PANCREATITIS By; Col. Abrar Hussain Zaidi. INTRODUCTION Pancreatitis is an inflammatory process in...

PANCREATITISPANCREATITIS

By;By;

Col. Abrar Hussain ZaidiCol. Abrar Hussain Zaidi

INTRODUCTIONINTRODUCTION

Pancreatitis is Pancreatitis is

an inflammatory process an inflammatory process

in which in which pancreatic enzymes pancreatic enzymes

auto digest the gland.auto digest the gland.


Inflammation of PancreasInflammation of Pancreas AcuteAcute ChronicChronic Recurrent acuteRecurrent acute Acute on chronicAcute on chronic


Acute pancreatitisAcute pancreatitis - May heal without any loss of - May heal without any loss of function or morphologic changes. function or morphologic changes.

Recurrent pancreatitisRecurrent pancreatitis - recurs intermittently, - recurs intermittently, contributing to the functional and morphologic loss contributing to the functional and morphologic loss of the gland. of the gland.

Chronic pancreatitisChronic pancreatitis-persistent low grade -persistent low grade inflammations. inflammations.


Clinical importance Clinical importance -?-?


One of the One of the commonest conditionscommonest conditions that that a physician or a surgeon comes a physician or a surgeon comes

acrossacross

Associated Associated morbidity is high morbidity is high

The The cost of treatment is highcost of treatment is high

In severe cases the In severe cases the mortality mortality may be 20-30%may be 20-30%


Prevention of disease is possible Prevention of disease is possible

If If

we are we are aware of etiological factorsaware of etiological factors and pathogenesisand pathogenesis

ANATOMYANATOMY

PHYSIOLOGYPHYSIOLOGY

EXOCRINE FUNCTIONEXOCRINE FUNCTION ENDOCRNE FUNCTIONENDOCRNE FUNCTION

Acute pancreatitisAcute pancreatitis

EPIDEMIOLOGYEPIDEMIOLOGY

3% of all cases of abdominal pain admitted to hospital.3% of all cases of abdominal pain admitted to hospital.

40 cases per year per 100,000 adults.[International]40 cases per year per 100,000 adults.[International]

Ranges between 5 and 80 per 100,000 populationRanges between 5 and 80 per 100,000 population

The highest incidence recorded in the United States and The highest incidence recorded in the United States and Finland Finland

In 80% of cases: mild and resolves without serious prob.In 80% of cases: mild and resolves without serious prob. Sex No predilection exists.Sex No predilection exists. Age- 35-64 years Age- 35-64 years

PATHOPHYSIOLOGYPATHOPHYSIOLOGY

located in the retroperitoneal space located in the retroperitoneal space No capsuleNo capsule, , inflammation can spread easilyinflammation can spread easily. . Local effectsLocal effects

Acute edematous pancreatitisAcute edematous pancreatitis : When : When Parenchyma edema and peripancreatic fat Parenchyma edema and peripancreatic fat necrosis occur first necrosis occur first

Haemorrhagic or narcotizing pancreatitis:Haemorrhagic or narcotizing pancreatitis: When necrosis involves the parenchymaWhen necrosis involves the parenchyma, , accompanied by hemorrhage and dysfunction of accompanied by hemorrhage and dysfunction of the glandthe gland


pancreatic abscessespancreatic abscesses andand PseudocystsPseudocysts

due to necrotizing pancreatitis because due to necrotizing pancreatitis because

enzymes can be walled off by enzymes can be walled off by

granulation tissuegranulation tissue


systemic effectssystemic effects ; ;

Due to cytokines: bradykinins and phospholipase A. Due to cytokines: bradykinins and phospholipase A.

Cytokines cause Cytokines cause

Vasodilatation, increase in vascular permeability, pain, Vasodilatation, increase in vascular permeability, pain, and leukocyte accumulation in the vessel walls. and leukocyte accumulation in the vessel walls.

