Lecture By Dr.Wael Alsadani ER Resident.

1. PANCREATITIS (ACUTE & CHRONIC)
90

2. 1-Manage severe acute pancreatitis
► A 34-year-old woman
► is evaluated for continued severe mid-epigastric pain that radiates to the
back-nausea-vomiting………5 days after being hospitalized for acute
alcohol-related pancreatitis
► She has not been able eat or drink and has not had a bowel movement
since being admitted
► On physical examination the temperature is 38.2 °C -blood pressure is
132/84 mm Hg-pulse rate is 101/min-respiration rate is 20/min-no scleral
icterus or jaundice-abdomen is distended and diffusely tender with
hypoactive bowel sounds

3. ► CT scan of the abdomen shows a diffusely
edematous pancreas with multiple
peripancreatic fluid collections, and no
evidence of pancreatic necrosis
Which of the following is the most appropriate
next step in the management of this patient?
A- Enteral nutrition by nasojejunal feeding
tube
B-Intravenous imipenem
C-Pancreatic débridement
D-Parenteral nutrition

4. ► Enteral feeding is the preferred route of providing nutrition in patients with
severe acute pancreatitis
► This patient has moderate to severe acute pancreatitis and after 5 days
remains febrile, continues to be in pain, and cannot take in any oral nutrition
► The patient will likely have an extended period before being able to take in
oral nutrition
► Two routes are available for providing nutrition in patients with severe acute
pancreatitis enteral nutrition-parenteral nutrition
► Enteral nutrition is provided through a feeding tube ideally placed past the
ligament of Treitz so as not to stimulate the pancreas
► Parenteral nutrition is provided through large peripheral or central
intravenous line
► Enteral nutrition is preferred over parenteral nutrition because of its lower
complication rate……..especially a lower infection rate
► Enteral nutrition is associated with a significantly lower incidence of
infections-reduced surgical interventions to control complications of
pancreatitis-reduced length of hospital stay-faster attenuation of
inflammation-fewer septic complications

5. ► Imipenem therapy is only helpful in acute pancreatitis when there is
evidence of pancreatic necrosis
► Pancreatic necrosis is diagnosed by contrast-enhanced CT scan……….that
shows nonenhancing pancreatic tissue
► In patients with noninfected pancreatic necrosis, prophylactic antibiotics
may↓incidence of sepsis-↓systemic complications (for example, respiratory
failure)-↓local complications (for example, infected pancreatic necrosis or
pancreatic abscess)
► antibiotic use in acute pancreatitis of mild to moderate severity shown no
benefit from-but may lead to development of nosocomial infections with
resistant pathogens
► Similarly pancreatic débridement is recommended only in infected
pancreatic necrosis

6. 2-Diagnose pancreatic necrosis
► A 44-year-old man with a long history of alcohol abuse is evaluated on the sixth
day of hospitalization for acute pancreatitis
► On admission to the hospital he was afebrile-blood pressure was 150/88 mm Hg-
pulse rate was 90/min-respiration rate was 16/min
► Abnormal findings were limited to the abdomen, which was flat and tender to
palpation -without peritoneal signs-Bowel sounds were normal
► Plain abdominal and chest radiographs were normal
► Abdominal ultrasonography revealed a diffusely enlarged, hypoechoic pancreas
-without evidence of gallstones or dilated common bile duct
► He was treated with aggressive intravenous hydration and opioid analgesia
► For the past 2 days, the patient has had repeated febrile episodes-persistent
severe abdominal pain-increasing shortness of breath

7. ► On physical examination T 38.6 °C -BP 98/60 mm Hg - pulse rate is 112/min- RR
22/min-oxygen saturation is 92% with the patient breathing oxygen 3 L/min-Breath
sounds are decreased at the base of both lungs-The abdomen is distended and
diffusely tender with hypoactive bowel sounds
► Laboratory studies reveal leukocyte count of 19,800/µL-creatinine 1.4 mg/dL
-amylase 388 U/L-lipase 842 U/L.
► Which of the following is the most appropriate next step in the evaluation of this
patient?
A- CT scan of the abdomen with intravenous contrast
B-Endoscopic retrograde cholangiopancreatography
C-Endoscopic ultrasonography
D-Stool chymotrypsin

