MINISTRY OF HEALTH OF THE REPUBLIC OF MOLDOVA  

STATE UNIVERSITY OF MEDICINE AND PHARMACY"NICOLAE TESTEMIŢANU"

ACUTE PANCREATITIS SEVERITY CLASSIFICATION,COMPLICATIONS AND OUTCOME

Mahamied ManarGr.1638

Physiology

In response to a meal, the pancreas secretes digestive enzymes in an alkaline (pH 8.4) bicarbonate-rich fluid.

The proteolytic enzymes are secreated in an inactive form, the maintenance of this is important in preventing pancreatitis.

Pathophysiology

Due to many causes, pancreatic pro-enzymes will be activated, and not released to the duodenum, so they will return back to the pancreas in the active form and cause autodigestion of the pancreas, which in turn will lead to an acute inflammatory reaction.

Incidence

Acute pancreatitis accounts for 3% of all cases of abdominal pain.

The disease may occur at any age, with a peak in young men and older women.

Etiological Factors

1 Biliary tract disease 7 Scorpion venom

2 Alcohol 8 Drugs

3 Ischemia (hypotension, cardio-pulmonary by-pass, atheroembolism, vasculitis)

9 Pancreatic duct obstruction (tumor, pancreatic divisum, ampullary stenosis, ascaris infestiopn)

4 Duodenal obstruction 10 Metabolic (hypercalcemia, hyperthyroidism, Hyperlipidemia)

5 Trauma (external, operative, ERCP) 11 Viral infection (mumps, coxsaki B4)

6 Familial 12 Idiopathic

Clinical features (Symptoms)

1. Pain (sudden,intense,continuous, upper abdomen back, bizarre position)

2. Nausea and Vomiting

Clinical features (Signs)

General Local Shock Peritonitis

Fever Paralytic ileus

Jaundice Abdominal mass

Left pleural effusion Cullen’s sign. Grey Turner sign

Acute pulmonary failure

Subcutaneous necrosis

Cerebral abnormalities

Severity Classification

Pancreatitis severity ranges from mild to MOF with sepsis and necrotizing or hemorrhagic forms

Overall mortality: 10-15% Biphasic time to death

Prognostic scoring systems Atlanta classification Ranson Score Glasgow Score Modified Glascow

Atlanta Classification ACUTE PANCREATITIS

Acute pancreatitis is an acute inflammatory process of the pancreas, with variable involvement of other regional tissues or remote organ systems.

SEVERE ACUTE PANCREATITISSevere acute pancreatitis is associated with organ failure and/or local complications such as necrosis (with infection), pseudocyst or abscess. Most often this is an expression of the development of pancreatic necrosis, although patients with oedematous pancreatitis may manifest clinical features of a severe attack.

MILD ACUTE PANCREATITISMild acute pancreatitis is associated with minimal organ dysfunction and an uneventful recovery. The predominant pathological feature is interstitial oedema of the gland.

ACUTE FLUID COLLECTIONSAcute fluid collections occur early in the course of acute pancreatitis, are located in or near the pancreas, and always lack a wall of granulation of fibrous tissue.

PANCREATIC NECROSIS AND INFECTED NECROSISPancreatic necrosis is a diffuse or focal area(s) of non-viable pancreatic parenchyma, which is typically associated with peripancreatic fat necrosis. The onset of infection results in infected necrosis, which is associated with a trebling of the mortality risk.

ACUTE PSEUDOCYSTAn acute pseudocyst is a collection of pancreatic juice enclosed in a wall of fibrous or granulation tissue that arises following an attack of acute pancreatitis. Formation of a pseudocyst requires four or more weeks from the onset of acute pancreatitis.

PANCREATIC ABSCESSA pancreatic abscess is a circumscribed intra-abdominal collection of pus, usually in proximity to the pancreas, containing little or no pancreatic necrosis, which arises as a consequence of acute pancreatitis.

SPECIALIST UNITA specialist unit is one in which multidisciplinary expertise is available on-site. Full intensive care facilities are mandatory, together with recourse to ERCP at any stage on an emergency basis. Expert radiological input for dynamic scanning, percutaneous procedures and angiography is essential. A surgeon with pancreatico-biliary expertise should supervise management.

Glasgow Scoring system for the initial prediction of severity in acute pancreatitis

Age >55 years

White blood cell count >15 × 109/L

Glucose >10 mmol/l

Urea >16 mmol/l

PaO2 <60 mm Hg

Calcium <2 mmol/l

Albumin <3.2 g/l

Lactate dehydrogenase >600 units/L

Asparate/alanine aminotransferase >100 units/L

Modified Glasgow Score

Age >55 years PaO2 <60mmHg WCC >15x109/litre Ca2+ <2.0 mmol/L LDH >600 IU glucose >10 mmol/L urea >16 mmol/L albumin <3.2g/L

Minimum score: 0Maximum score: 8If score<3: severe pancreatitis unlikelyIf score>=3:severe pancreatitis likely

Ranson’s Criteria

Ranson's Criteria on Admission : age greater than 55 years a white blood cell count of > 16,000/µL blood glucose > 11 mmol/L (>200 mg/dL) serum LDH > 350 IU/L serum AST >250 IU/L Ranson's Criteria after 48 hours of admission : fall in hematocrit by more than 10 percent fluid sequestration of > 6 L hypocalcemia (serum calcium < 2.0 mmol/L (<8.0 mg/dL)) hypoxemia (PO2 < 60 mmHg) increase in BUN to >1.98 mmol/L (>5 mg/dL) after IV fluid

hydration base deficit of >4 mmol/L

Score 0-2: 2% mortality Score 3-4: 15% mortalityScore 5-6: 40% mortalityScore 7-8: 100% mortality

Differential diagnosis

Acute cholecystitis. Perforated peptic ulcer. Inferior wall MI. Intestinal obstruction. Mesenteric ischemia. Ruptured abdominal aortic

aneurysm.