Fat necrosis may cause hypocalcaemia. Pancreatic B-Fat necrosis may cause hypocalcaemia. Pancreatic B-cell injury may lead to hyperglycemia.cell injury may lead to hyperglycemia.


systemic effectssystemic effects ; ;

in its most severe form.in its most severe form. Acute respiratory distress syndrome (ARDS), Acute respiratory distress syndrome (ARDS), acute renal failure, acute renal failure, cardiac depression, cardiac depression, hemorrhage, and hypotensive shock hemorrhage, and hypotensive shock

CAUSESCAUSES Alcohol abuseAlcohol abuse - 44% of patients - 44% of patients

At cellular level - At cellular level - ethanol leads to intracellular ethanol leads to intracellular accumulation of digestive enzymesaccumulation of digestive enzymes and their and their premature activation and release.premature activation and release. At ductal level - At ductal level - increases the permeability of increases the permeability of ductules, enzymes reach the parenchymaductules, enzymes reach the parenchyma, resulting in , resulting in

pancreatic damage.pancreatic damage. Formation of protein plugs Formation of protein plugs due to due to increases the increases the protein content of the pancreatic juice and decreases protein content of the pancreatic juice and decreases bicarbonate levelsbicarbonate levels and trypsin inhibitor and trypsin inhibitor

concentrations. concentrations. This leads to the that block the pancreatic outflow and This leads to the that block the pancreatic outflow and obstruction.obstruction.

OTHER MAJOR CAUSESOTHER MAJOR CAUSES

Biliary calculiBiliary calculi

cholelithiasis, choledocholithiasis cholelithiasis, choledocholithiasis

calculi lodge in the pancreatic duct or ampulla of Vater calculi lodge in the pancreatic duct or ampulla of Vater and and obstruct the pancreatic ductobstruct the pancreatic duct,, leading to leading to extravasation of enzymes into the parenchyma.extravasation of enzymes into the parenchyma.

MedicationsMedications, including azathioprine, corticosteroids, , including azathioprine, corticosteroids, sulfonamides, thiazides, furosemides, NSAID”Ssulfonamides, thiazides, furosemides, NSAID”S

Viral infectionsViral infections TraumaTrauma

OTHER CAUSESOTHER CAUSES ERCPERCP Hypertriglyceridemia (When the triglyceride level exceeds 1000 mg/UHypertriglyceridemia (When the triglyceride level exceeds 1000 mg/U

Peptic ulcer diseasePeptic ulcer disease Abdominal or cardiopulmonary bypass surgery, -by ischemiaAbdominal or cardiopulmonary bypass surgery, -by ischemia

TraumaTrauma –blunt+penetrating –blunt+penetrating

Carcinoma of the pancreas,Carcinoma of the pancreas, - outflow obstruction - outflow obstruction

Viral infections, including mumps, coxsackievirus, cytomegalovirus (CMV), Viral infections, including mumps, coxsackievirus, cytomegalovirus (CMV), hepatitis virus, Epstein-Barr virus (EBV), and rubellahepatitis virus, Epstein-Barr virus (EBV), and rubella

Bacterial infections, such as mycoplasma ,TuberculosisBacterial infections, such as mycoplasma ,Tuberculosis

Intestinal parasites, such as Ascaris, which can block the pancreatic Intestinal parasites, such as Ascaris, which can block the pancreatic outflowoutflow

Pancreas divisumPancreas divisum

Scorpion and snake bitesScorpion and snake bites ischemia or vasculitisischemia or vasculitis Autoimmune pancreatitis Autoimmune pancreatitis

CLINICAL PRESENTATIONCLINICAL PRESENTATION

HistoryHistory The main presentationThe main presentation - - Epigastric painEpigastric pain or or

right upper quadrant pain radiating right upper quadrant pain radiating through, rather than around, to the back.through, rather than around, to the back.

Nausea and/or vomitingNausea and/or vomiting FeverFever History of previous biliary colic PhysicalHistory of previous biliary colic Physical PalpitationsPalpitations Muscular spasm –in extremities may be Muscular spasm –in extremities may be

noted secondary to noted secondary to hypocalcemia.hypocalcemia.


Ask the patient about ;Ask the patient about ; Recent surgery or invasive procedure e.g. Recent surgery or invasive procedure e.g.