8. ► CT scan of the abdomen with intravenous contrast is the most sensitive test
to diagnose pancreatic necrosis
► Pancreatic necrosis should be suspected in a patient with severe acute
pancreatitis ………..whose condition is not improving or is worsening after 5
days or more of treatment
► Pancreatic necrosis on CT scan can be identified as unenhanced areas of
the pancreas
► pancreatic necrosis in the setting of acute pancreatitis cannot detect by
endoscopic retrograde cholangiopancreatography or endoscopic
ultrasonography

9. ► Stool chymotrypsin can be measured when
chronic pancreatitis is suspected………..to help
evaluate for decreased pancreatic function
► Pancreatic necrosis is the most important
predictor of poor outcome in acute pancreatitis
► Patients who develop pancreatic necrosis
should be given antibiotic prophylaxis, usually
with imipenem
► The necrosis should be sampled for the
presence of infection………….and if infection is
present, surgical débridement is recommended

10. 3-Manage gallstone pancreatitis
► A 55-year-old woman
► is evaluated in the hospital for a 2-day history of epigastric abdominal pain -
nausea and vomiting - anorexia
► The patient has no significant medical history
► takes no medications
► On physical examination temperature is 38.0 °C - blood pressure is 124/76
mm Hg - pulse rate is 99/min - respiration rate is 16/min - There is scleral
icterus and a slight yellowing of the skin - mid-epigastric and right upper
quadrant tenderness - no palmar erythema, spider angiomata, or other
evidence of chronic liver disease

11. ► Abdominal ultrasonography shows a biliary tree with a dilated
common bile duct of 12 mm and cholelithiasis but no
choledocholithiasis
► Which of the following is the most appropriate next step in the
management of this patient?
A-CT scan of the abdomen and pelvis with pancreatic protocol
B- Endoscopic retrograde cholangiopancreatography
C-Hepatobiliary iminodiacetic acid (HIDA) scan
D-Magnetic resonance cholangiopancreatography

12. ► In patients with gallstone pancreatitis and evidence of biliary obstruction,
endoscopic retrograde cholangiopancreatography and stone removal will
reduces morbidity and mortality…………..by reducing the risk of biliary sepsis
► This patient has a classic presentation of acute pancreatitis with the acute onset
of epigastric abdominal pain, nausea, and vomiting - associated with markedly
elevated pancreatic enzymes
► The presence of stones in the gallbladder- dilated bile duct - elevated
aminotransferase levels…………….highly suggest gallstones as the cause of
pancreatitis
► The presence of scleral icterus – jaundice - elevated bilirubin level…….suggest
continuing bile duct obstruction
► Abdominal ultrasonography has a sensitivity of only 50% to 75% for
choledocholithiasis
► a common duct stone should be suspected in the correct clinical situation even
when ultrasonography does not show a stone
► Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy
and stone removal…..is the most appropriate procedure in patients with acute
gallstone pancreatitis and with imaging and biochemical evidence of biliary
obstruction from a common duct stone

13. ► The procedure can document the diagnosis of
choledocholithiasis and remove the gallstones………..which
lessens the morbidity and mortality due to biliary sepsis.
► CT scan acute pancreatitis and the presence of a common duct
stone=sensitivities ranging from 80% to 100%
► magnetic resonance cholangiopancreatography (MRCP) will
show acute pancreatitis and the presence of a common duct
stone=sensitivities ranging from 80% to 100%
► ERCP = diagnosis of choledocholithiasis
► Biliary scintigraphy may show obstruction of the cystic or
common bile duct…..but will not determine the cause
► However CT - biliary scintigraphy and MRCP………are not be
therapeutic for bile duct stones

