Acute & Chronic Pancreatitis - PowerPoint Presentation

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Acute & Chronic

Pancreatitis

Present

by:J.s.hosseini

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AnatomyRetroperitoneal Organ Weighs 75 To 100 G 15 To 20 Cm LongHeadNeckBodyTail 2

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Inflammation or infection of the pancreas Normally digestive enzymes secreted by the pancreas are not active until they reach the SI. When the pancreas is inflamed, the enzymes attack and .damages the tissue that produce them2 types: 1. Acute Pancreatitis 2. Chronic Pancreatitis 3

What is Pancreatitis?

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Acute Pancreatitis4

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Definition and Incidence Inflammatory disease with little or no fibrosis. Initiated by several factors: 90% of acute pancreatitis is secondary to acute cholelithiasis or ETOH abuse Develop additional complications 300,000 cases occur in the united states each year leading to over 3000 deaths.5

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Etiology: (GET SMASHED)G: GallstoneE: Ethanol T: TraumaS: SteroidM: MumpA :AutoimmuneS: Scorpion bitsH: HyperlipidemiaE: ERCPD: Drugs

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Clinical PresentationAbdominal painEpigastricRadiates to the backWorse in supine positionNausea and vomitingGardingTachycardia, Tachypnea, Hypotension, HyperthermiaElevated Hematocrit & Pre renal azotemiaCullen's signGrey Turner's sign7

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Grey Turner sign

Cullen’s sign

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Diagnosis: Biochemical serum amylase Nonspecific Returns to normal in 3-5 days Normal amylase does not exclude pancreatitis Level of elevation does not predict disease severity Urinary amylase P-amylaseSerum Lipase CBC Increased HbThrombocytosisLeukocytosis

Liver

Function Test

Serum Bilirubin elevated

Alkaline

Phosphatase

elevated

Aspartate

Aminotransferase elevated

 

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Assessment of SeverityCriteria 1.ranson2.APACHE-2Biochemical MarkersComputed Tomography Scan10

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Ranson CriteriaCriteria for acute gallstone pancreatitisAdmissionAge > 70WBC > 18,000Glucose > 220LDH > 400AST > 250During first 48 hoursHematocrit drop > 10 pointsSerum calcium < 8Base deficit >

5.0

Increase in BUN >

2

Fluid sequestration >

4L

11

<2

pos

sign: mortality rate is 0

3-5

pos

sign: mortality rate

is

10 to 20

%

>7

pos

sign: mortality rate is

>

50%

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CT scans of normal kidneys and pancreasSpleen

L Kidney

R Kidney

A

Stomach

Liver

V

Pancreas

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Pancreatic Necrosis13

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Treatmaent of Mild PancreatitisPancreatic restSupportive carefluid resuscitation – watch BP and urine outputPain ControlNG tubes and H2 blockers or PPIs are usually not helpfulRefeeding (usually 3 to 7 days) If:Bowel Sounds PresentPatient Is HungryNearly Pain-free (Off IV Narcotics)Amylase & Lipase Not Very Useful14

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Treatment of Severe PancreatitisPancreatic Rest & Supportive CareFluid Resuscitation – may require 5-10 liters/dayCareful Pulmonary & Renal Monitoring – ICUMaintain Hematocrit Of 26-30%Pain Control – PCA pumpCorrect Electrolyte Derangements (K+, Ca++, Mg++)Contrasted CT scan at 48-72 hoursProphylactic antibiotics if presentNutritional supportMay be NPO for weeksTPN

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ComplicationsLocal Phlegmon, Abscess, Pseudocyst, AscitesInvolvement of adjacent organs, with hemorrhage, thrombosis, bowel infarction, obstructive jaundice, fistula formation, or mechanical obstruction Systemic A. Pulmonary: pleural effusions, atelectasis, hypoxemia, ARDS.B. Cardiovascular: myocardial depression, hemorrhage, hypovolemia.C.Metabolic

:

Hypocalcemia,hyperglycemia,Hyperlipidemia,coagulopathy

D. GI Hemorrhage

E

.

Renal

F

.

Hematologic

G

.

CNS

H

. Fat

necrosis

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Management17

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Chronic Pancreatitis18

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Definition and PrevalenceDefined as chronic inflammatory condition that causes irreversible damage to pancreatic structure and function.Incurable5 To 27 Persons Per 100,000 19

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EtiologyAlcohol, 70% Idiopathic (including tropical), 20% Other, 10% Hereditary Hyperparathyroidism Hypertriglyceridemia Autoimmune pancreatitis Obstruction Trauma Pancreas divisum20

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Classification:1. calcific pancreatitis2. obstraction pancreatitis3. inflammatory pancreatitis4. auto immune pancreatitis5. asymptomic fibrosis6. tropical pancreatitis7. hereditary pancreatitis8. idiopathic pancreatitis 21

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Signs and SymptomsSteady And Boring PainNot ColickyNausea Or Vomiting Anorexia Is The Most Common Malabsorption And Weight LossApancreatic Diabetes22

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Laboratory StudiesTests for Chronic PancreatitisI. Measurement of pancreatic products in blood A. Enzymes B. Pancreatic polypeptide

II. Measurement of pancreatic exocrine secretion

A

. Direct measurements

1

. Enzymes

2

. Bicarbonate

B

. Indirect measurement

1

.

Bentiromide

test

2

. Schilling test

3

. Fecal fat, chymotrypsin, or

elastase

concentration

4

. [

14

C]-

olein

absorption

III. Imaging techniques

A

. Plain film radiography of abdomen

B

. Ultrasonography

C. Computed tomography

D. Endoscopic retrograde cholangiopancreatography

E. Magnetic resonance cholangiopancreatography

F. Endoscopic ultrasonography

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24Pancreatic calcifications. CT scan showing multiple, calcified, intraductal stones in a patient with hereditary chronic pancreatitisEndoscopic retrograde cholangiopancreatography in chronic pancreatitis. The pancreatic duct and its side branches are irregularly dilated

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CT features 25The cardinal CT features of CP are pancreatic atrophy, calcifications, and main pancreatic duct dilation .

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ERCP26ERCP is a highly sensitive radiographic test for CP.

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MRCP27MRCP allows a noninvasive alternative to ERCP for imaging the pancreatic duct.

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EUSEUS is a minimally invasive test that allows simultaneous assessment of ductal and parenchymal structure. 28

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TreatmentAnalgesiaEnzyme TherapyAntisecretory TherapyNeurolytic TherapyEndoscopic ManagementSurgical Therapy29

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ComplicationsPseudocystPancreatic AscitesPancreatic-Enteric FistulaHead-of-Pancreas MassSplenic and Portal Vein Thrombosis30

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Management32

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