the management of acute pancreatitis professor ravi kant mb, ms, frcs (edinburgh), frcs (glasgow),...
TRANSCRIPT
![Page 1: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/1.jpg)
THE MANAGEMENT OF ACUTE PANCREATITIS
Professor Ravi KantMB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS,
DNB, FAIS, FAMS,
1
![Page 2: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/2.jpg)
2
INTRODUCTION
![Page 3: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/3.jpg)
3
Introduction “In the growing world of EBM, only 30%
of surgery is based on evidence while 70% of medicine is evidence based” EJS, Sep 2005
![Page 4: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/4.jpg)
4
Introduction Stress will be on Diagnosis, workup,
prognostic predictors and management Basic sciences
![Page 5: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/5.jpg)
5
DEFINITION
![Page 6: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/6.jpg)
6
Definition “Acute pancreatitis”:
Inflammation of the pancreas without, or with minimal fibrosis.
![Page 7: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/7.jpg)
7
EPIDEMIOLOGY
![Page 8: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/8.jpg)
8
Epidemiology 300,000 annually in US 10-20% are severe Total annual cost of 2 billion $$$ (Biliary + alcoholic) 90% Even in the west, biliary pancreatitis is
the most prevalent type. Incidence among AIDS patients 4-22%
![Page 9: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/9.jpg)
9
Epidemiology Local statistics?
![Page 10: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/10.jpg)
10
Epidemiology “Profile of acute pancreatitis in Jizan,
Saudi Arabia” Saudi Med J. 2003 Jan;24(1):72-5. (KFCH), Jizan, KSA over 12 years regional 42% (biliary), 18% Post ERCP
“Pattern of acute pancreatitis” Saudi Med J. 2001 Mar;22(3):215-8.
Cross sectional, 2 years, Asir central hospital
68% found to be biliary
![Page 11: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/11.jpg)
11
PATHOPHYSIOLOGY
![Page 12: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/12.jpg)
12
Pathophysiology Causes
Biliary tract disease Alcohol
Hyperlipedemia Hypercalcemia Trauma ERCP Ischemia
Pancreatic neoplasia
Pancreas divisum Ampullary lesions Duodenal lesions Infections Venom Drugs idiopathic
![Page 13: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/13.jpg)
13
Pathophysiology Theories behind mechanism of biliary
pancreatitis Common channel theory Incompetent sphincter theory Co-localization theory
![Page 14: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/14.jpg)
14
PATHOPHYSIOLOGY Common channel theory
“Opie 1901” Detergent effect of bile
![Page 15: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/15.jpg)
15
Pathophysiology Critique of common channel theory
Higher hydrostatic pressure in PD Introduction of bile into PD in animal
models failed to cause AP
![Page 16: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/16.jpg)
16
Pathophysiology Incompetent sphincter theory
Incompetent sphincter of Oddi due to stone passage reflux AP
Critique How come papillotomy doesn’t routinely
cause AP??
![Page 17: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/17.jpg)
17
Pathophysiology Co-localization theory “Steer & Saluja”
1998 Most acceptable Stones PD ductal hypertension
ducutle rupture Ductal pH = 9 …… parynchemal pH = 7 trypsinogen + cathepsin B trypsin
autodigestion cascade
![Page 18: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/18.jpg)
18
Pathophysiology
![Page 19: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/19.jpg)
19
Pathophysiology
![Page 20: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/20.jpg)
20
Pathophysiology
![Page 21: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/21.jpg)
21
Pathophysiology Support of co-localization theory
CA-074me (cathepsin B inhibitor) prevented AP in 2 different models of acute pancreatitis
![Page 22: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/22.jpg)
22
Pathophysiology Alcoholic pancreatitis
No such thing as acute alcoholic pancreatitis
It is actually the first attack of chronic alcoholic pancreatitis
![Page 23: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/23.jpg)
23
DIAGNOSIS
![Page 24: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/24.jpg)
24
Diagnosis Clinical picture Investigations “Acute pancreatitis is a diagnosis of
exclusion” Schwartz’s
![Page 25: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/25.jpg)
25
Diagnosis Hx:
Epigastric pain Radiating to back Nausea, vomitting Precipitating factor?