ERCP ERCP Family history of hypertriglyceridemia.Family history of hypertriglyceridemia. Alcohol consumptionAlcohol consumption


EXAMINATIONEXAMINATIONPatients are acutely illPatients are acutely ill

TachypneaTachypnea HypotensionHypotension FeverFever Abdominal tenderness, distension, Abdominal tenderness, distension,

guarding, and rigidityguarding, and rigidity Mild jaundiceMild jaundice Diminished or absent bowel soundsDiminished or absent bowel sounds


EXAMINATIONEXAMINATION

Basilar rales, especially in the left lung.Basilar rales, especially in the left lung. Pleural effusionPleural effusion Because of contiguous spread of inflammation Because of contiguous spread of inflammation

from the pancreas from the pancreas

Severe cases may have;Severe cases may have; Grey TurnerGrey Turner sign (ie, bluish discoloration of sign (ie, bluish discoloration of

the flanks) the flanks) Cullen signCullen sign (ie, bluish discoloration of the (ie, bluish discoloration of the

periumbilical periumbilical area) area) caused by the retroperitoneal leak of blood from caused by the retroperitoneal leak of blood from

the pancreas in hemorrhagic pancreatitis.the pancreas in hemorrhagic pancreatitis.

Differential DiagnosesDifferential Diagnoses

Abdominal Aneurysm Abdominal Aneurysm HepatitisHepatitis CholangitisCholangitis Mesenteric IschemiaMesenteric Ischemia Cholecystitis and Biliary ColicCholecystitis and Biliary Colic Intestinal ObstructionIntestinal Obstruction CholelithiasisCholelithiasis CholedocholithiasisCholedocholithiasis GastroenteritisGastroenteritis Perforated viscus/du-perforationPerforated viscus/du-perforation Pancreatic cancerPancreatic cancer Malabsorption syndromesMalabsorption syndromes Ectopic pregnancyEctopic pregnancy

DIAGNOSTIC WORK-UPDIAGNOSTIC WORK-UP

HISTORY AND CLINICAL EXAMINATIONHISTORY AND CLINICAL EXAMINATION LABORATORY TESTSLABORATORY TESTS IMMAGING STUDIESIMMAGING STUDIES


Laboratory StudiesLaboratory Studies

leukocytosis leukocytosis ((WBC >12,000) -> polymorphs.WBC >12,000) -> polymorphs. Hyperglycemia.Hyperglycemia. Disturbed in the electrolyte Disturbed in the electrolyte

balance:Urea/creatinin Na, K, Cl, CO2, P, Mg---balance:Urea/creatinin Na, K, Cl, CO2, P, Mg---secondary to third spacing of fluids.secondary to third spacing of fluids.

Acid base disturbancesAcid base disturbances Amylase levelsAmylase levels, preferably the amylase P.> 3 , preferably the amylase P.> 3

times -suggest the diagnosis .[ serum/peritoneal]times -suggest the diagnosis .[ serum/peritoneal] Lipase - elevated / remain high for 12 days. Lipase - elevated / remain high for 12 days. AnemiaAnemia


Laboratory StudiesLaboratory Studies liver function testsliver function tests particularly in biliary calculi. particularly in biliary calculi. MiscMisc. Done in some hospitals in addition to the . Done in some hospitals in addition to the

above, especially to identify pancreatitis post ERCP .above, especially to identify pancreatitis post ERCP .

Urinary trypsinogen activation peptide Urinary trypsinogen activation peptide Increased serum trypsinogen2 Increased serum trypsinogen2 Trypsin 2-alpha 1 antitrypsin complex values Trypsin 2-alpha 1 antitrypsin complex values


Imaging StudiesImaging Studies

Plain X-rays Plain X-rays kidneys, ureters, bladder (KUB) kidneys, ureters, bladder (KUB) Exclude viscus perforation (ie, Exclude viscus perforation (ie, air under the air under the

diaphragm). diaphragm). In patients with a recurrent episode of chronic In patients with a recurrent episode of chronic

pancreatitis, pancreatitis, peripancreatic calcificationsperipancreatic calcifications may may be noted.be noted.


Ultrasonography Ultrasonography A screening test. poorly visualised in 25-50% of cases / A screening test. poorly visualised in 25-50% of cases /

overlying gas shadows overlying gas shadows Can Can show swollen pancreasshow swollen pancreas, dilated common bile duct, and , dilated common bile duct, and

free peritoneal fluid.free peritoneal fluid. Useful to Useful to detect presence of gallstones.detect presence of gallstones.

