ExocrineExocrine -P-Produces enzymes roduces enzymes tthat brehat bre

ak down ak down breakdown of the breakdown of the carbohydratescarbohydrates, , protein protein and and fatfat

EndocrineEndocrine Producing several important Producing several important

hormones,hormones, including including insullin , glucagoninsullin , glucagon

Acute inflammation of the Acute inflammation of the pancreaspancreas

Varying degree of regional tissue Varying degree of regional tissue involvement and remote organ involvement and remote organ systemssystems

Classified as acute unless there is Classified as acute unless there is evidence of chronic pancreatitis, evidence of chronic pancreatitis, otherwise considered as otherwise considered as exacerbation of inflammation exacerbation of inflammation superimposed on chronic superimposed on chronic pancreatitispancreatitis

Other ( 10 % ) => Other ( 10 % ) => includeinclude TraumaTrauma Postendoscopic retrograde Postendoscopic retrograde

cholangiopancreatographycholangiopancreatography Pancreatic malignancy , PUD ,IBD Pancreatic malignancy , PUD ,IBD

MedicationsMedications

Thizide Tetracycline Sulphonamid CThizide Tetracycline Sulphonamid Croticosteroideroticosteroide

Metabolic Metabolic - -

Hypertriglyceridemia ,HypercalcemiHypertriglyceridemia ,Hypercalcemiaa

InfectiousInfectious

-Viral , Bacterial , Parasitic-Viral , Bacterial , Parasitic

Gall stone (45 % )Gall stone (45 % )

Ethanol abuse (Alcohol )Ethanol abuse (Alcohol ) (35 %)(35 %)

Idiopathic ( 10 % )Idiopathic ( 10 % )

Clinical PresentationClinical Presentation

Epigastric pain or Upper abdominal / Diffuse Epigastric pain or Upper abdominal / Diffuse abdominal pain with radiation to backabdominal pain with radiation to back

Nausea & Vomiting Nausea & Vomiting

FeverFever

Nausea and Nausea and VVomiting omiting

TachycardiaTachycardia

Decreased or absent bowel soundsDecreased or absent bowel sounds

Abdominal tenderness , GuardingAbdominal tenderness , Guarding

Jaundice if there’s obstruction of the bile duct Jaundice if there’s obstruction of the bile duct

Cullen’s signCullen’s sign

Grey Turner’s SignGrey Turner’s Sign

Grey-Turner’s signGrey-Turner’s sign((HHemorrhagic emorrhagic ddiscoloration of the flanks) iscoloration of the flanks)

Cullen’s signCullen’s sign

((Hemorrhagic discoloration of the umbilicusHemorrhagic discoloration of the umbilicus) )

Physical examinationPhysical examination

Investigation Investigation

Marker of pancreatitis injuryMarker of pancreatitis injury

Serum amylaseSerum amylase

Most accurate when at least twice the upper limit of normal; Most accurate when at least twice the upper limit of normal; amylase levels and sensitivity decrease with time from onset amylase levels and sensitivity decrease with time from onset of symptomsof symptoms

Serum LipaseSerum Lipase Increased sensitivity in alcohol-induced pancreatitis; more Increased sensitivity in alcohol-induced pancreatitis; more specific and sensitive than amylase for detecting acute specific and sensitive than amylase for detecting acute pancreatitispancreatitis

Marker of biliary tract involvementMarker of biliary tract involvement

Alanine aminotransferaseAlanine aminotransferase ((ALT )ALT )

Elevate in gallstone pancreatitisElevate in gallstone pancreatitis

OtherOther

- C- C--reactive protein (CRP )reactive protein (CRP )

( Predictive of severity( Predictive of severity Late marker Late marker ) )

HHigh levels associated with pancreatic necrosisigh levels associated with pancreatic necrosis