14. 4-Evaluate acute pancreatitis
► A 42-year-old woman
► is evaluated in the emergency department for the acute onset of epigastric
pain …that radiates to the back …and is associated with nausea and
vomiting
► The patient had previously been healthy
► no history of alcohol or tobacco use
► Her only medication is an oral contraceptive pill
► On physical examination=temperature is 37.2 °C - blood pressure is 158/90
mm Hg - pulse rate is 101/min - respiration rate is 20/min - no scleral icterus
or jaundice
► The abdomen is distended with mid-epigastric tenderness - no rebound or
guarding - hypoactive bowel sounds

15. ► Radiography of the abdomen shows mild ileus
► Which of the following is the most appropriate
next step in the evaluation of this patient?
A-CT scan of the abdomen and pelvis
B-Endoscopic retrograde
cholangiopancreatography
C-Esophagogastroduodenoscopy
D- Ultrasonography of the abdomen

16. ► Gallstones=most common cause of acute pancreatitis in the United States -
diagnosed with abdominal ultrasonography
► The diagnosis of pancreatitis relies heavily on the serum amylase and
lipase…….which are elevated in 75% to 90% of patients
► Serum lipase is more specific and stays elevated longer than amylase
► The two most common causes of acute pancreatitis in the United States are
alcohol and gallstones
► this patient who does not consume alcohol , so gallstones are the most likely
cause of acute pancreatitis as shown by the pattern of liver enzymes
► Abdominal ultrasonography is the most sensitive test for detecting the
presence of gallstones and ductal dilation - can provide indirect evidence for
the presence of a retained common duct stone - Ultrasonography = has no
risk + widely available + inexpensive

17. ► CT scan is less sensitive than ultrasonography for the detection of
cholelithiasis
► CT with contrast is indicated in patients with moderate or severe pancreatitis
= to confirm the diagnosis - to grade the severity of pancreatitis - to
diagnose local complications such as pancreatic necrosis , pseudocyst &
abscess
► Magnetic resonance cholangiopancreatography is used if there is a
contraindication to intravenous radiocontrast
► Endoscopic retrograde cholangiopancreatography (ERCP) is the most
sensitive test for choledocholithiasis - can provide direct treatment by
removing common duct stones
► ERCP is indicated in patients with - persisting pancreatitis - persistent
elevation of aminotransferase levels - dilated bile ducts suggesting the
presence of retained bile duct stones - can do stone extraction with biliary
sphincterotomy so improves the outcome, prevents further attacks of acute
biliary pancreatitis, and reduces pancreatitis
► But in this patient there is not enough evidence yet that a common duct
stone is still present to perform this more invasive test before
ultrasonography
► Upper endoscopy = no role in determining the cause of acute pancreatitis

18. 5-Diagnose chronic pancreatitis
► A 51-year-old man
► is evaluated for an 8-month history of mid-epigastric pain that is worse after
eating - six to eight bowel movements a day usually occurring after a meal -
loss of 6.8 kg over the past 6 months
► The patient drinks six to eight cans of beer a day
► He takes no medications
► On physical examination BMI 21 - normal bowel sounds - mid-epigastric
tenderness - no hepatosplenomegaly or masses
► Rectal examination reveals brown stool - negative occult blood
► The remainder of the examination is normal
► Plain radiograph of the abdomen shows a normal bowel gas pattern and is
otherwise normal

19. Which of the following tests is most likely to
establish the diagnosis in this patient?
A-Colonoscopy
B- CT scan of the abdomen
C-Measurement of serum antiendomysial
antibodies
D-Stool for leukocytes, culture, ova, and parasite

