01/03/2011 Dr Kupe: Acute Pancreatitis

Dr Kupe
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W EDNES DA Y , FEB RUA R Y 23, 2011

Acute Pancreatitis

Definition
Acute inflammatory process of the pancreas with variable involvement of regional or remote tissues

Epidemiology
1–5/10,000
Predominant age:
- Acute pancreatitis: None
- Chronic pancreatitis: 35–45 years (usually related to alcohol)
Male = Female

Aetiology
I - idiopathic.(10%) Thought to be hypertensive sphincter or microlithiasis.
G - gallstone. (40%)
E - ethanol (alcohol) (35%)
T – trauma (usually in children), tumour
S - steroids
M - mumps (paramyxovirus) and other viruses (Epstein-Barr virus, CMV)
A - autoimmune disease (Polyarteritis nodosa, Systemic lupus erythematosus)-in pt <40
S - scorpion sting , snake bites
H - hypercalcemia, hyperlipidemia/hypertriglyceridemia and hypothermia
E - ERCP (4%) , emboli
D - drugs (SAND - steroids & sulfonamides, azathioprine, NSAIDS, diuretics such as furosemide and thiazides, &
didanosine) and duodenal ulcers

Pathophysiology

begins with injuries to acinar cells or impairment of zymogen granules secretion.

lysosomal and zymogen granule fuse, enabling trypsin production
trypsin triggers auto-digestion by zymogen activation cascade
secretory vesicles extrude into the interstitium, attracting inflammatory cells
Activated neutrophills release superoxide, proteolytic enzyme
Macrophages release cytokines (tumour necrosis factor alpha, IL-6, IL-8)
Mediators cause increased pancreatic vascular permeabilityà haemorrhage, edema, necrosis.

Presentation
epigastric/central abdomen dull, boring and steady pain, sudden onset, increasing severity. may radiate to back,
relieved by sitting forward
nausea, vomiting
fever, tachycardia, shock
jaundice (28%)
ileus, rigid abdomen, tenderness
periumbilical discoloration (Cullen’s sign) or in the flanks (Grey Turner’s sign) – due to methaemalbumin formed
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from digested blood tracks around the abdomen

* *
Cullen’s sign Grey Turner’s sign
Less common sign
Körte's sign (pain or resistance in the zone where the head of pancreas is located (in epigastrium, 6–
7 cm above the umbilicus)
Kamenchik's sign (pain with pressure under the xiphoid process)
Mayo-Robson's sign (pain while pressing at the top of the angle lateral to the Erector spinae muscles
and below the left 12th rib (left costovertebral angle(CVA))

Differential Diagnosis
Acute cholecystitis, organ rupture, AAA, PUD, any acute abdomen

Investigation
FBC an admission hematocrit > 47% may inidicate more severe disease
Leukocytosis may represent inflammation or infection

ABG if pt is dyspnoeic, monitor oxygenation, acid base status

CRP 24-48 hours after presentation

Calcium, magnesium, search for an etiology of pancreatitis (hypercalcemia or hyperlipidemia) or

cholesterol, and complications of pancreatitis (hypocalcemia resulting from saponification of fats
triglycerides in the retroperitoneum).

Amylase ↑ amylase (>1000u/ml, falls after 2d)

may be normal (in 10% of cases)

Lipase rises 4 to 8 hours from the onset

lipase more sensitive & specific (falls after 7-14d)

LFT ALT >150 U/L suggests gallstone pancreatitis and a more fulminant disease
course.

Serum electrolytes, electrolyte imbalances, renal insufficiency, and pancreatic endocrine

BUN, creatinine, dysfunction
glucose

LDH, BUN, and Measured at admission and at 48h to determine Ranson Criteria
bicarbonate

IgG4 evaluate for autoimmune pancreatitis

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Abdomen U/S if suspect gallstone + AST↑,
FNA- for bacterial infection

Endoscopic U/S evaluating the cause of severe pancreatitis, particularly microlithiasis and biliary
sludge, and can help identify periampullary lesion

Abdominal CT Indicated for severe pancreatitis

scanning scan within the first 72h

Acute pancreatitis. Pancreatic necrosis. Note the nonenhancing pancreatic body anterior to the
splenic vein. Also present is peripancreatic fluid extending anteriorly from the pancreatic head.

MRI alternative for CT, in pt with contrast allergy or renal insufficiency.

Image: Focal pancreatitis involving pancreatic head. Pancreatic head is enlarged w ith adjacent
ill-defined peripancreatic inflammation and fluid collections

ERCP Indication: severe acute gallstone pancreatitis that is not responding to

supportive therapy or with ascending cholangitis with worsening signs and
symptoms of obstruction,

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This patient w ith acute gallstone
pancreatitis underw ent
endoscopic retrograde
cholangiopancreatography. The
cholangiogram show s no stones
in the common bile duct and
multiple small stones in the
gallbladder. The pancreatogram
show s narrow ing of the
pancreatic duct in the area of the
genu, the result of extrinsic
compression of the ductal
system by inflammatory changes
in the pancreas.

AXR Limited role in acute pancreatitis

detect free air in the abdomen, ‘sentinel loop’ of proximal jejunum (solitary air-
filled dilatation)

erect CXR exlude other causes, eg perforation.