CT –scanCT –scan is the is the most reliable imaging modalitymost reliable imaging modality in the diagnosis in the diagnosis of acute pancreatitis. of acute pancreatitis. The criteria for diagnosis are divided by The criteria for diagnosis are divided by Balthazar and colleagues into 5 grades:Balthazar and colleagues into 5 grades:

Grade A - Normal pancreasGrade A - Normal pancreas Grade B - Focal or diffuse gland enlargementGrade B - Focal or diffuse gland enlargement Grade C - Intrinsic gland abnormality recognized by haziness on Grade C - Intrinsic gland abnormality recognized by haziness on

the scanthe scan Grade D - Single ill-defined collection or phlegmonGrade D - Single ill-defined collection or phlegmon Grade E - Two or more ill-defined collections or the presence of Grade E - Two or more ill-defined collections or the presence of

gas in or nearby the pancreasgas in or nearby the pancreas


Misc. TestsMisc. Tests

Urine para-aminobenzoic acid testUrine para-aminobenzoic acid test (ie, bentiromide [Chymex] (ie, bentiromide [Chymex] test) is used for chronic pancreatitis to assess for the reserve test) is used for chronic pancreatitis to assess for the reserve function of the pancreas. In patients with severe pancreatic function of the pancreas. In patients with severe pancreatic insufficiency and malabsorption, the sensitivity is 80–90%. In insufficiency and malabsorption, the sensitivity is 80–90%. In those with mild-to-moderate functional impairment, the sensitivity those with mild-to-moderate functional impairment, the sensitivity is as low as 37–46%.is as low as 37–46%.

Serum trypsinogen assaySerum trypsinogen assay or the serum trypsin test can also be or the serum trypsin test can also be used to assess the function of the pancreas in chronic pancreatitis. used to assess the function of the pancreas in chronic pancreatitis. Only a very low level of serum trypsinogen (<20 ng/mL) is Only a very low level of serum trypsinogen (<20 ng/mL) is reasonably specific (90%) for chronic pancreatitis, and these are reasonably specific (90%) for chronic pancreatitis, and these are seen in advanced chronic pancreatitis with steatorhea.7 seen in advanced chronic pancreatitis with steatorhea.7

Both of these tests are available Both of these tests are available to test for the pancreatic to test for the pancreatic reservereserve in chronic pancreatitis, in chronic pancreatitis, and their specificity is similar and their specificity is similar in the advanced versus the moderate chronic pancreatitis. in the advanced versus the moderate chronic pancreatitis. Ordering them is according to availability.Ordering them is according to availability.

Value in acute on chronic pancreatitis Value in acute on chronic pancreatitis


Peritoneal aspirationPeritoneal aspiration - free fluid without - free fluid without bacterial contamination +>amylase+>TLC.bacterial contamination +>amylase+>TLC.

ERCP with a sphincterotomyERCP with a sphincterotomy is warranted is warranted within the first 72 hours. within the first 72 hours. where a dilated where a dilated obstructed common bile duct is diagnosed by CT obstructed common bile duct is diagnosed by CT or USG with elevated plasma bilirubin (>5 mg/dL)or USG with elevated plasma bilirubin (>5 mg/dL)

Laparoscopy or laparotomyLaparoscopy or laparotomy:: where suspicion where suspicion is high but tests are inconclusive.is high but tests are inconclusive.

Severity and prognostic Severity and prognostic assessmentassessment

Prediction is Prediction is difficult and unreliabledifficult and unreliable.. Clinically apparent organ failureClinically apparent organ failure indicates a indicates a

severe attack. severe attack. Scoring systems: do increase accuracy.Scoring systems: do increase accuracy. Initially assessing the severity of an attack Initially assessing the severity of an attack

into mild or severe has important into mild or severe has important implications for management - and may implications for management - and may prevent deaths. prevent deaths.

Severity and prognostic Severity and prognostic assessmentassessment

Scoring systems:Scoring systems: GlasgowGlasgow RansonRanson Apache II scores Apache II scores

can indicate prognosis particularly can indicate prognosis particularly

Glasgow prognostic scoreGlasgow prognostic score

Age >55 years Age >55 years WBC >15 x109/l WBC >15 x109/l Urea >16mmol/l Urea >16mmol/l Glucose >10mmol/l Glucose >10mmol/l pO2 <8kPa (60mmhg) pO2 <8kPa (60mmhg) Albumin <32g/l Albumin <32g/l Calcium <2mmol/l Calcium <2mmol/l LDH >600 units/l LDH >600 units/l AST/ALT >200 units AST/ALT >200 units