Plain Films Abdomen & CXRPlain Films Abdomen & CXR Localized segment of small Localized segment of small

intestine (“sentinel loop”)intestine (“sentinel loop”) Generalize ileusGeneralize ileus Calcifications (stones, or pancreas Calcifications (stones, or pancreas

with chronic calcific pancreatitis)with chronic calcific pancreatitis) Pneumobilia following stone Pneumobilia following stone

passage and/or bilioenteric fistula passage and/or bilioenteric fistula formationformation

Severe ascitesSevere ascites Retroperitoneal gas (pancreatic Retroperitoneal gas (pancreatic

abscess)abscess) 30% with CXR abnormalities 30% with CXR abnormalities

(elevated hemidiaphragm, pleural (elevated hemidiaphragm, pleural effusion, basal atelectasis, effusion, basal atelectasis, pulmonary infiltrates)pulmonary infiltrates)

Radiological Findings

Abdominal ultrasoundCholelithiasis, biliary sludge, bile duct dilation, and pseudocysts

CT of abdomen

MRCP (Magnetic resonance cholangiopancreatography)

Other testing will reveal……Other testing will reveal……

Urine amylase increased for 1-2 weeksUrine amylase increased for 1-2 weeks Elevated WBCElevated WBC Decreased serum calciumDecreased serum calcium Elevated serum bilirubin, AST, ALT, LD, Elevated serum bilirubin, AST, ALT, LD,

and alkaline phosphataseand alkaline phosphatase Serum triglycerides >150mg/dlSerum triglycerides >150mg/dl

PulmonaryPulmonaryAtelactasisAtelactasis Pleural effusionsPleural effusions ARDSARDS

CardiovascularCardiovascular Cardiogenic shockCardiogenic shock

NeurologicNeurologic Pancreatic Pancreatic

encephalopathyencephalopathy

MetabolicMetabolic Metabolic acidosisMetabolic acidosis HypocalcemiaHypocalcemia Altered glucose metabolismAltered glucose metabolism

HematologicHematologic GI bleedingGI bleeding

RenalRenal Prerenal failurePrerenal failure

Treatment.

Mild Acute PancreatitisSevere Pancreatitis

(pancreatic necrosis or infected)

Supportive CareAntibiotic iv

--I.V. fluid resuscitationI.V. fluid resuscitation-Nutritional support-Nutritional support

-Analgesia-Analgesia

Fine needle aspiration (FNA )

Percutaneous Drainage

If not improve

If infected pancreatic necrosis

Anti-inflammatory & Antisecretory agents drug

Antibiotic in Acute PancreatitisAntibiotic in Acute Pancreatitis

Imipenem-cilastin 500 mg iv 8 hr x 2 wks

Quinolone group ( Ciprofloxacin or Ofloxacin ) ร่�วมกั�บ Metronidazole

Third generation cephalosporin ( Cefotaxime ) ร่�วมกั�บ Metronidazole

Mild acute pancreatitis ไม�ได้�เป็�นข้�อบ�งชี้��ในกัาร่ทำ�า surgery

ควร่ทำ�า FNA เพื่��อใชี้�ในกัาร่แยกัร่ะหว�าง sterile และ infected pancreatic necrosis ในผู้$�ป็%วยทำ��ม�อากัาร่ sepsis

กัาร่ใชี้� Prophylactic antibiotic สามาร่ถลด้อ�ตร่ากัาร่ต)ด้เชี้��อแต�ไม�ลด้survival

Infected pancreatic necrosis ทำ��ม�อากัาร่ข้อง sepsisเป็�นข้�อบ�งชี้��ในกัาร่ทำ�าsurgery และ Radiological drainage

ผู้$�ป็%วยทำ��เป็�น sterile necrosis ( FNA negative) ควร่ได้�ร่�บกัาร่ร่�กัษาแบบconservative

ไม่�แนะน�ให้�ทำ�กรผ่�ตั�ดในช่�วง 14 ว�นแรกห้ลั�งจกม่�อกรในผ่��ป่�วย necrotizing pancreatitis