Management of severe acute pancreatitis

Rest the patient (Relief pain): Pethidine 1mg/kg + antispasmodic.

Rest the pancreas: NPO(nil per os). Rest the bowel: nothing by the mouth. Resuscitation: IV fluid, electrolytes

replacement. Resist enzymatic activity: Protease

inhibitors. Resist infection: Antibiotics. Repeated examination. Repeated serum estimations:Ca+2,

Mg+2. Respiratory support.

Management

Urgent ERCP and biliary sphincterotomy within 72 hours improves outcome of severe gallstone pancreatitis.

Surgery in case of:1) Uncertain diagnosis.2) Infected pancreatic necrosis.3) Complicated pancreatitis.

Causes of death:

1.Hypovolemic shock.2.Electrolyte disturbances.3.Sepsis.4.Renal failure.5.Respiratory failure.

Complications

Systemic Local

(More common in the first week) (Usually develop after the first week)

Cardiovascular•Shock•ArrhythmiasPulmonary•ARDSRenal failureHaematological•DICMetabolic•Hypocalcaemia•Hyperglycaemia•Hyperlipidaemia

Gastrointestinal•IleusNeurological•Visual disturbances•Confusion, irritability•EncephalopathyMiscellaneous•Subcutaneous fat necrosis•Arthralgia

Acute fluid collectionHemorrhagic pancreatitisSterile pancreatic necrosisInfected pancreatic necrosisPancreatic abscessPseudocystPancreatic ascitesPleural effusionPortal/splenic vein thrombosisPseudoaneurysmChronic pancreatitis

Hemorrhagic pancreatitis

Definition: Bleeding into the parenchyma and

retroperitoneal structures with extensive pancreatic necrosis.

Signs: Abdominal pain Shock Cullen’s sign, Grey turner’s sign &

Fox’s sign

Grey Turner’s signCullen’s sign

Cullen’s sign

Fox’s sign

Acute fluid collection

Located in or near the pancreas The fluid is sterile, and most such

collections resolve. No intervention is necessary unless a

large collection causes symptoms or pressure effects.

Sterile and infected pancreatic necrosis

• Refers to a diffuse or focal area of non-viable parenchyma that is typically associated with peripancreatic fat necrosis.

• Necrotic areas 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.

• Necrotizing pancreatitis accounts for 10% of all pancreatitis but is lethal disease.

Management

1.Laparostomy

2.Pancreatic necrosictomy

3.Peritoneal lavage

Pancreatic abscess

Definition: is a circumscribed collection of pus intra-

abdominal resulting from tissue necrosis, liquefaction, and infection.

It may be an acute fluid collection or a pseudocyst that has become infected

Presentation:• Fever• Unresolving pancreatitis• Epigastric mass

is a late complication of acute necrotizing pancreatitis.

It is estimated that approximately 3% of the patients suffering from acute pancreatitis will develop an abscess.

Abdominal CT scans with needle aspiration to send for culture & Gram stain should be performed.

Organisms found Gram –ve (most common) E.coli, pseudomonas, klebsiella

Gram +ve Staphylococcus aureas, candida

Tx: Antibiotics and percutanous drain placement OR Operative debridement and drain placement.

An unremoved infected abscess may lead to sepsis, fistula formation and recurrent pancreatitis.

Pseudo cyst

Definition: Encapsulated collection of pancreatic fluid by

inflammatory fibrosis NOT epithelial cell lining, that's why called “pseudo"cyst.

Its incidince is approximately 1 in 10 after alcoholic pancreatitis.

Presentation: Epigastric pain Vomiting Mild fever Weight loss

Signs Palpable epigastric mass, Tender epigastrium,

Ileus

Investigations:

CBC >> leuckocytosis Amylase >> high Bilirubin>> high if there

is obstruction US >> fluid filled mass CT >> fluid filled mass,

Multiple cysts ERCP : radiopaque

contrast material fills the cyst if there is a communicating pseudocyst

DDx :Cystadenocarcinoma,cystadenomaComplications :

Infection Bleeding into the cyst Fistula Pancreatic ascitis Gastric outlet obstruction Biliary obstruction SOB

Treatment : drainage of the cyst or observation

50% will resolve spontaneously within 6 weeks

infection: Percutaneous external drainage & IV antibiotics

bleeding: angiogram and embolization

Cysts larger than 5cm have a small chance of resolving & a higher chance of complications(bleeding, Infection, rupture).

Treatment options are percutanous CT guided aspiration or operative drainage (cystogastrostomy, cystoduodenostomy).

A biopsy should be taken during surgical drainage to rule out cystic carcinoma.

Case history

A 53-year-old man presents to the emergency department complaining of severe mid-epigastric abdominal pain that radiates to the back. The pain improves when the patient leans forwards or assumes the fetal position and worsens with deep inspiration and movement. He also complains of nausea, vomiting, and anorexia, and gives a history of heavy alcoholic intake this past week. He is tachycardic, tachypnoeic, and febrile with hypotension. He is slightly agitated and confused. He is diaphoretic with decreased breath sounds over the base of the left lung.

Thank you