![Page 26: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/26.jpg)
26
Diagnosis Physical
V/S variable Epigastric tenderness Cullen’s / Grey Turner’s (1%) Findings of complication(s)
![Page 27: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/27.jpg)
27
Cullen’s sign
![Page 28: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/28.jpg)
28
Grey Turner’s sign
![Page 29: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/29.jpg)
29
Diagnosis Serum markers
Amylase Easiest to measure and most widely used Rises immediately Peaks in few hours Remains for 3-5 days “Three fold rise is diagnostic” May be normal in severe attacks May be falsely negative in hyperlipedimic patients Inverse correlation between severity and serum
amylase level No need to repeat
![Page 30: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/30.jpg)
30
Diagnosis Serum markers
Urine amylase Remains elevated for a few more days Increase excretion of amylase with
attacks of AP Of great value when dealing with severe
pancreatitis
![Page 31: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/31.jpg)
31
Serum markers P/S – amylase
P amylase increases specificity to 93% Lipase
“the serum marker of highest probability of disease”
Specificity of 96% Remains elevated for longer time than
total amylase
Diagnosis
![Page 32: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/32.jpg)
32
Diagnosis
![Page 33: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/33.jpg)
33
Causes of hyperamylesemia Pancreatitis p Choledocolethiasis p Parotitis s Renal failure s/p Liver cirrhosis s/p perforated bowel p mesenteric infarction p intestinal obstruction p Appendicitis p Peritonitis. P Gyne disease s
Malignancies Lung CA Ovarian CA
pancreatic CA Colonic CA pheochromocytoma; Thymoma multiple myeloma breast cancer
![Page 34: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/34.jpg)
34
RADIOLOGY (diagnostic)
![Page 35: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/35.jpg)
35
Radiology Diagnostic role
X-ray U/S CE-CT
![Page 36: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/36.jpg)
36
Radiology X-ray
Air in the duodenal C loop Sentinel loop sign Colon cutoff sign All these signs are non specific
![Page 37: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/37.jpg)
37
Radiology CE-CT
Enlargement of the pancreas (focal/diffuse)
Irregular enhancement Shaggy Pancreatic contour Thickening of fascial planes fluid collections.
Intraperitoneal / retroperitoneal Retroperitoneal air
![Page 38: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/38.jpg)
38
Radiology
U/S Diagnosis of gallstones F/U of pseudocysts. Dx pseudoaneurysms EAUS vs. EUS
![Page 39: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/39.jpg)
39
PROGNOSIS
![Page 40: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/40.jpg)
40
Prognosis Course either mild or severe
Mild = edematous pancreatitis Severe = necrotic pancreatitis No such thing as moderate pancreatitis
![Page 41: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/41.jpg)
41
Prognosis Serum markers CT Systemic complications Prognostic scores
Ranson Apache II Modified Glasgow Atlanta
Atlanta Consensus1992
![Page 42: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/42.jpg)
42
Prognostic scores Ranson’s
Published in 1974 Predictor of morbidity/mortality
<2 0% mortality 3-5 10-20% >7 >50% mortality
Critique of Ranson’s 11 parameters 48 hours No predictor value beyond 48hrs Too pessimistic for today’s healthcare system
![Page 43: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/43.jpg)
43
![Page 44: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/44.jpg)
44
Prognostic scores APACHE II
Immediate Acute and chronic parameters Complicated >7 = severe pancreatitis
![Page 45: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/45.jpg)
45
Prognostic biochemical markers Biochemical markers of prognosis
Ideally High sensitivity High specificity Discriminate severe from mild Immediate Widely available
Amylase & lipase Highly sens./spec. Lack prognostic value
![Page 46: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/46.jpg)
46
Prognostic biochemical markers
Alternatives CRP 2 macroglobulin PMN elastase 1 antitrypsin Phospholipase A2
“CRP seems to be the marker of choice in these settings”
CRP >150 is diagnostic of severe pancreatitis
![Page 47: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/47.jpg)
47
Prognostic biochemical markers Other markers
IL-6 Urinary TAP
These showed great promise in models and clinical trials
Failed in larger scale trials
![Page 48: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/48.jpg)
48
CT scan (prognostic aspect) “CT scanning with bolus IV contrast has
become the gold standard for detecting and assessing the severity of pancreatitis”
