Pancreatitis

Objectives

Define acute and chronic pancreatitisEtiologySigns and symptomsDiagnosisTreatmentsComplications

Acute Pancreatitis

Diffuse inflammationEnzymatic destructionInterstitial edema and inflammationHemorrhage and necrosis

Etiology Acute Pancreatitis

AlcoholBiliary tract diseaseHyperlipidemiaHereditaryHypercalcemiaTraumaIschemia, infections, venom

Etiology

Azathioprine, estrogens, isoniazid, metronidazole, tetracycline, valproicacid, trimethoprim-sulfamethoxazole

Clinical Presentation

Noncrampy, epigastric abdominal pain“knifing” or “boring through” to the backNausea and vomitingTachycardia, tachypnea, hypotension, hyperthermia Voluntary and involuntary guarding

What is this? Why?

Cullen’s Sign

Hemorrhagic pancreatitisBlood dissects up the falciformligament

What is this? Why?

Grey Turner’s Sign

Hemorrhagic pancreatitisBlood dissect into the posterior retroperitoneal soft tissue in the flank

Fox’s Sign

Rare findingBluish discoloration below the inguinal ligament or at the base of the penis.

Tests

labs- amylase and lipaseCT scan CXR-elevation of left diaphragmAXR- sentinal loop sign

-colon cutoff sign

Early Prognostic Signs

Ranson’s prognostic signs of pancreatitisCriteria for acute gallstone pancreatitis

Ranson’s

At admission: Age >55yWBC >16,000/mm3Blood glucose >200 mg/dlLDH >350 IU/LAST >250 U/dl

Ranson’s

Initial 48 hoursHct fall >10%BUN elevation> 5 mg/dlSerum Calcium<8 mg/dlPao2< 60 mmHgBase deficit >4 mEq/lFluid sequestration > 6 L

Acute Gallstone Pancreatitis

At admission:Age > 70yWBC >18,000Blood glucose > 220LDH > 400AST >250

Acute Gallstone Pancreatitis

Initial 48 hHCT fall > 10%BUN elevation > 2Calcium < 8Base deficit > 5Fluid sequestration > 4 L

Prognosis

Mortality zero; less than 2 criteriaMortality 10% to 20%; 3 to 5 criteriaMortality > 50%; more than 7

Treatment Mild Pancreatitis

Supportive Restriction of oral intakeNGTH2 blockersPain control

When Resume Diet?

After ABD pain has decreasedAmylase returns to normalDiet: low-fat and low-protein

Severe Pancreatits

NPOSupportive care in the ICUAggressive fluid resus.TPN

Complications

Paralytic ileusHyperglycemiaHypocalcemiaRenal failureHemorrhage-erosion into a major vessel

Complications

NecrosisInfected necrosisAbscessPseudocystThrombosis of splenic vein- sinistralportal hypertension and gastric varices

Chronic Pancreatitis

Chronic inflammatory conditionFibrosis, duct ectasis and acinaratrophy Irreversible destruction of tissue

Etiology of Chronic Pancreatitis

Alcohol 70%IdiopathicHerditary hyperparathyroidismHypertriglyceridemiaAutoimmune Obstruction , traumaPancreas divisum

Presentation

Chronic pain- epigastric radiates to backAnorexiaWeight lossIDDMSteatorrhea

Diagnosis

Pancreatic calcificationsChain of lakes

Treatment

Control painSmall-volume, frequent, low-fat, high-protein, high-carbohydrate meals.OctreotideLipase and trypsinERCP with stents, sphincterotomy, stone extraction

Treatment Operative

SphincteroplastyPeustow- side-to-side longitudinal pancreasticojejunostomyCeliac plexus neurolysis with alcolholinjectionThoracoscopic splanchnicectomy