acute pancreatitis

Gallstones continue to be the most common cause of acute pancreatitis in most series

Alcohol is the second most common cause

"GET SMASH'D" Gallstones, Ethanol, Trauma, Steroids, Mumps, Autoimmune, Scorpion bites, Hyperlipidemia, Drugs(azathioprine, diuretics)

Abdominal pain Nausea and vomiting signs may vary from mild tenderness to

generalised peritonitis. Grey-Turner's sign Cullen's sign

MOF- Respiratory,cardiovascular failure &acute renal failure.

Metabolic (hypocalcaemia,hypomagnesaemia,

hyperglycaemia) Haematological (DIC) Fever - systemic inflammation, or acute

cholangitis, due to bacterial infection-LATE

a recognised entity occurs in cases of shock of unknown origin, during the postoperative period, in renal transplant peritoneal dialysis patients,

and in diabetic ketoacidosis.

Typical clinical features + a high plasma concentration of pancreatic

enzymes serum amylase concentrations decline quickly

over two to three days Relate it to onset of abdominal pain

several non-pancreatic diseases (visceral perforation, small bowel obstruction and ischaemia, leaking aortic aneurysm, ectopic pregnancy),

tumours also secrete amylase

superior sensitivity and specificity preferable to serum amylase for the

diagnosis of acute pancreatitis

History physical examination, liver function tests, and biliary ultrasonography will indicate the

correct cause in most cases. If not, follow-up investigations, should

include fasting plasma lipids and calcium, viral antibody titres, and repeat biliary ultrasonography.

detect free air in the abdomen, colon cut-off sign, a sentinel loop, or an ileus. calcifications within the pancreas - chronic

pancreatitis.

Plain radiographs clues alternative abdominal emergency, detect and stage complications of acute

severe pancreatitis, especially pancreatic necrosis

pancreatic necrosis cannot be appreciated until at least three days after the onset of symptoms.

Patients with persisting organ failure, signs of sepsis, clinical deterioration occurring after an initial

improvement Follow-up scans

also provide prognostic information based on the following grading scale developed by Balthazar:

A - Normal B - Enlargement C - Peripancreatic inflammation D - Single fluid collection E - Multiple fluid collections

The chances of infection and death are virtually nil in grades A and B

steadily increase in grades C through E. Patients with grade E pancreatitis have a 50%

chance of developing an infection and a 15% chance of dying.

only be used in the following situations: severe acute pancreatitis secondary to stones biliary pancreatitis - worsening jaundice and

clinical deterioration despite maximal supportive therapy.

with sphincterotomy and stone extraction, may reduce the length of hospital stay, the complication rate, and, possibly, the mortality rate.

in the setting of suspected SOD (sphincter of oddi dysfunction)

PRSS1 genetic testing is recommended in symptomatic patients with any of the following features

n Recurrent attacks of acute pancreatitis for which no cause

has been found

Idiopathic chronic pancreatitis

A family history of pancreatitis in a first or second degree relative

Unexplained pancreatitis occurring in a child

Supplemental oxygen

adequate fluid resuscitation A urinary catheter Central venous monitoring All patients with severe acute pancreatitis

should be managed in a high dependency unit or intensive therapy unit.

opiate analgesia. A nasogastric tube is not useful routinely but

may be helpful if protracted vomiting occurs in the presence of a radiologically demonstrated ileus.

All patients with severe acute pancreatitis should be managed in a high dependency unit or intensive therapy unit with full monitoring and systems support (recommendation grade B).

no proven therapy for the treatment of acute pancreatitis.

Patients with alcohol-induced pancreatitis may need alcohol-withdrawal prophylaxis. Lorazepam, thiamine, folic acid, and multi-vitamins are generally used in this group of patients.

imaging of the common bile duct is required. If the presence of stones in the common bile duct

is confirmed, a cholecystectomy with common bile duct exploration (either surgical or postoperatively with endoscopic retrograde cholangiopancreatography [ERCP]) should be performed during the same hospitalisation in mild to moderate disease soon after the attack resolves.

A longer delay, even of a few weeks, is associated with a high recurrence (80%) of acute pancreatitis and re-admission

If the pancreatitis is severe, some allow a few months for the inflammation to completely resolve before performing a cholecystectomy

In patients who are not candidates for surgery because of comorbidities with a high American Association of Anesthesiology (ASA) index, sepsis, or severe disease,

ERCP must be considered. Urgent ERCP is indicated in patients with biliary

sepsis and obstructive jaundice that show no improvement in 48 hours after the onset of the attack.

ERCP is a diagnostic and therapeutic intervention

If mild to moderate pancreatitis is found, cholecystectomy with intra-operative cholangiogram should be performed but the pancreas should be left alone.

