PANCREATITISR. NANDINII

Group K1

Overview:

Acute Pancreatitis Chronic Pancreatitis

Anatomy of pancreas Physiology of pancreas Pancreatitis : - Definition

- Classification

ANATOMY

ANATOMY

Duct of Wirsung (Main pancreatic duct)

PHYSIOLOGY

Acute pancreatitis: Epidemiology

Incidence about 50 per 100,000 population per year 80% have mild disease 40% with severe disease dev. infected pancreatic

necrosis The mortality ass. with infected necrosis is about 40% 50% of deaths occur within first week due to MOF This usually occurs in the absence of local complications

Source: Surgical Tutor co.uk

Most Common etiologies:

Idiopathic Obstruction

Choledocolithiasis Ampullary or pancreatic tumours

Alcohol

Source: Surgical Tutor co.uk

Pathophysiology acute pancreatitis

Symptoms Abdominal pain

Laboratory Elevated amylase or lipase

> 3x upper limits of normal Radiology

Abnormal CECT, Abd USG / MRI

DiagnosisDiagnosis

Grey Turner sign Cullen’s sign

CT Scan of acute pancreatitis

CT showssignificantswellingand inflammationof the pancreas

CONSENSUS CLASSIFICATION(Revision of the Atlanta 1992 classification)

Morphologic Types of Acute Pancreatitis

1992 ATLANTA

Interstitial edematous pancreatitis

Acute necrotizing pancreatitis

REVISED

Interstitial edematous pancreatitis

Acute necrotizing pancreatitis

-parenchymal necrosis alone

-peripancreatic necrosis alone

-combined type

Interstitial edematous pancreatitis

Localized / diffuse enlargement of the pancreas

Normal homogenous / slightly heterogenous enhancement

Mild inflammatory changes in the peripancreatic soft tissue : i.e: stranding

Figure 1 A 63yold. There is peripancreatic fat stranding (arrows) without an acute peripancreatic fluid collection.

Interstitial edematous pancreatitis

Figure 2 (A) Acute interstitial oedematous pancreatitis and acute peripancreatic fluid collection (APFC) in the left anterior pararenal space (white arrows showing the borders of the APFC). (B) A few weeks later, a follow up CT shows complete resolution of the APFC with minimal residual peripancreatic fat stranding.

Acute necrotizing pancreatitis

Inflammation associated with pancreatic parenchymal necrosis and/or peripancreatic necrosis

Lack of pancreatic parenchymal enhancement by intravenous contrast agent and/or Presence of findings of peripancreatic necrosis

Sterile /Infected Figure 3 Acute necrotic collection (ANC) in a 47-year-old woman involving the pancreatic parenchyma alone. Thin white arrows denote a newly developed, slightly heterogeneous collection in the region of the neck and body of the pancreas, without extension in the peripancreatic tissues.

Acute necrotizing pancreatitis

Figure 4 (A) Acute necrotic collections (ANC) in a 44-year-old man with acute necrotising pancreatitis involving only the peripancreatic tissues. Note enhancement of the entire pancreatic parenchyma (white stars) and the heterogeneous, non-liquid peripancreatic components in the retroperitoneum (white arrows pointing at the borders of the ANC). (B) The ANC in the same patient as (A) but imaged a few weeks later demonstrate a heterogeneous collection with areas of fat (black arrowheads) surrounded by fluid density. This finding is typical for peripancreatic necrosis. White arrows denote border of ANC; white stars denote enhancement

Gall stone pancreatitis by ERCP

Complication Complication

Phases

Early Occurs within 1st week

Involves early inflammation with variable degree of pancreatic edema & ischemia

Leads to resolution / permanent necrosis & liquefaction

Severity is entirely based on clinical parameters

Late Begins after the first week,

can extend to weeks or months

Characterized by increasing necrosis, infection & MOF

Imaging becomes more important for detecting local complications & directing treatment

Modified Marshall Scoring System for Organ Dysfunction

Grades of Severity:

▸ Mild acute pancreatitis

▸ No organ failure

▸ No local or systemic complications

▸ Moderately severe acute pancreatitis

▸ Organ failure that resolves within 48 h (transient organ failure) and/or

▸ Local or systemic complications without persistent organ failure

▸ Severe acute pancreatitis

▸ Persistent organ failure (>48 h)

–Single organ failure

–Multiple organ failure

Management

Mild pancreatitis

-Fasting

-Fluid restriction

-Analgesia

-Treat underlying cause

-No role for antibiotic

Severe pancreatitis

-Admission to ICU

-Monitoring

-Supportive therapy

-Nutritional support

-CT scan

-ERCP (in 72hours or ASAP)

ERCP : Endoscopic retrograde cholangiopancreaticography

Chronic Pancreatitis

Etiology

Pathology

31

Pain Exocrine failure Endocrine failure Loss of appetite & loss of weight Intermittent jaundice

Investigations:32

CT - chronic pancreatitis

MANAGEMENT

Conservatively Endoscopic & Radiological Surgical

Glasgow (Imrie) prognostic score

PO2<60mmHg

Age>55y

Neutrophils + all WBC>15 x109/L

Calcium<2mmol/L

Raised urea>16mmol/L

Enzymes AST>200U/L, LDH >600U/L

Albumin<32g/L

Sugar, glucose>10mmol/L

Summary:

Common causes of acute pancreatitis are idiopathic, gallstones & alcohol.

Diagnosed if patient has 2 of the following: abdominal pain, serum amylase > 3 times of upper limit or abnormal imaging finding.

Revised Atlanta classification is useful in determining the prognosis & chances for patient to develop MOF.

Always assess severity of patients upon admission & 48 hours later to determine prognosis.

Management is supportive & treat underlying cause.

References:

Banks, P. et al. Classification of acute pancreatitis—2012: Revision of the Atlanta classification and definitions by international consensus, 2012. Gut;62:102–111.

Kumar, V., Abbas, AK., Fausto, N. & Mitchell, R., Basic Pathology 7th ed, 2007. Elsevier Ltd, Philadelphia, 1121.

Lichtman, MA., Shafer, JA., Felgar, RE. & Wang, N., Lichtmans Atlas of Hematology, 2007, McGraw Hill, Canada, 215-216.

Surgical-Tutor, http://www.surgical-tutor.org.uk/default-home.htm, Acute Pancreatitis, [Accessed on: 26th March 2013.]

Williams, NS. et al. Bailey & Loves Short Practice of Surgery 25th edition, 2008. Edward Arnold Ltd, Great Britain, 816-820.