Acute pancreatitis

By:Elias S.

Acute pancreatitis An acute inflammatory process of the

Pancreas Associated with sever abdominal pain

and elevated pancreatic enzymes Incidence

US – 79.8/100,000/yr Accounts for >220,000 Hosp. Admissions/yr

England – 5.4/100,000/yr Incidence increases with Age

The two most common causes: Gall stones Alcoholism

20% - idiopathic

Acute pancreatitis cont…. Gallstones

30-60% of AP More in women ed in small GS ,<5mm (Microlithiasis) Only 3-7% of GS P’ts develop AP

Alcoholism 15-30% of AP More in men Dose dependant Only 10% of alcoholics develop AP

Pathogenesis Inciting event – Not clearly known

Alcohol ? Sensitization of acinar cells to CCK-induced

premature activation Zymogens ? Toxic metabolites – acetaldehyde

Fatty acid ethyl esterase ?Generation of oxidative stress

Gallstone ?Obstruction of the ampulla: Blockage of

drainage Reflux of bile

?Edema resulting from passage of stone Once began – Similar cascade of events

Inappropriate intrapancreatic activationOf trypsinogen to trypsin

trypsinPancreatic

autodigestion

Activation ofMore trypsin

Activation of otherEnzyme cascades

ComplementsKallikrine-kinin

CoagulationFibrinolysis

Activation ofChemotrypsinePhospholipase

Elastase

autodgestion

Release of more active enzymesFrom injured cells

More & wide Destruction(vicious cycle)

Pathogenesis cont… Chemoattraction,activation & sequestration

of neutrophils release of proinflammatory Cytokines and other mediators (TNF,IL-1,6,8 ; prostaglandins,leukotriens, Bradykinins,Histamine….) More Damage

Systemic response: SIRS (vascular indothelial injury, microvascular thrombosis)

Fever, ARDS , circulatory collapseshock , Renal failure, myocardial depression, DIC

Infection (local/systemic) In 30% of p’ts with acute sever pancreatitis Cause: enteric organisms Compromized gut barrier Bacterial translocation lethal

Diagnosis Characteristic abdominal pain Predisposing factor to pancreatitis Elevated serum amylase (>3x ULN)

Problems with serum Amylase test Normal:If delay in taking sample(2-5days)

Hypertriglyceridemia associated pancreatitis Ch. Pancreatitis

ed in many other conditions: salivary g., liver, kidney, small int., fallopian tube Ca of lung, Esophagus, ovary, breast

More specific tests: Serum -Lipase,

-Trypsinogen-2,Trypsinogen activation P. Imaging modalities – X-ray, Abd.US, EUS, CT,

MRI ERCP,MRCP

Predicting severity 2 broad categories

Edematous (mild): recovery in 5-7 days Necrotizing (sever) : high rate of complications

mortality severity:

defined by the presence of local/systemic complications

Predicting severity Clinical assesment Scoring systems (Ranson,Glasgow,APACHE II..) Serum markers (CRP) CT scan (CT severity index)

Clinical assesement Warning signs

Thirst Poor urine output Progressing tachycardia Tachypnea Hypoxemia Agitation, confusion Rising Hct Lack of improvement in symptoms in the 1st

48 hr Consider ICU admission!

Risk factors that adversly affect survival

Organ failure CVS: SBP <90mmhg or tachycardia >130/m Pulmonary: Po2 <60 mmhg Renal: oliguria(<50ml/hr) or ing BUN & Cr GI bleeding

Pancreatic necrosis Obesity (BMI>30) Age >70 Hct >44% C-reactive protein >150mg/dl urinary trypsinogen activation peptide

Local complications

Pancreatic necrosis Pancreatic fluid collections

abscess Pseudocysts

Ascitis Pleural effusion

Rx General principles of therapy

Reversing pancreatic inflammation Correcting underlying predisposing factor

Mild pancreatitis: Self-limited; subsides spontaneously in3-7days Supportive care (IV fluids, pain control), NPO

Sever pancreatitis: - ICU care Fluid resuscitation: 250-300ml/hr for the 1st 48hrs Asses O2 saturation – supplemental O2

maintain SpO2 >95% Adequate pain control – IV

opiates(Morphine,Meperidine) Nutritional support: Enteral feeding > TPN Preventing infections: three approaches

Enteral feeding – Maintain gut barrier integrity ? Selective decontamination of the gut ? Prophylactic antibiotics

Prophylactic antibiotics- controversial

Initial studies (mid-1970s) failed to show benefit

Recent meta-analysis of 8 controlled trials Reduced mortality

An other meta-analysis(4 trials) Reduced infection & Mortality

Subsequent,largest,multicenter, placebo controlled trial (114 p’ts, iv ciprofloxacilllin+metronidazol with placebo) – No benefit!

Further doubt on the benefit Selection of resistant organisms Development of fungal infection

Experimental agents Gabexate mesilate (proteinase

inhibitor) Somatostatine , octreotide

Correcting predisposing factor Gallstone pancreatitis

Removal of the stones (ERCP) Cholecystectomy (to prevent recurrence)

After recovery, prior to discharge Medication induced – Stop the drug Hypertriglyceridemia

Low-fat diet, w’t reduction, Exercise,cessation of alcohol intake

Surgery

THANK YOU