDOCYST TREATMENT- TRANSPAPILLARY
DRAINAGE; IF COMMUNICATING- STENT
PSEUD0CYST TREATMENT-EXTERNAL DRAINAGE
SURGICAL TREATMENT – if proximal duct disrupted- WHIPPLE
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