“Currently, IV bolus contrast enhanced CT scanning is routinely performed on patients who are suspected of harboring severe pancreatitis, regardless of their Ranson’s or APACHE scores” Schwartz’s
![Page 49: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/49.jpg)
49
CT scan (prognostic aspect)
![Page 50: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/50.jpg)
50
CT scan (prognostic aspect)
![Page 51: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/51.jpg)
51
CT scan (prognostic role) Balthazar CT-severity index (CTSI)
CTSI considers degree of necrosis Also considers the CT grade A final score is given and correlates with
mortality and complication development
![Page 52: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/52.jpg)
52
CT scan (prognostic role) Balthazar grading
Grade A - Normal-appearing pancreas 0 Grade B - Enlargement of the pancreas 1 Grade C - Pancreatic gland abnormalities a with
peripancreatic fat infiltration 2 Grade D - A single fluid collection 3 Grade E - Two or more fluid collections 4
![Page 53: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/53.jpg)
53
CT scan (prognostic role) Grade of necrosis and the points
assigned per grade are as follows: None 0 points Grade 0.33 2 points Grade 0.5 4 points Grade > 0.5 6 points
![Page 54: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/54.jpg)
54
CT scan (prognostic role) Overall prognostic outlook:
CTSI Mortality Complication
0-3 3% 8%
4-6 6% 35%
7-10 17% 92%
![Page 55: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/55.jpg)
55
Is CT superior???
“Computed Tomography Severity Index, APACHE II Score, and Serum CRP Concentration for Predicting the Severity of Acute Pancreatitis”*
n=55 CTSI,APACHE and CRP had p <0.01
![Page 56: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/56.jpg)
56
Prognosis Recommendation for assessing
severity: Mild is defined as:
No systemic complications Low APACHE/Ranson scores CE-CT findings (Balthazar) CRP level <150
Santorini1999
![Page 57: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/57.jpg)
57
MANAGEMENT
![Page 58: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/58.jpg)
58
MANAGEMENT Management depends on severity We will consider management of
edematous pancreatitis separately from necrotizing pancreatitis for purpose of simplification
![Page 59: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/59.jpg)
59
MANAGEMENT OF MILD PANCREATITIS
![Page 60: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/60.jpg)
60
Management (mild) Core of treatment based on
Physiological monitoring Metabolic support Maintenance of fluids and electrolytes
![Page 61: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/61.jpg)
61
Management (mild) NG suction H2 blockers
Gastric acid reaching the duodenum will activate pancreatic secretion???
Large studies failed to show any benefit
![Page 62: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/62.jpg)
62
Management (mild)
![Page 63: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/63.jpg)
63
Management (mild)
![Page 64: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/64.jpg)
64
Management (mild) What is the role of anti-secretory
agents? Atropin Calcitonin Somatostatin Glucagon Flurouracil
Unproven benefit*
![Page 65: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/65.jpg)
65
Management (mild) Pancreatitis is an autodigestive process Role of protease inhibitors?
Aprotinin Gabexate mesylate Camostate Phospholipase A2 inhibitors FFP
No benefit
![Page 66: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/66.jpg)
66
Management (mild) Pancreatitis is an inflamatory process Role of anti-inflamatory drugs?
Indomethacin Prostaglandin inhibitors Interleukin-10
No measurable benefit
![Page 67: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/67.jpg)
67
Management (mild) Vascular injury is mediated by platelet
aggregating factor What’s the role of PAF inhibitors?
PAF acetylhydrolase Lexipafant
Great results in models Great results in small clinical trials Failed in larger studies
Verdict: useless
![Page 68: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/68.jpg)
68
Management (mild) Question to audience: When dealing with acute pancreatitis,
do u start Abx therapy? (hands please) “Antibiotic therapy has not proved to be
of value in the absence of signs or documented sources of infection”
![Page 69: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/69.jpg)
69
Management (mild) Mainstay of management is supportive
NPO IVF
When to resume oral intake? Absence of pain Absence of tenderness Patient feeling hungry
On average takes about 3-7 days Sips of water and build up to low protein low
fat diet
![Page 70: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/70.jpg)
70
Management (mild) Any drug therapy for acute pancreatitis?
