2. MANAGEMENT
In most patients (85-90%) with mild acute pancreatitis,
the disease is self-limited and subsides spontaneously,
usually within 3-7 days.
However, a conservative (non-invasive) approach is
indicated(1) analgesics for pain, (2) IV fluids and
colloids to maintain normal intravascular volume, and
(3) no oral alimentation.
A brief period of fasting may be sensible mainly in
patients who are nauseated or in pain.
3.
4. SEVERE ATTACK
Markers of severity within 24 hours are
-SIRS, Hct>44%,BUN>22mg%
Admit the patient to ICU, Give Analgesic drugs and Aggressive
fluid rehydration.
Oxygen masks may be applied and Invasive monitoring of vital
signs, central venous pressure, urine output and blood gases
should be carried out.
Frequent monitoring of haematological and biochemical
parameters
Nasogastric drainage, it is not essential but may be of value in
patients with vomiting.
5. Antibiotic prophylaxis can be considered (imipenem,
cefuroxime). The overall rate of infected necrosis is
20%.
CT scan(contrast enhanced) essential if organ failure,
clinical deterioration or signs of sepsis develop. Its
severity can be judged by Balthazar scoring system.
6. ERCP within 36-72 hours for severe gallstone
pancreatitis or signs of cholangitis.
Supportive therapy for organ failure if it develops
(inotropes, ventilatory support, haemofiltration, etc.)
If nutritional support is required, consider enteral
(nasogastric) feeding instead of TPN.
9. LOCAL COMPLICATIONS
Usually develops after the first week.
A CT scan should be performed where clinical resolution
does not take place and signs of of sepsis develop.
These complications carry a significant burden of
mortality.
10. Pancreatic necrosis is a Diffuse or focal area of non-viable
parenchyma in the pancreas and can be identified by an
absence of contrast enhancement on CT.
These are sterile to begin with, but can become subsequently
infected, probably due to translocation of gut bacteria.
Infected necrosis is associated with a mortality rate of up to
50%.
If the pancreatic fluid aspirate is purulent, percutaneous
drainage of the infected fluid should be carried out. The tube
drain inserted should have the widest bore possible.
11. If the area involved is the head of pancreas midline laprotomy
should be carried out. The duodenocolic and gastrocolic
ligaments should be divided and the lesser sac opened.
Thorough debridement of the dead tissue around the
pancreas should be carried out.
If the body and tail of the gland are primarily involved, a
retroperitoneal approach though a left flank incision may be
more appropriate.
Laproscopy- A rigid laparoscope is inserted into the
peripancreatic area through a retroperitoneal approach, and
vigorous irrigation and suction is combined with a gradual
nibbling away of the necrotic debris.
12. This is a circumscribed collection of pus, and may be an
acute fluid collection or a pseudocyst that has become
infected. Percutaneous drainage with the widest
possible drains should be done
Pancreatic Ascites is a chronic, generalised, peritoneal,
enzyme-rich effusion usually associated with pancreatic
duct disruption. Paracentesis will reveal turbid fluid with
a high amylase level.
Pancreatic effusion is an encapsulated collection of fluid
in the pleural cavity. Concomitant pancreatic ascites may
be present, or there may be a communication with an
intra-abdominal collection.
13. Bleeding may occur into the gut, into the
retroperitoneum or into the peritoneal cavity. Possible
causes include bleeding into a pseudocyst cavity, or
diffuse bleeding from a large raw surface.
14. A pseudocyst is a extra pancreatic collection of amylase-rich
fluid enclosed in a wall of fibrous or granulation tissue.
Disruption of Pancreatic ductal system is common, however
the course may vary from spontaneous healing to tense
ascites.
Cause – 90% pancreatitis
10% trauma
They are often single but, occasionally, patients will develop
multiple pseudocysts.
A pseudocyst is usually identified on ultrasound or a CT scan.
It is important to differentiate a pseudocyst from an acute
fluid collection or an abscess and a cystic neoplasm.
15.
16. Distinguishing a pseudocyst from a cystic
neoplasm
History
Appearance on CT and ultrasound
FNA of fluid, preferably under EUS guidance and
Cytology typically reveals inflammatory cells in
pseudocyst fluid.
CEA (high level in mucinous tumours .400ng/ml)
Amylase (level usually high in pseudocysts, but
occasionally in tumours)
17. Complications
Process Outcomes
Infection Abscess
Systemic sepsis
Rupture(prime cause of death)
into the gut
into the peritoneum
GI bleeding
peritonitis
Enlargement
Pressure effects
Obstructive jaundice from
biliary compression
Bowel obstruction
Erosion into a vessel Haemorrhage into the cyst
Haemoperitoneum ( A triad of
findings-inc size of mass,
localized bruise over mass and
a sudden dec in Hb and
Hematocrit without external
blood loss)
18. Management
Pseudocysts that are thick-walled or large (over 6 cm in
diameter), have lasted for a long time (over 12 weeks) are
less likely to resolve spontaneously.
1. Percutaneous drainage to the exterior under radiological
guidance should be avoided. It carries a very high likelihood
of recurrence.
2. Endoscopic drainage usually involves puncture of the cyst
through the stomach or duodenal wall under EUS guidance,
and placement of a tube drain with one end in the cyst
cavity and the other end in the gastric lumen.
3. Surgical drainage involves internally draining the cyst into
the gastric or jejunal lumen. Pseudocysts that have
developed complications are best managed surgically.
