Post on 22-Nov-2014
description
By:
Dr. Sameen Jawed
House Surgeon
Civil Hospital Sukkur
•6 inches long, Retroperitoneal exo as well as endocrine gland•Head, neck, body & tail
•Dual Functions
•Exocrine-Trypsinogen, Chymotrypsinogen, Lipase, Amylase, Elastase, Esterase, Phospholipase A2, Lysophospholipase
•Endocrine-Insulin, Glucagon, Somatostatin
A group of reversible lesions characterized by inflammation of the pancreas
Male: female ratio is 1:3- in those with gallstones
6:1 in those with alcoholism
Non-traumatic(75%)Biliary tract diseasesAlcoholCa Pancreas Viral infection(EBV, CMV, mumps) Drugs(steroid, thiazide, furosemide) Scorpion bites Hyperlipidemia Hyperparathyroidism, Diabetes Mellitus, Porphyria Autoimmune diseases
Traumatic (5%) Operative trauma(Cardiopulmonary bypass, Billroth
type 2) Blunt/penetrating trauma Lab test(ERCP / angiography)
Idiopathic(20%)
(Morphological)Interstitial Edematous
Pancreatitis
Acute Necrotizing Pancreatitis
Parenchymal necrosis alone
Peripancreatic necrosis alone
Combined type
•(According to Severity)
•Mild Acute Pancreatitis
•Moderately Acute Pancreatitis
•Severe Acute Pancreatits
The most common symptoms and signs include:Severe epigastric painNausea, vomiting, diarrhea and loss of
appetiteFever/chillsHemodynamic instability, including shockIn severe case may present with tenderness,
guarding, rebound.Muscle Twitches, cramps & Spasm
Grey-Turner's signCullen's sign
Cullen’s sign – discolouration around umbilicus
Grey-Turner’s sign- discolouration in the flanks
Interstitial edema
Impaired blood flow
Ischaemia
Acinar cell injury
Interstitial inflammation oedema
GallstoneChronic alcoholism
Release of intracellular proenzymes and lysosomal hydrolases
Activation of enzymes
ACTIVATED ENZYMES
Delivery of proenzymes to lysosomal compartment
Intracellular activation of enzymes
Proteolysis(proteases)
Fat necrosis(lipase, phospholipase)
Haemorrhage(elastase)
Alcohol, drugstrauma, ischaemia,viruses
Metabolic injury(experimental)Alcohol, duct obstruction
DUCT OBSTRUCTION ACINAR CELL INJURYDEFECTIVE INTRACELLULAR TRANSPORT
Full blood countSerum Amylase & LipaseElectrolyte abnormalitiesElevated LDH in biliary diseaseBlood sugarUltrasound abdomenAbdominal CT scan & MRI
Renal failureEctopic pregnancyDiabetic ketoacidosisMesenteric ischaemia/infarction (but will
show bacterial contamination of peritoneal aspirate)
Small bowel perforation/obstructionRuptured or dissecting aortic aneurysmAtypical myocardial infarction
predicting the severity of acute pancreatitisAt admission age in years > 55 years white blood cell count > 16000 cells/mm3 blood glucose > 11 mmol/L (> 200 mg/dL) serum AST > 250 IU/L serum LDH > 350 IU/L At 48 hours Calcium (serum calcium < 2.0 mmol/L (< 8.0 mg/dL) Hematocrit fall > 10% Oxygen (hypoxemia PO2 < 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
If the score ≥ 3, severe pancreatitis likely If the score < 3, severe pancreatitis is unlikely
Hemorrhagic peritoneal fluidObesity Indicators of organ failureHypotension (SBP <90 mmHG) or tachycardia > 130
beat/minPO2 <60 mmHgOliguria (<50 mL/h) or increasing BUN and creatinineSerum calcium < 1.90 mmol/L (<8.0 mg/dL) serum albumin <33 g/L (<3.2.g/dL)>
