pancretitis
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Transcript of pancretitis
pancretitis
Dr-Monther AburedenGeneral surgeon-MOH
Liver and kidney transplant surgeon
DEFINITIONS
Inflammation of glandular parenchymal lead to injury and destruction of acinar components Acute: reversible Chronic : progressive
Acute Pancreatitis
CLASSIFICATION
• Mild• Moderate• Sever 25%
Acute pancreatitisEtiology:
1-Gallbladder stones 2-immoderate alcohol consumption 3-hyperlipedemia 4-drug induce 5- infectious causes: mumps,coxaki B 6-Post ERCP 7-Heredatery
pathophysiology
1-The critical step: Pancreatic outflow obstruction2-Activation of pancreatic enzymes3-Autodigestion4-Release of cytotoxines 5-Activation of inflammatory response6-Organ failure
The Pancreas
9
Diagnosispain,vomiting
Diagnosis24 h
• 3x Normal levels of amylase( 50 – 150 U/Dl) or lipase (10 – 140 U/L)
• Abdominal Pain• Vomiting
Acute Pancreatitis phtsical examination
• Cyanosis, Dyspnea• Bowel sounds decreased or absent• Low-grade fever, Leukocytosis• Hypotension, Tachycardia• Jaundice • Abnormal lung sounds - Crackles• Discoloration of abdominal wall – Turner’s or Cullen’s
sign• SIGNS OF SHOCK
Prognosis – Ranson’s (Severe > 3)• Ranson’s Score
– 5 on Admission• Age > 55 y• Glucose >200 mgldl• WBC > 16000• LDH > 350 iu/l• AST > 250 iu/l
– 6 after 48 hours from presentation• Hct > 10% decrease• Calcium < 8 mg/dl• Base Deficit > 4 mEq/l• BUN > 8• Fluid Sequestration >= 6L• PaO2 < 60
APACHE II scale
agetemperaturemean arterial pressure heart rate PaO2
arterial pH serum potassium serum sodiumserum creatinine hematocrit white blood cell count Glasgow Coma Scale score chronic health status
Assesment of severity25%Sever
1-CRP: >130 mg/l(first 72h)=complicated pancreatitis
2-Hematocrit:!!!!!!!! ↓bad sign: necrosis ↑bad sign:dehydrated3-Ct scan
ComplicationsLocal
• Pancreatic fluid collection: temporary,persistant
• Pancreatic necrosis• Significant hemorrhage
Systemic
• INFLAMMATORY PROCESS• Syestamatic Inflammatory Syndrome• Multiple Organ
Dysfunction:Respiratory,CVS,Renal failur
Managments
• Fluid • Pain killer• Abs• Nutrition• ERCP• Cholecystectomy
Fluid
• Urine output,• H.R• BP,• CVP
Pain
• NSAIDs• weak opioid• strong opioid• epidural anasthesia
Antibiotics
Nutrition
• Early Enteral feeding(no sepsis)
ERCP
• cholangitis
Cholecystectomy
When to go for surgery
• infected pancreatic necrosis
Chronic pancreatitis
• Dynamic disease: progressive loss of pancreatic parenchyma caused by inflammation and tissue destruction and subsequent synthesis of fibrotic tissue
Causes
TIGAROToxic: Alcohol, Ca,lipid,smoking,uremiaIdiopathicGeneticAutoimmuneRadiationObstruction
Dynamic disease
• Stage A: Recurrent abdominal pain+_mild impairment of pancreatic function• Stage B: more frequent attaches ,more sever+significant impairment in pancreatic function• Stage C: End stage ….less sever less frequent attaches…BUT marked impairment of endocrine and exocrine function
pathogenesis
• ???• Necrosis-fibrosis hypothesis• Protein plug hypothesis• Oxidative stress theory• Toxic –metabolic theory• ………………………………….
Diagnosis
History: recurrent attaches of abdominal painEpigastric and radiating to the backWeight loss:fear,malabsorbtionSteatorrhea(late,90% lost)Imaging
Imagingplain x ray
ERCPgold stander image
Dilated TortuosMultiple side branches
managemant
• Conservative• Endoscopic • surgery
pain
1-stop Alcohol intake
2-Analgesia:NSAIDS…Opioids
3-celiac plexus neurolysis
Pancreatic exocrine enzyme supplement
• Weight loss or steatorrhea:mandatory
malnutreition
• Frequent meals• protein: High• sugar :High• Fat: medium chain fatty acids?
Endoscopic treatment
• Sone:extraction• Stricture:dilatation and stenting
surgery
• Drainage procedures• Resection procedures
QUIZ
Standard supportive measures for patients with mild pancreatitis include the following:A. Intravenous fluid and electrolyte therapy.B. Withholding of analgesics to allow serial abdominal examinationsC. Subcutaneous octreotide therapyD. Nasogastric decompressionE.prophylactic antibiotics
Which of the following is the most popular single marker test for acute pancreatitis severity used today?
1. Trypsinogen activation peptide 2. TNF- alpha3. C Reactive Protein4. Interleukin 6&8
Which of the following is associated with gut atrophy?
1. NG feedings2. Jejunal feedings3. Parenteral feedings4. Enteric feedings
• Severity of acute pancreatitis correlate with levels of all of the following excepta) Glucoseb) Amylasec) Transaminased) Calcium