Acute Pancreatitis

1. Acute Pancreatitis
Shiwani Kamath

2. Acute Pancreatitis
• Inflammation of the gland parenchyma of the
pancreas
• Acute condition presenting with abdominal
pain and is usually associated with raised
pancreatic enzyme levels in the blood or urine
as a result of pancreatic inflammation

3. Pathogenesis
Defective
intracellular
transport and
secretion of
pancreatic zymogens
Pancreatic duct
obstruction
Hyperstimulation of
pancreas
Reflux of infected bile
or duodenal contents
into pancreatic duct
Proenzymes
Activated proteolytic enzymes
Acute Pancreatitis
(-) Pancreatic secretory trypsin
inhibitors

4. Etiology
Common (90% of cases)
– Gallstones
– Alcohol
– Post-ERCP
– Idiopathic
Rare
– Post-surgical
– Trauma
– Drugs
– Metabolic
– Pancreas divisum
– Sphincter of Oddi dysfunction
– Infection
– Hereditary
– Renal failure
– Organ Transplantation
– Severe hypothermia
– Petrochemical exposure

5. Clinical Features
Symptoms
• Severe, constant upper abdominal pain
– with increasing intensity over 15-20 minutes
– radiating to back
• Nausea and vomiting
• Abdominal distension

6. Clinical Features
Signs
• Epigastric tenderness with guarding and rebound
(later)
• Decreased/absent bowel sounds
• Grey Turner’s Sign: Discoloration of the flanks
• Cullen’s Sign: Discoloration of the periumbilical
region
• Small, red, tender nodules on the skin of the legs
• Abdominal distension – shifting dullness
• Signs of pleural effusion

7. Clinical Features
Cullen’s Sign

8. Clinical Features
Turner’s Sign

9. Complications
Pancreatic
• Acute Fluid Collection
• Pseudocyst
• Abscess
• Necrosis
• Pancreatic Ascites and Effusion

10. Complications
Systemic and Other Systems
Systemic
• Systemic inflammatory
response syndrome
• Hypoxia
• Hypergylcemia
• Hypocalcemia
• Reduced serum albumin
concentration
• DIC
Gastrointestinal
• Hemorrhage
• Portal/Splenic Vein
Thrombosis
• Erosion into colon
• Duodenal Obstruction
• Obstructive jaundice
• Paralytic Ileus

11. Investigations
• Serum amylase (N: 23-85 IU/L)
• Serum lipase (N: 0 – 160 IU/L)
• Ultrasound
– Confirms diagnosis
– Shows gallstones, biliary obstruction, pseudocyst
• Contrast enhanced CT
– 6-10 days after admission
– Decreased pancreatic enhancement – necrotizing
– Gas within necrotic material – infection, abscess
– Other organ involvement

12. Acute Pancreatitis
Normal Pancreas

13. CT Findings
Tail Indistinct
Intraperitoneal fluid
PANC
PANC
LIVERLIVER

14. CT Findings
Severe Pancreatitis
Peripancreatic edema
and inflammation
Necrosis
(less
enhancement)PANC
PANCLIVERLIVER
GBGB

15. • CBC: leucocytosis
• Electrolyte abnormalities include hypokalemia,
hypocalcemia
• Elevated LDH in biliary disease
• Glycosuria ( 10% of cases)
• Hyperglycaemia in severe cases
• Serum phosphate
• LFTs
• RFTs
• C – Reactive Protein - elevated
Routine

16. To rule out other conditions
i.e. perforated ulcer disease.
Nonspecific findings
-cutoff colon sign gaseous distension seen in
proximal colon associated with narrowing of the
splenic flexure
-Widening of the duodenal C loop caused by severe
pancreatic head edema
Complications of lung such as pleural effusion,
pulmonary edema and interstitial inflammation.
X ray

18. MANAGEMENT

19. • Establish the diagnosis
• Assess severity
• Early Treatment (Resuscitation)
• Detection and Treatment of Complications
• Treating Underlying Cause
MANAGEMENT
Steps

20. • RANSON’S CRITERIA
• MODIFIED GLASGOW CRITERIA
• Acute Physiology and Chronic Health
Evaluation (APACHE II)
MANAGEMENT
Assessment of Severity of Disease

21. • RANSON’S CRITERIA
• MODIFIED GLASGOW CRITERIA
• Acute Physiology and Chronic Health
Evaluation (APACHE II)
MANAGEMENT
Assessment of Severity of Disease

22. Non-gallstone pancreatitis, the parameters are:
At admission:
•Age in years > 55 years
•White blood cell count > 16000 cells/mm3
•Blood glucose> 10 mmol/L (> 200 mg/dL)
•Serum AST > 250 U/L
•Serum LDH > 700 U/L
Within 48 hours:
•Serum calcium < 2.0 mmol/L (< 8.0 mg/dL)
•Oxygen (hypoxemia PaO2 < 60 mmHg)
•BUN increased by 1.8 or more mmol/L (5 or more mg/dL) after IV fluid
hydration
•Base deficit (negative base excess) > 4 mEq/L
•Sequestration of fluids > 6 L
MANAGEMENT
Ranson’s Criteria

23. Gallstone pancreatitis, the parameters are:
At admission:
•Age in years > 70 years
•White blood cell count > 18000 cells/mm3
•Blood glucose > 12.2 mmol/L (> 220 mg/dL)
•Serum AST > 250 IU/L
•Serum LDH > 400 IU/L
Within 48 hours:
•Serum calcium < 2.0 mmol/L (< 8.0 mg/dL)
•Oxygen (hypoxemia PaO2 < 60 mmHg)
•BUN increased by 1.8 or more mmol/L (5 or more mg/dL) after IV fluid
hydration
•Base deficit (negative base excess) > 5 mEq/L
•Sequestration of fluids > 4 L
MANAGEMENT
Ranson’s Criteria

24. MANAGEMENT
Glasgow’s
alanine

25. MANAGEMENT
APACHE II

26. • Initial Assessment
– Clinical Impression
– BMI > 30
– Pleural Effusion (on CX-ray)
– APACHE II Score > 8
• 24 Hours After Admission
– Clinical Impression
– APACHE II Score > 8
– Glasgow > 3
– Persisting Organ Failure
– CRP > 150 mg/L
• 48 Hours After Admission
– Clinical Impression
– Glasgow > 3
– Persisting, Multiple, and Progressive Organ Failure
– CRP > 150 mg/L
MANAGEMENT
Factors Predicting Severity within 48 hours of admission

27. • Intravenous fluid administration
• Analgesics
• Anti-emetics
• Recommended brief period of fasting
• Frequent, non-invasive observation
MANAGEMENT
Conservative Measures

28. • Admission to HDU or ICU
• Analgesia
• Aggressive fluid rehydration
• Oxygen
• Monitor Vitals, central venous pressure, urine output, blood gases
• Monitor hematological and biochemical parameters
• Nasogastric drainage
• Antibiotic prophylaxis (imipem, cefuroxime)
• CT scan
• ERCP
• Supportive therapy for organ failure
• Nasogastric feeding for nutritional support
MANAGEMENT
Severe Acute Pancreatitis

29. • Cholecystectomy within 2 weeks following
resolution of pancreatitis
• Necrotising pancreatitis/Pancreatic Abscess
– Endoscopic/surgical necresectomy
• Pseudocyst
– Drainage into stomach, duodenum or jejunum
– Endoscopic/Surgical
– After 6 weeks
MANAGEMENT
Surgical Management of Severe Pancreatitis

30. Thank You