PANCREATITISPANCREATITIS

SAI YAN AUSAI YAN AU

CHEE SIONG KOHCHEE SIONG KOH

INTRODUCTIONINTRODUCTION

Mrs Emilie Rezek, a 78 years old Mrs Emilie Rezek, a 78 years old elderly female, presents with an elderly female, presents with an hour’s history of severe epigastric hour’s history of severe epigastric pain radiating to the back.pain radiating to the back.

PAST HISTORYPAST HISTORY

““Bad turn” of the heart about 1 month agoBad turn” of the heart about 1 month ago Admitted to RHH and had a cardiac stentingAdmitted to RHH and had a cardiac stenting On a background of chest pain 6 to 7 years On a background of chest pain 6 to 7 years

ago ago Exertion inducedExertion induced On medication – LoprexOn medication – Loprex Worsening over the 6 to 7 yearsWorsening over the 6 to 7 years

Acute Myocardial Infarction 10 years agoAcute Myocardial Infarction 10 years ago

Long standing stomachache Long standing stomachache (DYSPEPSIA) – gastroscopy in 1994(DYSPEPSIA) – gastroscopy in 1994

CholecystectomyCholecystectomy On ZoloftOn Zoloft

No hypertensionNo hypertension No diabetes mellitusNo diabetes mellitus No asthma and epilepsyNo asthma and epilepsy NKANKA

PRESENTING PRESENTING COMPLAINT(PC)COMPLAINT(PC)

EPIGASTRIC PAINEPIGASTRIC PAIN

HISTORY OF PCHISTORY OF PC

EPIGASTRIC PAINEPIGASTRIC PAIN Started 1 day after discharge from RHHStarted 1 day after discharge from RHH Was sleeping at time of attackWas sleeping at time of attack Lasted for 15 min and spontaneous Lasted for 15 min and spontaneous

resolve for 10 min and started again – resolve for 10 min and started again – call for ambulancecall for ambulance

Ripping pain on a scale of 6/10(1Ripping pain on a scale of 6/10(1stst episode) and 10/10( 2episode) and 10/10( 2ndnd episode) which episode) which radiates to the backradiates to the back

EPIGASTRIC PAINEPIGASTRIC PAIN No relieving or aggravating factorsNo relieving or aggravating factors Other associated features includes Other associated features includes

shortness of breath, nausea and shortness of breath, nausea and perspiration(diaphoresis)perspiration(diaphoresis)

FAMILY HISTORYFAMILY HISTORY

Father died in world war II – Father died in world war II – traumatic injuries traumatic injuries

Mother died in world war II – Mother died in world war II – marrow problemmarrow problem

Has 3 sons:Has 3 sons: One has heart diseaseOne has heart disease One died of traumatic injuriesOne died of traumatic injuries One is a/wOne is a/w

SOCIAL HISTORYSOCIAL HISTORY

Came from Prague in 1949 with husbandCame from Prague in 1949 with husband Lives alone since death of husbandLives alone since death of husband Able to cook and clean the house until 2 Able to cook and clean the house until 2

months ago when shortness of breath months ago when shortness of breath worsenedworsened

Non smoker Non smoker Non drinkerNon drinker Has a dogHas a dog

SYSTEMIC REVIEWSYSTEMIC REVIEW

Cardiovascular systemCardiovascular system Chest pain Chest pain Shortness of breath of few years Shortness of breath of few years

worsened 2 to 3 months agoworsened 2 to 3 months ago No palpitation No palpitation No PNDNo PND

GastrointestinalGastrointestinal Vomiting for 3 to 4 times for past 2 Vomiting for 3 to 4 times for past 2

monthsmonths Constipated for past 2 months – goes to Constipated for past 2 months – goes to

toilet every 3 daystoilet every 3 days No loss of appetiteNo loss of appetite No loss of weightNo loss of weight No diarrhoeaNo diarrhoea Good energy statusGood energy status

CardiovascularCardiovascular Chest painChest pain Shortness of breath worsened 2 to 3 Shortness of breath worsened 2 to 3

months agomonths ago No palpitationNo palpitation No PNDNo PND

Other systemsOther systems No positive findingsNo positive findings

CLINICAL EXAMINATIONCLINICAL EXAMINATION

Elderly ladyElderly lady Not cyanosed or jaundicedNot cyanosed or jaundiced Non cachecticNon cachectic AfebrileAfebrile Heart rate - 76/min, regular rhythmHeart rate - 76/min, regular rhythm Blood pressure - 140/80 mmHgBlood pressure - 140/80 mmHg Respiratory rate - 20/minRespiratory rate - 20/min

Positive findings : -Positive findings : - GITGIT

Right cholecystectomy scarRight cholecystectomy scar Right upper quadrant tendernessRight upper quadrant tenderness Non distended abdomenNon distended abdomen No organ enlargementNo organ enlargement No enlarged lymph nodesNo enlarged lymph nodes No palpable massNo palpable mass No ascites No ascites No renal bruitNo renal bruit Bowel sound presenceBowel sound presence

CVS, RESPI, MSK, GUT, HAEMO, CVS, RESPI, MSK, GUT, HAEMO, ENDO AND NEURO – no abnormal ENDO AND NEURO – no abnormal findingsfindings

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS

PancreatitisPancreatitis Peptic ulcer disease ?Peptic ulcer disease ? Acute Myocardial Infarction ?Acute Myocardial Infarction ?

LOCATION OF PANCREASLOCATION OF PANCREAS

Elongated structure that lies in the epigastrium and the left upper Elongated structure that lies in the epigastrium and the left upper quadrant.quadrant.

