pancretitis

Dr-Monther AburedenGeneral surgeon-MOH

Liver and kidney transplant surgeon

DEFINITIONS

Inflammation of glandular parenchymal lead to injury and destruction of acinar components Acute: reversible Chronic : progressive

Acute Pancreatitis

CLASSIFICATION

• Mild• Moderate• Sever 25%

Acute pancreatitisEtiology:

1-Gallbladder stones 2-immoderate alcohol consumption 3-hyperlipedemia 4-drug induce 5- infectious causes: mumps,coxaki B 6-Post ERCP 7-Heredatery

pathophysiology

1-The critical step: Pancreatic outflow obstruction2-Activation of pancreatic enzymes3-Autodigestion4-Release of cytotoxines 5-Activation of inflammatory response6-Organ failure

The Pancreas

9

Diagnosispain,vomiting

Diagnosis24 h

• 3x Normal levels of amylase( 50 – 150 U/Dl) or lipase (10 – 140 U/L)

• Abdominal Pain• Vomiting

Acute Pancreatitis phtsical examination

• Cyanosis, Dyspnea• Bowel sounds decreased or absent• Low-grade fever, Leukocytosis• Hypotension, Tachycardia• Jaundice • Abnormal lung sounds - Crackles• Discoloration of abdominal wall – Turner’s or Cullen’s

sign• SIGNS OF SHOCK

Prognosis – Ranson’s (Severe > 3)• Ranson’s Score

– 5 on Admission• Age > 55 y• Glucose >200 mgldl• WBC > 16000• LDH > 350 iu/l• AST > 250 iu/l

– 6 after 48 hours from presentation• Hct > 10% decrease• Calcium < 8 mg/dl• Base Deficit > 4 mEq/l• BUN > 8• Fluid Sequestration >= 6L• PaO2 < 60

APACHE II scale

agetemperaturemean arterial pressure heart rate PaO2

arterial pH serum potassium serum sodiumserum creatinine hematocrit white blood cell count Glasgow Coma Scale score chronic health status

Assesment of severity25%Sever

1-CRP: >130 mg/l(first 72h)=complicated pancreatitis

2-Hematocrit:!!!!!!!! ↓bad sign: necrosis ↑bad sign:dehydrated3-Ct scan

ComplicationsLocal

• Pancreatic fluid collection: temporary,persistant

• Pancreatic necrosis• Significant hemorrhage

Systemic

• INFLAMMATORY PROCESS• Syestamatic Inflammatory Syndrome• Multiple Organ

Dysfunction:Respiratory,CVS,Renal failur

Managments

• Fluid • Pain killer• Abs• Nutrition• ERCP• Cholecystectomy

Fluid

• Urine output,• H.R• BP,• CVP

Pain

• NSAIDs• weak opioid• strong opioid• epidural anasthesia

Antibiotics

Nutrition

• Early Enteral feeding(no sepsis)

ERCP

• cholangitis

Cholecystectomy

When to go for surgery

• infected pancreatic necrosis

Chronic pancreatitis

• Dynamic disease: progressive loss of pancreatic parenchyma caused by inflammation and tissue destruction and subsequent synthesis of fibrotic tissue

Causes

TIGAROToxic: Alcohol, Ca,lipid,smoking,uremiaIdiopathicGeneticAutoimmuneRadiationObstruction

Dynamic disease

• Stage A: Recurrent abdominal pain+_mild impairment of pancreatic function• Stage B: more frequent attaches ,more sever+significant impairment in pancreatic function• Stage C: End stage ….less sever less frequent attaches…BUT marked impairment of endocrine and exocrine function

pathogenesis

• ???• Necrosis-fibrosis hypothesis• Protein plug hypothesis• Oxidative stress theory• Toxic –metabolic theory• ………………………………….

Diagnosis

History: recurrent attaches of abdominal painEpigastric and radiating to the backWeight loss:fear,malabsorbtionSteatorrhea(late,90% lost)Imaging

Imagingplain x ray

ERCPgold stander image

Dilated TortuosMultiple side branches

managemant

• Conservative• Endoscopic • surgery

pain

1-stop Alcohol intake

2-Analgesia:NSAIDS…Opioids

3-celiac plexus neurolysis

Pancreatic exocrine enzyme supplement

• Weight loss or steatorrhea:mandatory

malnutreition

• Frequent meals• protein: High• sugar :High• Fat: medium chain fatty acids?

Endoscopic treatment

• Sone:extraction• Stricture:dilatation and stenting

surgery

• Drainage procedures• Resection procedures

QUIZ

Standard supportive measures for patients with mild pancreatitis include the following:A. Intravenous fluid and electrolyte therapy.B. Withholding of analgesics to allow serial abdominal examinationsC. Subcutaneous octreotide therapyD. Nasogastric decompressionE.prophylactic antibiotics

Which of the following is the most popular single marker test for acute pancreatitis severity used today?

1. Trypsinogen activation peptide 2. TNF- alpha3. C Reactive Protein4. Interleukin 6&8

Which of the following is associated with gut atrophy?

1. NG feedings2. Jejunal feedings3. Parenteral feedings4. Enteric feedings

• Severity of acute pancreatitis correlate with levels of all of the following excepta) Glucoseb) Amylasec) Transaminased) Calcium