“None of the evaluated medical treatments is recommended (level A)”*
Meta-analysis considering gabexate mesylate, octreiotide, aprotinin and lexipafant
![Page 71: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/71.jpg)
71
MANAGEMENT OF SEVERE PANCREATITIS
![Page 72: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/72.jpg)
72
Management (severe) Severe pancreatitis:
> Ranson / APACHE CRP >150 Systemic complications Necrosis on CE-CT Hemodynamic compromise
![Page 73: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/73.jpg)
73
Management (severe) Complications
Local Phlegmon Abcess Pseudocyst Ascitis pseudoanurysm Adjacent organ
envolvment
Systemic pulmonary Cardiac Hematological GI Renal Metabolic CVS Fat necrosis
![Page 74: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/74.jpg)
74
![Page 75: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/75.jpg)
75
![Page 76: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/76.jpg)
76
![Page 77: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/77.jpg)
77
![Page 78: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/78.jpg)
78
Pseudocyst
![Page 79: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/79.jpg)
79
Management (severe) Sterile necrosis
Absence of retroperitoneal air on CT Prognosis
0% mortality without complications 38% with single sys. complication
![Page 80: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/80.jpg)
80
Management (severe) How to approach sterile necrosis?:
No sys. Comp., no infec. (i.e. uncomplicated) supportive
Sys. Comp. + infection? ( mild complication) CT guided aspiration gram stain/culture Abx
Mult. Sys comp + toxicity/shock (frank complication) surgical debridment
SEVERITY
![Page 81: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/81.jpg)
81
Management (severe) Role of prophylactic Abx?
Previously thought to have no role in sterile necrosis Prophylaxis indicated whenever there is necrosis Drugs with proven benefit
Imipenem Flagyl 3rd gen. Cephalosporins
Abx prophylaxis reduced:* Sepsis by 21.1% Mortality by 12.3%
![Page 82: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/82.jpg)
82
Management (severe) Role of Antifungal medication
Candida is a common inhabitant of upper GI tract
Risk of secondary infection Empiric fluconazole?
Clansy TE “current management of necrotizing pancreatitis”*
![Page 83: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/83.jpg)
83
Management (severe) Nutritional support
NPO with resumption of diet when fit If NPO > 7 days… TPN vs. Jujenal tube feeding?
TPN: gastric mucosal atrophy bacterial translocation
Jujenal tube feeding: induces pancreatic secretion Inconclusive studies:
Jujenal T. feeding is superior*
![Page 84: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/84.jpg)
84
Management (severe) Benefit of enteral feeding
Prospective randomized trial n=34 Severe acute pancreatitis “enteral feeding modulates the inflamatory
and sepsis response in acute pancreatitis”*
![Page 85: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/85.jpg)
85
Management (severe) NG vs. NJ feeding
Prospective randomized trial N=50 Mortality as endpoint
No statistically significant benefit of NJ*
NG mortality NJ mortality
18.5% 31.8%
![Page 86: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/86.jpg)
86
Management (severe) Something very important has been
missing in the presentation… Where is pain management? Also missing from the research scene
![Page 87: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/87.jpg)
87
Specific considerations of biliary pancreatitis
![Page 88: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/88.jpg)
88
Management (severe) Specific consideration of biliary
pancreatitis: Majority of stones will pass within hours Some might impact Patient at risk of subsequent stone obst.
NECROSECTOMY
![Page 89: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/89.jpg)
89
Management (severe) If hyperbili is dropping:
Lap chole with surgical duct clearance <72 hours vs. >72 (within admission) If patient critical ERCP stone clearance Routine ERCP NOT ADVOCATED
![Page 90: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/90.jpg)
90
Management (severe) If hyper bili persists:
confirm presence of stone before ERCP (MRCP, EUS)
![Page 91: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/91.jpg)
91
Suggested algorithm
![Page 92: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/92.jpg)
92
![Page 93: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/93.jpg)
93
Conclusion Acute pancreatitis is a hot area for
research Advances at the cellular level show
promise to “halt”pancreatitis Most patients need just supportive care No indication for Antibiotics in mild type Severe pancreatitis needs antibiotics Surgical management ►gallstones /
complications
![Page 94: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/94.jpg)
94
Your comments….