• Score 0 to 2 : 2% mortality Score 3 to 4 : 15% mortality • Score 5 to 6 : 40% mortality Score 7 to 8 : 100%
mortality
On Admission: Age>55 years Arterial oxygenation saturation (PaO2)<8
Kpa(60mmhg) Total leucocyte count>15000/mm3 Serum Urea>16 m.mol/L Blood Glucose>10 m.mol/L (200mg/dl) Within 48 hrs: Serum Calcium<2 m.mol/l Serum Albumin<3.2 mg/dl LDH>600 IU/L AST/ALT>600 IU/L Score >= 3 indicates Acute Severe Pancreatitis Score < 3 indicates Acute Mild Pancreatitiss
Balthazar GradeBalthazar Grade Appearance on CT CT Grade Points Grade A Normal CT 0 points Grade B Focal or diffuse enlargement of the pancreas 1
point Grade C Pancreatic gland abnormalities and peripancreatic inflammation
2points Grade D Fluid collection in a single location 3
points Grade E Two or more fluid collections and / or gas bubbles in or adjacent 4
points to pancreas Necrosis ScoreNecrosis Percentage Points No necrosis 0 points 0 to 30% necrosis 2 points 30 to 50% necrosis 4 points Over 50% necrosis 6 points
Score > 4 Severe Pancreatitis Score < 2 Mild disease
The numerical CTSI (Computed Tomography Severity Index) has a maximum of ten points, it is the sum of the Balthazar grade points and pancreatic necrosis grade points
Score > 2 or more defines presence of organ dysfuntion
ImmediateShockSIRS/DIVCARDSOrgan Failure
LatePancreatic pseudocystPancreatic abscessPancreatic necrosisProgressive jaundicePersistent duodenal ileusPancreatic ascites & Pleural
effusion
Cavity surrounding outside of pancreas filled with necrotic products and liquid secretions
Abdominal painPalpable epigastric mass Nausea, vomiting, and anorexiaElevated serum amylaseResolves SponatneouslyInternal or External drainage
A large pus-containing cavity within pancreasUsually after the 4-6 weeks of PancreatitisResults from extensive necrosisUpper abdominal painAbdominal massHigh feverLeukocytosis
Treated Surgically
Relief of painPrevention or alleviation of shock Decrease respiratory failure↓ of pancreatic secretionsMaintain Fluid/electrolyte balanceAntiemetic if necessaryAntibiotic prophylaxisDetermine & treat specific etiology
IV Pethidine, IV Buprenorphine IV Benzodiazepines
Antispasmodic agent Bentyl Pro-Banthine
Spasmolytics – Nitroglycerine
Positioning – sitting up and leaning forward
BloodPlasma ExpandersAlbuminRinger Lactate Solution250–500 ml per hour of isotonic crystalloid
solution during first 12-24 hrsBolus of 1 litre in Severe casesAssesment within 6 hrs is essential till 24-48
hrs
Oxygen InhalationMonitoring O2 SaturationSemi-fowlers position
Keeping NPON.G SuctionAntacids, H2 Receptor Anatagonists, Anti
Spasmodics
Particularly Paralytic IleusFrequent vomiting
CalciumMagnessiumGlucoseAll should be corrected if derranged
Broad-spectrum antibioticsciprofloxacin, ofloxacin, imipenem, and
pefloxacinMetronidazole
Enteral Nutrition is superior to Parenteral NutritionIn mild cases: Immediate oral feeding Low fat solid diet
In Severe cases: Nasogastric feeding Nasojejunal feeding
Energy 25 to 35 kcal/kg/dayprotein 1.2 to 1.5 g/kg/daycarbohydrates 3 to 6 g/kg/day lipids 2 g/kg/day.
Surgical therapy – If related to gallstones
ERCPEndoscopic sphincterotomyLaparoscopic cholecystectomy
Necrosectomy for Infected Necrosis
Avoid AlcoholAvoid Culprit Drugs