For severe pancreatitis, the lesser sac should be opened and the pancreas fully inspected. Some surgeons place drains and irrigating catheter around the pancreas.

during the same hospital admission, unless a clear plan has been made for

definitive treatment within the next two weeks (recommendation grade C).

should be delayed in patients with severe acute pancreatitis until signs of lung injury and systemic disturbance have resolved.

infected necrosis -high mortality rate (40%). diagnosed either by the presence of gas

within the pancreatic collection or by fine needle aspiration

All patients with persistent symptoms and > 30% pancreatic necrosis,

and those with smaller areas of necrosis and clinical suspicion of sepsis,

should undergo image guided fine needle aspiration to obtain material for culture 7–14 days after the onset of pancreatitis (recommendation grade B).

sterile necrosis - managed conservatively. infected necrosis -radiological or surgical

intervention.

Some trials show benefit, others do not. At present there is no consensus on this

issue. If antibiotic prophylaxis is used, it should be given for a maximum of 14 days

rationale -mortality for infected pancreatic

necrosis is higher than that for sterile necrosis.

No conclusive evidence to support the use of enteral nutrition in all patients with severe acute pancreatitis.

enteral route is preferred if that can be tolerated (recommendation grade A).

nasogastric route effective in 80% of cases (recommendation grade B).

The use of enteral feeding may be limited by ileus. If this persists for more than five days, parenteral nutrition will be required.

clinical impression of severity, obesity, or APACHE II>8 in the first 24 hours

of admission, and C reactive protein >150 mg/l, Glasgow score 3 or more, or persisting organ failure after 48 hours in

hospital (recommendation grade B).

The definitions of severity, as proposed in the Atlanta criteria, should be used.

organ failure present within the first week, which resolves within 48 hours, should not be considered an indicator of a severe attack (recommendation grade B).

Bradley reported the criteria for severe acute pancreatitis developed at the International Symposium on Acute Pancreatitis held in Atlanta, Georgia.

Criteria for severe acute pancreatitis - one or more of the following:

(1) Ranson score on admission >= 3 (or during the first 48 hours)

(2) APACHE II score >= 8 at any time during course

(3) presence of one or more organ failures (4) presence of one or more local complications

Scoring systems increase accuracy of prognosis.

Use of the Glasgow Prognostic Score/Ranson's Criteria/Acute Physiology and Chronic Health Evaluation II (APACHE II) score can indicate prognosis, particularly if combined with measurement of CRP >150 mg/L.

Ranson criteria for pancreatitis at admission LEGAL:

Leukocytes > 15 x109/l Enzyme AST > 250

units/l Glucose > 10mmol/l Age > 55 LDH > 600 units/l

Ranson criteria for pancreatitis: initial 48 hours "C & HOBBS" (Calvin and Hobbes):

Calcium < 2mmol/l Hct drop > 10% Oxygen < 8 kpa BUN > 1mmol/l Base deficit > 4mmol/l Sequestration of fluid > 6L

NUMBER OF POSITIVE CRITERIA 0-2 <5% mortality 3-4 20% mortality 5-6 40% mortality 7-8 100% mortality

uses age, and 7 laboratory values collected during the first 48 hours following admission, to predict severe pancreatitis.

It is applicable to both biliary and alcoholic pancreatitis.

The score can range from 0 to 8. If the score is >2, the likelihood of severe pancreatitis is high. If the score is <3, severe pancreatitis is unlikely.

Age >55 years WBC >15 x 109/L Urea >16 mmol/L Glucose >10 mmol/L pO2 <8 kPa (60 mm Hg) Albumin <32 g/L Calcium <2 mmol/L LDH >600 units/L AST/ALT >200 units

The majority of patients with acute pancreatitis will improve within 3 to 7 days of conservative management.

The cause should be identified, a plan to prevent recurrence should be initiated

before the patient is discharged. In gallstone pancreatitis, a cholecystectomy should be

considered before discharge in mild cases and a few months after the discharge date in patients with severe symptoms.

In patients who are not candidates for surgery, endoscopic retrograde cholangiopancreatography (ERCP) must be considered.

include: (1) pancreatic necrosis (2) pancreatic abscess (3) pancreatic pseudocyst

Organ failures include: (1) shock (systolic blood pressure less than 90

mm Hg) (2) pulmonary insufficiency (PaO2 <= 60 mm Hg

on room air) (3) renal failure (serum creatinine > 2 mg/dL after

fluid replacement) (4) gastrointestinal bleeding, with > 500 mL

estimated loss within 24 hours (5) DIC (thrombocytopenia and

hypofibrinogenemia and fibrin split products) (6) severe hypocalemia (<= 7.5 mg/dL)

Thanks !