Ranson's criteriaRanson's criteria

Present on admission: Present on admission: Age >55 years Age >55 years WBC >15 x109/l WBC >15 x109/l Glucose >10mmol/l Glucose >10mmol/l LDH >600 units/l LDH >600 units/l SGOT >250 units/l SGOT >250 units/l

Developing during first 48 hours:Developing during first 48 hours: Haematocrit fall 10% Haematocrit fall 10% Urea increase >8mg/dl Urea increase >8mg/dl Serum Ca <8mg/dl Serum Ca <8mg/dl Arterial O2 saturation <60mmHg Arterial O2 saturation <60mmHg Base deficit >4meq/l Base deficit >4meq/l Estimated fluid sequestration >600ml Estimated fluid sequestration >600ml

Any 3 factors means severe in both systems.Any 3 factors means severe in both systems.

scoring.scoring. A Ranson score of 0-2 has a minimal mortality A Ranson score of 0-2 has a minimal mortality

raterate, and the patient is admitted to the regular , and the patient is admitted to the regular ward for medical therapy and support.ward for medical therapy and support.

A Ranson score of 3-5 has a 10-20% mortality A Ranson score of 3-5 has a 10-20% mortality rate, and the patient should be admitted to the rate, and the patient should be admitted to the intensive care unit.intensive care unit.

A Ranson score A Ranson score after 48 hours higher than 5 has a after 48 hours higher than 5 has a mortality rate of more than 50%mortality rate of more than 50% and is associated and is associated with more systemic complications.with more systemic complications.

TreatmentTreatment

According to severityAccording to severity

Mild cases in wardsMild cases in wards Severe cases to be Treat in ITU or high Severe cases to be Treat in ITU or high

dependency unit.dependency unit.

Majority - treated conservativelyMajority - treated conservatively

Emergency surgery in small proportion of Emergency surgery in small proportion of casescases

Elective surgery in biliary calculiElective surgery in biliary calculi

TreatmentTreatment

Emergency Department CareEmergency Department Care

Most of the cases are treated conservatively, and Most of the cases are treated conservatively, and approximately 80% respond to such treatment. approximately 80% respond to such treatment.

Fluid resuscitationFluid resuscitation Monitor accurate intake/output and electrolyte Monitor accurate intake/output and electrolyte

balance of the patient.balance of the patient. Crystalloids / packed red blood cells –[ in the case Crystalloids / packed red blood cells –[ in the case

of hemorrhagic pancreatitis]of hemorrhagic pancreatitis] CVP line with monitoring-- severe fluid loss and CVP line with monitoring-- severe fluid loss and

very low blood pressure.very low blood pressure.

TREATMENTTREATMENTIn Wards/ICUIn Wards/ICUThe goal -to relieve pain and minimize complicationsThe goal -to relieve pain and minimize complications.. AnalgesicsAnalgesics . . Meperidine is preferred over Meperidine is preferred over morphinemorphine because of the because of the greater spastic effect of the latter on the sphincter of Oddi.greater spastic effect of the latter on the sphincter of Oddi. Parenteral NSAID”SParenteral NSAID”S

Anti ulcer drugsAnti ulcer drugs Prevention of gastric/duodenal stress ulcersPrevention of gastric/duodenal stress ulcers

AntibioticsAntibiotics Empiric- enteric anaerobic and aerobic gram-Empiric- enteric anaerobic and aerobic gram- Adjust as per c/s reports.Ceftriaxone Adjust as per c/s reports.Ceftriaxone Aminoglycosides/ MetronidazoleAminoglycosides/ Metronidazole

TREATMENTTREATMENT

Rationale for antibioticsRationale for antibiotics Other conditions, such as biliary pancreatitis Other conditions, such as biliary pancreatitis

associated with cholangitis, also need antibiotic associated with cholangitis, also need antibiotic coverage. The preferred antibiotics are the ones coverage. The preferred antibiotics are the ones secreted by the biliary system, such as ampicillin secreted by the biliary system, such as ampicillin and third-generation cephalosporins.and third-generation cephalosporins.

Continuous oxygen saturationContinuous oxygen saturation should be should be monitored by pulse oximetry, and acidosis should monitored by pulse oximetry, and acidosis should be corrected. When tachypnea and pending be corrected. When tachypnea and pending respiratory failure develops, intubation should be respiratory failure develops, intubation should be performed.performed.