Soft, lobulated and situated on the posterior abdominal wall Soft, lobulated and situated on the posterior abdominal wall behind the peritoneum.behind the peritoneum.

Crosses the transpyloric planeCrosses the transpyloric plane Divided into a head, neck, body, and tail.Divided into a head, neck, body, and tail.

THE PANCREASTHE PANCREAS

Here is the normal gross appearance of the adult pancreas; a small Here is the normal gross appearance of the adult pancreas; a small portion of duodenum is at the left next to the head; the tail of the portion of duodenum is at the left next to the head; the tail of the pancreas is at the right. The pancreas has a tan, lobular architecture. pancreas is at the right. The pancreas has a tan, lobular architecture. Adjacent adipose tissue and lymph nodes are closely apposed. Adjacent adipose tissue and lymph nodes are closely apposed.

PANCREATITISPANCREATITIS

Definition : -Definition : - An inflammatory disorder of the An inflammatory disorder of the

pancreas pancreas Characterized by abdominal painCharacterized by abdominal pain Attacks range from mild to severeAttacks range from mild to severe Can occur as acute form (acute Can occur as acute form (acute

pancreatitis), recurrent acute form pancreatitis), recurrent acute form (chronic relapsing pancreatitis) and (chronic relapsing pancreatitis) and persistent (chronic pancreatitis)persistent (chronic pancreatitis)

ACUTE PANCREATITISACUTE PANCREATITIS

Mild, self -limited, and more seriousMild, self -limited, and more serious Female > maleFemale > male Peak incidence - between 50 to 60 YOPeak incidence - between 50 to 60 YO Most common causes - gallstones, Most common causes - gallstones,

alcoholalcohol Other causes - iatrogenic or traumatic, Other causes - iatrogenic or traumatic,

metabolic, infection and idiopathicmetabolic, infection and idiopathic

Pathophysiology : -Pathophysiology : - Sudden onset of diffuse inflammationSudden onset of diffuse inflammation Acute haemorrhage Acute haemorrhage Causes extensive necrosis of the organCauses extensive necrosis of the organ

Clinical features : -Clinical features : - Mild attackMild attack Moderate attack Moderate attack Severe attackSevere attack

This is an example of acute pancreatitis. The pancreas is This is an example of acute pancreatitis. The pancreas is swollen and does not show the typical tan, lobulated swollen and does not show the typical tan, lobulated architecture. Instead, it has areas of hemorrhagic necrosis that architecture. Instead, it has areas of hemorrhagic necrosis that appear as blotchy black red areas at the mid right of the appear as blotchy black red areas at the mid right of the photograph.photograph.

Mild attackMild attack Acute abdominal painAcute abdominal pain Minimal/rapidly resolving abdo signsMinimal/rapidly resolving abdo signs Minimum systemic illnessMinimum systemic illness

Moderate attackModerate attack Severe acute abdo painSevere acute abdo pain TachycardiaTachycardia Abdo distension, tenderness and Abdo distension, tenderness and

guardingguarding

Severe attacksSevere attacks Severe acute abdominal painSevere acute abdominal pain Severe toxaemia and shockSevere toxaemia and shock Generalised peritonitisGeneralised peritonitis ARDSARDS

Reference : Essential Surgery, Burkitt,Quick and Gatt, 2nd Edition, page 275

INVESTIGATIONSINVESTIGATIONS

Serum amylase level ( >1200 Serum amylase level ( >1200 i.u/mL)i.u/mL)

Liver Function Tests (ALT) – raised 3 Liver Function Tests (ALT) – raised 3 times more than normal in gallstone times more than normal in gallstone pancreatitispancreatitis

Plain x – rays of chest ( erect ) and Plain x – rays of chest ( erect ) and abdomen ( supine )abdomen ( supine )

ERCPERCP Peritoneal tapPeritoneal tap

MANAGEMENT MANAGEMENT

““NIL by mouth” and I/V fluidsNIL by mouth” and I/V fluids Nasogastric aspirationNasogastric aspiration Broad - spectrum I/V antibioticsBroad - spectrum I/V antibiotics Intensive careIntensive care

Fluild and electrolyte managementFluild and electrolyte management Treatment of hypocalcaemiaTreatment of hypocalcaemia Ventilatory supportVentilatory support

surgerysurgery

CHRONIC PANCREATITISCHRONIC PANCREATITIS

Continuous or relapsing Continuous or relapsing inflammation of the pancreas inflammation of the pancreas leading to irreversible morphologic leading to irreversible morphologic damage and permanent damage and permanent impairment of functionimpairment of function

Etiology – alcohol, gallstonesEtiology – alcohol, gallstones Pathophysiology : -Pathophysiology : -

Loss of pancreatic parenchymaLoss of pancreatic parenchyma Replacement by fibrous tissueReplacement by fibrous tissue

Clinical features : -Clinical features : - Persistent and severe upper Persistent and severe upper

abdominal painabdominal pain Steatorrhoea, vomiting, abdo Steatorrhoea, vomiting, abdo

distension and progressive weight distension and progressive weight loss.loss.

INVESTIGATIONINVESTIGATION

Serum amylaseSerum amylase Ultrasound Ultrasound Abdominal x-rayAbdominal x-ray CT scanCT scan ERCPERCP

MANAGEMENTMANAGEMENT

Medical interventionMedical intervention Treat the painTreat the pain Maintain nutritional statusMaintain nutritional status Reduced symptomsReduced symptoms

SurgerySurgery Removal of pancreatic duct stonesRemoval of pancreatic duct stones Partial pancreatectomy of the head Partial pancreatectomy of the head

and tailand tail Sphincteroplasty of the pancreatic Sphincteroplasty of the pancreatic

duct openingduct opening