20. ► Patients with chronic pancreatitis=the three classic findings in chronic
pancreatitis are abdominal pain that is usually mid-epigastric - postprandial
diarrhea - and diabetes mellitus secondary to pancreatic endocrine
insufficiency
► This patient has chronic pancreatitis secondary to alcohol abuse…………
SO has resulted in malabsorption
► Malabsorption occurs in patients with chronic pancreatitis when
approximately 80% of the pancreas is destroyed
► because the damaged pancreatic gland is no longer producing the
pancreatic exocrine enzymes to absorb food so malabsorption occurs that
presents with diarrhea and steatorrhea - weight loss - deficiencies of fat-
soluble vitamins
► Patients with a typical presentation may not need additional testing
► However, most patients with chronic pancreatitis have only nonspecific
abdominal pain ………….so require diagnostic radiographic imaging studies

21. ► The presence of pancreatic calcifications on radiographs confirms the
diagnosis
► Plain films of the abdomen will show pancreatic calcifications in
approximately 30% of patients…………so confirms the diagnosis
► But most patients require abdominal CT scans, which are able to detect
pancreatic calcification in up to 90% of patients
► CT scanning can also exclude other causes of pain
► Radiographic evidence of pancreatic ductal dilation – pseudocysts - or mass
lesions ………….may also help identify the cause of pain and determine the
type of therapy
► Antiendomysial antibodies are a marker for celiac disease ……….. but
celiac disease is unlikely in this patient with an evident history of pancreatic
malabsorption

22. ► colonoscopy is indicated as a screening tool for
asymptomatic patients beginning at the age of 50
years - and for patients with a change in bowel
habits and weight loss
► But this patient’s history suggests pancreatic
malabsorption so colonoscopy is less likely than
abdominal CT scan to confirm the diagnosis
► Stool studies are appropriate fordetermining the
cause of an acute infectious diarrhea……but this
patient has had diarrhea for 8 months
…………..so infectious diarrhea is not usually
associated with such a degree of weight loss

23. 6-Diagnose chronic pancreatitis
► A 42-year-old man
► is evaluated in the hospital for a 1-year history of postprandial abdominal pain that
radiates to the back -worse after eating - and is associated with nausea
► He has no (vomiting -weight loss -change in bowel habits)
► The patient has had at least five alcohol-containing drinks a day for 20 years
► he has reduced his intake in the past year because of continued abdominal pain
► On physical examination vital signs are normal - BMI is 24 - mild epigastric tenderness
- no guarding or rebound - normal bowel sounds
► Laboratory studies reveal normal complete blood count - normal fasting glucose -
normal liver chemistry tests - amylase is 221 U/L and lipase 472 U/L.
► esophagogastroduodenoscopy , AXR, ultrasonography, and CT scan of the abdomen
are normal
► Which of the following is the most appropriate next step in the evaluation of this patient?
A-Biliary scintigraphy
B-Colonoscopy
C- Endoscopic retrograde cholangiopancreatography
D-easurement of stool elastase

24. ► Endoscopic retrograde cholangiopancreatography is the most sensitive
imaging test for chronic pancreatitis
► diagnosis of chronic pancreatitis in a patient with early disease can be
difficult
► No blood or stool tests are currently available for the accurate diagnosis of
early chronic pancreatitis
► This patient’s pain is most likely secondary to chronic pancreatitis with
minimally elevated pancreatic enzymes and a history of harmful drinking
► The patient has no evidence of exocrine or endocrine insufficiency and thus
likely has early chronic pancreatitis
► Normal liver enzymes, normal upper endoscopy, and a normal abdominal
ultrasonography and CT scan of the abdomen make biliary causes and
peptic ulcer disease………less likely the cause of pain
► Endoscopic retrograde cholangiopancreatography (ERCP) has a sensitivity
of nearly 95% for chronic pancreatitis - can show ductal dilation,strictures
and irregularity in both the main duct and its side branches