TREATMENTTREATMENT

NG intubationNG intubation if the patient is vomiting if the patient is vomiting [for symptomatic relief and to avoid aspiration][for symptomatic relief and to avoid aspiration]

Guided aspirationGuided aspiration of necrotic areas, if of necrotic areas, if necessary.necessary.

An An ERCPERCP may be indicated for common duct may be indicated for common duct stone removalstone removal

Surgery in Acute pancreatitisSurgery in Acute pancreatitis Diagnostic/TherapeuticDiagnostic/Therapeuticfor complicationsfor complications BleedingBleeding PseudocystsPseudocysts Abscess Abscess drain, repair, or remove the affected tissuesdrain, repair, or remove the affected tissues where there is fulminent infection and necrosis. where there is fulminent infection and necrosis. open surgical debridement. open surgical debridement. Postoperative lavage or abdominal packing Postoperative lavage or abdominal packing closure of abdomen - partial or nonclosure of abdomen - partial or non

Establish a feeding jejunostomyEstablish a feeding jejunostomy..

Surgery in Acute pancreatitisSurgery in Acute pancreatitis

For phlegmon of the pancreasFor phlegmon of the pancreas,, surgery can achieve surgery can achieve drainage of any abscess or drainage of any abscess or

scooping of necrotic pancreatic tissue.scooping of necrotic pancreatic tissue. It should It should be followed by postoperative be followed by postoperative lavage lavage of the of the pancreatic bed.pancreatic bed.

In patients with hemorrhagic pancreatitis, surgery In patients with hemorrhagic pancreatitis, surgery is indicated to is indicated to achieve hemostasisachieve hemostasis, particularly , particularly because major vessels may be eroded in acute because major vessels may be eroded in acute pancreatitis.pancreatitis.

Patients Patients who fail to improve despite optimal who fail to improve despite optimal medical treatmentmedical treatment or patients who push the or patients who push the Ranson score even further are taken to the Ranson score even further are taken to the operating room. Surgery in these cases may lead operating room. Surgery in these cases may lead to a better outcome or confirm a different to a better outcome or confirm a different diagnosis.diagnosis.

Surgery in Acute pancreatitisSurgery in Acute pancreatitis

Sphincterotomy - Sphincterotomy - In biliary pancreatitis, a (ie, In biliary pancreatitis, a (ie, surgical emptying of the common bile duct) can surgical emptying of the common bile duct) can relieve the obstruction. relieve the obstruction.

A cholecystectomy may be performed to clear the A cholecystectomy may be performed to clear the system from any source of biliary stones.system from any source of biliary stones.

Hyperbaric oxygen therapy - administration of Hyperbaric oxygen therapy - administration of 100% oxygen at a pressure of 2.5 atmospheres 100% oxygen at a pressure of 2.5 atmospheres for 90 min twice daily for 5 days has been shown for 90 min twice daily for 5 days has been shown to improve to improve

Complications in Acute Complications in Acute pancreatitispancreatitis

Local complicationsLocal complications Pancreatic necrosisPancreatic necrosis -Infected necrosis is almost -Infected necrosis is almost

always fatal without intervention.always fatal without intervention. Acute Fluid CollectionsAcute Fluid Collections are common in patients are common in patients

with severe pancreatitis (occurring in 30%-50%).with severe pancreatitis (occurring in 30%-50%). Pancreatic abscessPancreatic abscess is a collection of pus adjacent is a collection of pus adjacent

to pancreas presenting several months after to pancreas presenting several months after attack.attack.

Acute pseudocyst Acute pseudocyst rupture or haemorrhage in pseudocyst.rupture or haemorrhage in pseudocyst. Pancreatic ascitesPancreatic ascites occurs when a pseudo-cyst occurs when a pseudo-cyst

collapses into peritoneal cavity or major collapses into peritoneal cavity or major pancreatic duct breaks down and releases pancreatic duct breaks down and releases pancreatic juices into peritoneal cavity.pancreatic juices into peritoneal cavity.


Systemic complicationsSystemic complications Respiratory:Pulmonary oedema/Pleural effusionsRespiratory:Pulmonary oedema/Pleural effusions Consolidation/ARDSConsolidation/ARDS

Cardiovascular:Hypovolaemia/Shock/arrhythmiasCardiovascular:Hypovolaemia/Shock/arrhythmias

Disseminated intravascular coagulopathy (DIC)Disseminated intravascular coagulopathy (DIC)

Renal dysfunction due to hypovolaemia, intra-vascular Renal dysfunction due to hypovolaemia, intra-vascular coagulation. Usually avoided by adequate fluid replacement coagulation. Usually avoided by adequate fluid replacement plus/minus low-dose dopamine but acute tubular or cortical plus/minus low-dose dopamine but acute tubular or cortical necrosis can follow.necrosis can follow.