![Page 95: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/95.jpg)
95
Pancreatic Psudocyst
![Page 96: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/96.jpg)
96
Definition:Pseudocysts are encapsulated localized collection of pancreatic enzyme, inflammatory fluid and necrotic debris on pancreas or in part or the whole of the lesser sac. They are distinguished from other types of pancreatic cysts by their lack of an epithelial lining.
![Page 97: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/97.jpg)
97
Causes Acute or chronic pancreatitis
abdominal trauma.
Duct obstruction.
![Page 98: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/98.jpg)
98
Presenting symptoms
Epigastric pain
Nausea
Vomiting
Weight loss
Mild Fever
Jaundice
![Page 99: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/99.jpg)
99
Physical Examination•The sensitivity of physical examination findings is limited.
•Tender abdomen.•Palpable mass in the abdomen with an indistinct lower edge.•The upper limit is not palpable .
![Page 100: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/100.jpg)
100
Physical Examination•The sensitivity of physical examination findings is limited.
•tender abdomen.•palpable mass in the abdomen with an indistinct lower edge.•The upper limit is not palpable .
![Page 101: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/101.jpg)
101
Physical Examination•Its usually resonant to percussion because it is covered by the stomach.•It moves very slightly with respiration.•it is not possible to elicit fluctuation or a fluid thrill. •Peritoneal signs suggest rupture of the cyst or infection
![Page 102: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/102.jpg)
102
Differential diagnosis:•Acute pancreatic fluid collections.•Serous cystadenoma of the pancreas•Mucinous cystadenoma of the pancreas•Mucinous cystadenocarcinoma•Pancreatic retention cyst
![Page 103: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/103.jpg)
103
Investigations:
•Lab studies
•Imaging studies
• E.R.C.P
![Page 104: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/104.jpg)
104
Serum tests: Amylase and lipase levels are
often elevated but may be normal
Bilirubin and LFT findings may be elevated if the biliary tree is involved.
![Page 105: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/105.jpg)
105
Lab Studies Analysis of the cyst fluid may help
differentiate pseudocysts from tumors.
Attempt to exclude tumors in any patient who does not have a clear history of pancreatitis.
![Page 106: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/106.jpg)
106
Analysis of cyst fluid Carcinoembryonic antigen (CEA) and
carcinoembryonic antigen-125 (CEA-125) tumor marker levels are low in pseudocysts and elevated in tumors.
Fluid viscosity is low in pseudocysts and elevated in tumors.
Amylase levels are usually high in pseudocysts and low in tumors.
Cytology is occasionally helpful in diagnosing tumors, but a negative result does not exclude tumors.
![Page 107: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/107.jpg)
107
Abdominal CT scan CT scan is the investigation of
choice in pancreatic pseudocysts. It has a sensitivity of 90-100% and is not operator dependent.
The usual finding on CT scan is a large cyst cavity in and around the pancreas.
Multiple cysts may be present.
![Page 108: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/108.jpg)
108
Abdominal CT scan The pancreas may appear irregular or
have calcifications. Pseudoaneurysms of the splenic artery,
bleeding into a pseudocyst, biliary and enteric obstruction, and other complications may be noted on CT scan.
The CT scan provides a very good appreciation of the wall thickness of the pseudocyst, which is useful in planning therapy.
![Page 109: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/109.jpg)
109
Abdominal ultrasound:
While cystic fluid collections in and around the pancreas may be visualized via ultrasound,
the technique is limited by operator skill, the patient's habitus, and overlying bowel gas.
As such, ultrasound is not the study of choice for diagnosis.
![Page 110: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/110.jpg)
110
MRMR is not necessary for the diagnosis of pseudocysts; however, it is useful in detecting a solid component to the cyst and in differentiating between organized necrosis and a pseudocyst.
![Page 111: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/111.jpg)
111
MRIA solid component makes catheter drainage difficult; therefore, in the setting of acute necrotizing pancreatitis with resultant pseudocyst, an MRI may be very important before a planned catheter drainage procedure.
![Page 112: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/112.jpg)
112
Endoscopic Retrograde Cholangiopancreatography
(ERCP) is not necessary in diagnosing pseudocysts; however, it is useful in planning drainage strategy.