25. ► CT scan of the abdomen =has a sensitivity of up to 90% for diagnosing
chronic pancreatitis and should be ordered with thin cuts of the pancreas to
improve sensitivity
► Endoscopic ultrasonography=may also be used to diagnose chronic
pancreatitis - sensitivities is equal to ERCP for moderate and advanced
chronic pancreatitis - but with lower sensitivity and specificity for mild and
early chronic pancreatitis
► Magnetic resonance cholangiopancreatography does not have sensitivities
or specificities that match ERCP in the diagnosis of mild and early chronic
pancreatitis and cannot be routinely recommended
► Biliary scintigraphy is used to diagnose acute cholecystitis - but does not
have a role in diagnosing chronic pancreatitis
► Stool elastase can be abnormal in patients with more advanced chronic
pancreatitis=particularly those who have malabsorption - but stool elastase
has poor sensitivity in patients with early chronic pancreatitis
► Colonoscopy has a low yield in patients with upper abdominal pain

26. 7-Treat chronic pancreatitis with pancreatic duct stones
► A 38-year-old man is evaluated for a 2-month history of progressive mid-epigastric
pain that is worse after eating - postprandial nausea - 4.6-kg weight loss
► The patient has a 5-year history of chronic pancreatitis
► has six alcohol-containing drinks a day
► His medications are Amitriptyline - oral morphine - and pancreatic enzyme
supplements
► On physical examination BMI 20 - appears to be in mild distress - There is epigastric
tenderness without rebound or guarding - The liver is slightly enlarged, but there are
no palpable masses
► Laboratory studies reveal normal complete blood count - serum amylase of 175 U/L
- lipase of 333 U/L
► CT scan of the abdomen and pelvis shows - multiple pancreatic calcifications - a
calcified stone in the head of the pancreas within the main pancreatic duct - dilation
of the duct in the body and tail of the gland
► In addition to alcohol cessation, which of the following is the most appropriate
management for this patient?
A-Celiac nerve block
B- Endoscopic retrograde cholangiopancreatography with removal of stones
C-Increasing the dose of pancreatic enzymes
D-Pancreatoduodenectomy

27. ► Endoscopic treatment of pain in chronic pancreatitis is performed by
removing pancreatic duct stones and placing stents in pancreatic duct
strictures ….to decrease pancreatic duct pressure
► Patients with chronic pancreatitis must avoid alcohol
► Patients who continue to drink alcohol have an increase in painful attacks
and mortality
► Pain in chronic pancreatitis results from chronic inflammation - chronic
noxious stimulation of the nerves to the pancreas - and increased pancreatic
intraductal pressure secondary to pancreatic duct stones, calcifications, or
strictures
► Large stones in the pancreatic duct can be - crushed with extracorporeal
shock wave lithotripsy - Then endoscopic retrograde
cholangiopancreatography can remove the stones and place stents in
pancreatic duct strictures to decrease pancreatic duct pressure…….so
symptom improvement in 11% to 75% of patients and resolution of stricture
in 10% to 50%

28. ► A surgical pancreatoduodenectomy (Whipple procedure) can be performed
to relieve pain - but is effective only in patients who have disease limited to
the head of the pancreas and who have failed to respond to medical and
endoscopic therapy
► A surgical procedure to divert the pancreatic duct into the small intestine
=The procedure involves removing pancreatic tissue that overlies the ductal
system in the head of the pancreas - has been used widely in the treatment
of patients with a chronic pancreatitis and is effective in many patients…..but
a less invasive procedure is preferred to surgical intervention as the next
management step
► Celiac nerve block =has been used to treat chronic pancreatitis pain - but is
considered by many experts to be an unproved therapy and even in patients
who respond, pain returns in 2 to 6 months and significant procedural
complications have been reported - Furthermore, it would not be the first
procedure of choice in a patient with a pancreatic ductal stone and evidence
of obstruction
► Pancreatic enzyme supplements are not effective for pain control in chronic
pancreatitis

29. THANK YOU
DR: WAEL AHMED EL-SADANY
ER resident