GIT: Haemorrhage/IleusGIT: Haemorrhage/Ileus


Metabolic:Metabolic:

HypocalcaemiaHypocalcaemia HypomagnesaemiaHypomagnesaemia HyperglycaemiaHyperglycaemia


Weber Christian disease:Weber Christian disease: Subcutaneous fat necrosis - relapsing febrile Subcutaneous fat necrosis - relapsing febrile

nodular nonsuppurative panniculitis. Recurring nodular nonsuppurative panniculitis. Recurring crops of tender nodules in skin and subcutaneous crops of tender nodules in skin and subcutaneous fat of trunk, thighs and buttocks, which is more fat of trunk, thighs and buttocks, which is more common in middle-aged women.common in middle-aged women.

Often ulcerate and scar on healing.Often ulcerate and scar on healing. Difficult to treat - prednisolone or Difficult to treat - prednisolone or

immunosuppressives.immunosuppressives.

Splenic vein thrombosisSplenic vein thrombosis

Prognosis-acute PancreatitisPrognosis-acute Pancreatitis

Mild edematous pancreatitisMild edematous pancreatitis occurs in about occurs in about 80% cases, and the mortality rate is 80% cases, and the mortality rate is below 1%.below 1%.

Severe acute pancreatitisSevere acute pancreatitis occurs in about 20% occurs in about 20% of presentations, with a mortality rate reaching of presentations, with a mortality rate reaching 30%.30%. . .

Follow-up Follow-up acute Pancreatitisacute Pancreatitis

further Outpatient Carefurther Outpatient Care The patient should be monitored routinely with physical The patient should be monitored routinely with physical

examination and examination and amylase and lipase assays.amylase and lipase assays. TransferTransfer Transfer patients with Ranson scores of 0-2 to a hospital floor. Transfer patients with Ranson scores of 0-2 to a hospital floor. Transfer patients with Ranson scores 3-5 to an intensive care unit. Transfer patients with Ranson scores 3-5 to an intensive care unit.

Transfer patients with Ranson scores higher than 3 to an intensive Transfer patients with Ranson scores higher than 3 to an intensive

care unit with emergency surgery as a possibility, depending on care unit with emergency surgery as a possibility, depending on the patient's progress and findings on abdominal CT scanning.the patient's progress and findings on abdominal CT scanning.

Patient EducationPatient Education Educate patients about the disease and advise them to avoid Educate patients about the disease and advise them to avoid

alcohol in binge amounts and to discontinue any risk factor, such alcohol in binge amounts and to discontinue any risk factor, such as fatty meals and abdominal trauma.as fatty meals and abdominal trauma.

Summary –acute Summary –acute pancreatitispancreatitis

Begins with:Begins with: the digestive enzymes becoming the digestive enzymes becoming active inside the pancreas and active inside the pancreas and autodigestionautodigestion

Could be :Could be : acute/acute recurrent /acuteon acute/acute recurrent /acuteon chronic chronic

Common causes:Common causes: are gallstones and alcohol are gallstones and alcohol abuse. abuse.

Sometimes no causeSometimes no cause for pancreatitis can be for pancreatitis can be found. found.

Symptoms of acute pancreatitisSymptoms of acute pancreatitis include pain in include pain in the abdomen, nausea, vomiting, fever, and a the abdomen, nausea, vomiting, fever, and a rapid pulse. rapid pulse.

Treatment include:Treatment include: intravenous fluids, intravenous fluids, analgesics oxygen, antibiotics, anti ulcer and analgesics oxygen, antibiotics, anti ulcer and surgery. surgery.

May becomes chronic-May becomes chronic- when pancreatic tissue is when pancreatic tissue is destroyed and scarring developsdestroyed and scarring develops

Questions-acute Questions-acute Pancreatitis ?Pancreatitis ?

PANCREATITIS By; Col. Abrar Hussain Zaidi. INTRODUCTION Pancreatitis is an inflammatory process in...

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