Criteria for Severity

Several examples of scoring system:

Scoring System Criteria

Modified Glasgow Pa O2 <8kPa

Criteria Age >55
Neutrophils WCC> 15x 109/L
Calcium < 2mmol/L
Raised urea >16mmol/L
Enzymes: LDH>600iu/L, AST >200iu/L
Albumin<32g/L
Sugar : blood glucose >10 mmol/L

Ranson's Criteria Present on Admission - GA LAW

Glucose (blood) greater than 200 mg/dl
Age >55 years
LDH (serum) > 350 I.U./L
AST >250 I.U./L
WBC > 16,000/ul

Developing During the First 48 Hours: - C HOBBS

Calcium (serum) < 8 mg/dl
Hematocrit fall > 10%
Oxygen (arterial) saturation l< 60 mm Hg
BUN increase> 8 mg/dl.
Base deficit > 4 meq/L
Sequestration of fluid > 600 ml

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Computed
Tomography Balthazar Appearance on CT CT
Severity Index Grade Grade
(CTSI)/ Points
Balthazar score
Grade A Normal CT 0 points

Grade B Focal or diffuse enlargement of the pancreas 1 point

Grade C Pancreatic gland abnormalities and 2 points

peripancreatic inflammation

Grade D Fluid collection in a single location 3 points

Grade E Two or more fluid collections and / or gas 4 points

bubbles in or adjacent to pancreas

Dx for severe pancreatitis : Ranson score >3, APACHE score >8, modified Glasgow score >3. Balthazar score –
proven to be more accurate

Management
Fluids (large 0.9% saline) to stabilize vital signs, urine flow >30mL/h, urinary catheter & consider
CVP monitoring

Nutrition Early initiation of enteral nutritional supplementation

TPN (2nd line)has been shown to reduce mortality rate

Antibiotics imipenem. (Controversial)

Analgesia pethidine or morphine(may cause sphincter of oddi to contract more but it is a better
analgesic, no CI)

Monitor Hourly pulse, BP, urine output, daily FBC, U&E, Ca, glucose, amylase, ABG

If worsening take to ICU. O2 if PaO2 ↓. Suspected abscess/necrosis(CT) à PTN +laparotomy &

debridement. Antibiotic controversial (imipenem)

ERCP if suspected CBD stone or clinical deterioration. Not in acute condition

Follow up Ensure alcohol incontinence

Within weeks to months after onset: check for signs of intra-abdominal infection,
pancreatic pseudocyst, intra-abdominal hemorrhage, colon perforation, obstruction or
fistulization, and multiorgan system failure.
CT-guide needle aspiration in the setting of necrotizing pancreatitis
Repeat CT/US to monitor complication (eg. pseudocyst)

Surgery for indication: infected pancreatic necrosis, diagnostic uncertainty, complications.

infected
Closed management - necrosectomy with closed continuous postoperative
pancreatic
necrosis lavage
Open management - necrosectomy with planned staged reoperations at
definite intervals (up to 20+ reoperations in some cases)

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Management
for
Definition Pseudocyst-peripancreatic fluid collections persisting for more
pancreatic
than 4 weeks are termed acute pseudocysts. Pseudocysts lack
pseudocyst
an epithelial layer and, thus, are not considered true cyst.

Imaging

*
CT scan of a large symptomatic pancreatic pseudocyst abutting
the posterior wall of the stomach.

Investigation fluid in lesser sac, T↑, a mass + persistent ↑

amylase/LFT: 40% resolve spontaneously 6-12wk, supportive
mgt until thick wall has formed,drainage externally or into
stomach , biopsy to rule out malignancy.

Indication for symptomatic (pain, bleeding, or infection)

intervention larger than 7 cm and are rapidly expanding

Percutaneous for pt with very large fluid collection

aspiration

Endoscopic by transpapillary or transmural techniques

technique The proximal end of the stent is placed into the cyst cavity
Success rate= 83%, complication rate = 12%

Transmural for noncommunicating pseudocysts

enterocystostomy Success rate= 85%, complication rate = 17%

Surgical cyst- Internal pseudocyst enteric anastomosis

enterostomy operative mortality rate of 3-5%

Pancreatitic Pancreatic abscesses generally occur late in the course of pancreatitis. Many of these
abscess respond to percutaneous catheter drainage and antibiotics. Those that do not respond
require surgical debridement and drainage.

Complications

Early Shock, ARDS, renal failure, Disseminated intravascular coagulation (DIC), sepsis,
SIRS, Ca2+↓

Late(>1wk) pseudocyst (most common)

Pancreatic necrosis
Infection (Within the first 1-3 weeks)
abscess

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bleeding (eg: splenic artery), thrombosis
fistula, recurrent oedematous pancreatitis.

Prognosis
80% improve rapidly
20% have at leat one complication from which 1/3 die
Ranson scoring:

Ranson score of 0–2: Minimal mortality

Ranson score of 3–5: 10–20% mortality
Ranson score of >5: >50% mortality

Posted by Dr Kupe at 8:10 AM

Labels: Pancreatitic Diseases, Surgery

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