![Page 113: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/113.jpg)
113
Complications Infection of the pseudocyst patients develop fever or an elevated WBC count.
Treat infection with antibiotics and urgent drainage.
Gastric outlet obstruction, manifesting as nausea and vomiting, is an indication for drainage.
![Page 114: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/114.jpg)
114
Complications Rupture
A controlled rupture into an enteric organ occasionally causes GI bleeding.
On rare occasions, a profound rupture into the peritoneal cavity causes peritonitis
![Page 115: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/115.jpg)
115
Continue
Bleeding is the most feared complication and is
caused by the erosion of the pseudocyst into a vessel. Consider the possibility of bleeding in
any patient who has a sudden increase in abdominal pain coupled with a drop in hematocrit level or a change in vital signs.
![Page 116: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/116.jpg)
116
Continue
Bleeding is the most feared complication and
is caused by the erosion of the pseudocyst into a vessel. Therapy is emergent surgery or
angiography with embolization of the bleeding vessel.
![Page 117: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/117.jpg)
117
Management: 4X4, 5X5, 6X6 All cysts do not require treatment. In
many cases the pseudocysts may improve and go away on their own.
In a patient with a small (less than 5cm) cyst that is not causing any symptoms, careful observation of the cyst with periodic CT scans is indicated.
![Page 118: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/118.jpg)
118
Management: If a pseudocyst is persistent over
many months or causing symptoms then treatment of the cyst is required.
![Page 119: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/119.jpg)
119
External DrainageCatheter drainage:•Percutaneous catheter drainage is the procedure of choice for treating infected pseudocysts,• allowing for rapid drainage of the cyst and identification of any microbial organism. A high recurrence and failure rate exist.
![Page 120: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/120.jpg)
120
Continue Percutaneous catheter drainage
is contraindicated in patients who are poorly compliant and cannot manage a catheter at home.
It is also contraindicated in patients with strictures of the main pancreatic duct and in patients with cysts containing bloody or solid material.
![Page 121: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/121.jpg)
121
Internal drainage:•The majority of patients who require treatment for their pseudocysts are treated by surgery.
![Page 122: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/122.jpg)
122
Internal drainage:In the surgical procedure a connection is created between the cyst and an adjacent intestinal organ to which the cyst is adherent to such as the stomach. This connection allows the cyst to drain into the stomach.
![Page 123: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/123.jpg)
123
Continue Cysto-gastrostomy a connection is created between the back wall of the
stomach and the cyst , the cyst drains into the stomach.
Cysto-jejunostomy: a connection is created between the cyst and the
small intestine. Cysto-duodenostomy:a connection is created between the duodenum and
the cyst. During surgical drainage procedure biopsy of cyst
wall must be done to rule out a cystic carcinoma.
![Page 124: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/124.jpg)
124
Endoscopic technique In this procedure a gastroenterologist
drains the pseudocyst through the stomach by creating a small opening between the cyst and the stomach during endoscopy.
![Page 125: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/125.jpg)
125
Endoscopic technique In selected patients this treatment can
successfully treat pseudocyst. The disadvantage of this technique is that
if there is dead tissue in the pseudocyst cavity or if the cyst is very large then infection or recurrence of pseudocyst with this technique may occur.
![Page 126: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/126.jpg)
126
Insertion of a pancreatic stent:
In this technique the gastroenterologist may insert a drain into the cyst during an ERCP.
If the drain is placed directly into the cyst then the fluid from the cyst is drained into the intestine through this tube.
![Page 127: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/127.jpg)
127
Prognosis Most pseudocysts resolve without
interference, and patients do well without intervention.
Outcome is much worse for patients who develop complications or who have the cyst drained.
![Page 128: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/128.jpg)
128
Prognosis The failure rate for drainage
procedures is about 10%, the recurrence rate is about 15%, and the complication rate is 15-20%.
![Page 129: THE MANAGEMENT OF ACUTE PANCREATITIS Professor Ravi Kant MB, MS, FRCS (Edinburgh), FRCS (Glasgow), FACS, FICS, DNB, FAIS, FAMS, 1](https://reader036.vdocument.in/reader036/viewer/2022062300/56649e585503460f94b51a00/html5/thumbnails/129.jpg)
129