ACUTE AND CHRONIC PANCREATITIC DISORDERS.pptx

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1. PANCREATITIS By- Dr. ASHWIN RATHOD POSTGRADUATE DEPARTMENT OF GENERAL SURGERY NCMCH, ISRANA

2. ANATOMY AND PHYSIOLOGY THE PANCREAS is situated in the retroperitoneum It is divided into head( constitutes 30%), body, and tail ( together constitutes 70%). The head lies within the curve of the duodenum, overlying the body of the second lumbar vertebra and the vena cava. The aorta and superior mesenteric vessels lie behind the neck of the gland. Pancreas weighs about 80g Of this about 80-90% is composed of exocrine acinar tissue.

3. PANCREATITIS Pancreatitis is inflammation of the pancreatic parenchyma. For clinical purposes, it is useful to divide it into : 1. Acute pancreatitis: which presents as an emergency 2. Chronic pancreatitis: which is a prolonged and frequently lifelong disorder resulting from the development of fibrosis within the pancreas. Note: it is possible that acute and chronic are different phases of the same process

4. Acute pancreatitis It is defined as an acute condition presenting with complaint of abdominal pain, a threefold rise or greater rise in the serum levels of the pancreatic enzymes amylase and lipase.

5. CAUSES Most common cause is gall stone induced 2 nd most common is alcohol induced Most common cause in children is : blunt trauma abdomen Iatrogenic cause : ERCP Drug induced : antiretroviral drugs, thiazides metronidazole, chemotherapeutic agents Hyperparathyroidism Incresed triglycerides Pancreatic divisum Idiopathic

6. PATHOPHYSIOLOGY OF PANCREATITIS Inactivated enzymes in pancreatic enzymes  duodenum  alkali medium  activation Any stimulus  increased calcium  co-localization of zymogen and lysosome  fuse trypsin releases cathepsin B  activated trypsin  acinar death  inflammatory cascade

7. CLINICAL FEATURES pain in epigastrium radiating to back, relieved on bending Out of proportion symptoms. Features of peritonitis: guarding, rigidity, rebound tenderness ( severe pancreatitis) Signs of acute hemorrhagic pancreatitis: Cullen sign : discoloration around the umbilicus. Grey turner sign : discoloration in flanks. Fox sign : discoloration in the inguinal region.

8. Cullen sign Grey turner sign Fox sign

9. DIAGNOSIS IF PANCREATITIS Abdominal pain consistent with pancreatitis More than 3 fold rise in pancreatic enzymes above the upper limit Characteristic findings of pancreatitis by imaging If any 2 of the above positive then it is diagnosed as pancreatitis.

10. INVESTIGATIONS 1.Serum: amylase and lipase Amylase: rises quickly, shorter half-life, sensitive Lipase: rises gradually, longer half-life, more specific. They are not predictive of severity of the attack. Liver enzymes can be raised in biliary pancreatitis Can develop hypocalcemia

11. RADIOLOGICAL SIGNS Colon cut off sign (ileus on xray ) Sentinel loop ( focal dilated jejunal loop) Gasless abdomen ( also seen in acute gastroenteritis, diarrhea ) Best imaging modality: CECT abdomen (IOC) Done after 72 hours, it can underestimate the severity Portal venous phase in CECT is most sensitive for pancreatic necrosis

12. SEVERITY CRITERIAS GLASGOW CRITERIA

13. RANSON CRITERIA

14. qSOFA score : used for MODS

15. OTHER CRITERIA ARE 4. BISAPS SCORE 5. C-REACTIVE PROTEIN : more than 150 IU/L is severe pancreatitis 6. Apache system : acute physiology and chronic health evaluation score 7. Modified marshall score 8. BALTHAZAR GRADING: best scoring system for acute pancreatitis ( CT severity index)

16. MANAGEMENT OF ACUTE PANCREATITIS Nil per oral ( bowel rest) + ryles tube. IV fluids Analgesics to control pain No role empirical antibiotics ( given if severe pancreatitis , infected necrosis, necrosis more than 50%) Nutrition: early phase of acute severe pancreatitis: parenteral nutrition (TPN)  start enteral nutrition ERCP: not used routinely only used in biliary pancreatitis, pain more than 48 hours, features of obstruction, patient with documented stones in gall bladder Cholecystectomy in gall stone induced pancreatitis

17. Complications in pancreatitis Systemic complication: any organ can be affected Sirs: systemic inflammatory response syndrome, due to inflammatory mediators. Sepsis Septic shock MODS : multiorgan dysfunction syndrome ARDS : acute respiratory distress syndrome CHF : congestive heart failure

18. Local complication Pancreatic ascites Peripancreatic fluid collection Pancreatic necrosis Pseudocyst Vascular complications: splenic artery thrombosis Left-sided pleural effusion pseudocyst

19. CHRONIC PANCREATITIS It is defined as a continuing inflammatory disease of the pancreas characterized by irreversible morphological changes. Typically causing pain and permanent loss of function.

20. CAUSES OF CHRONIC PANCREATITIS Most common cause: alcohol

21. CLINICAL FEATURES Exocrine insufficiency : more common, malabsorption Endocrine insufficiency  diabetes mellitus Pain : ineffective drainage due to fibrosis or calcium carbonate stone inmain pancreatic duct Burnt out pancreas: pain subsides as destruction increases ( acini die off)

22. INVESTIGATIONS Exocrine insufficiency: test for malabsorption -fetal fat test Fetal elastase test - NBT PABA test 2. Endocrine insufficiency : blood sugar level and insulin values 3. IOC; MRCP with secretin stimulation ( chain of lake appearance) 4. Gold standard : ERCP 5.Minimal change disease: endoscopic ultrasound 6. CECT SCAN: fibrosis + calcification

23. MANAGEMENT Exocrine insufficiency: supplementation of exogenous pancreatic enzymes (9000 IU) + proton pump inhibitors Endocrine insufficiency: insulin or oral hypoglycemic drugs Pain: opioid or non opioid pain killers If all these fail then intervention required

24. Medical treatment of chronic pancreatitis Treat the addiction ● Help the patient to stop alcohol consumption and tobacco smoking ● Involve a dependency counsellor or a psychologist Alleviate abdominal pain ● Eliminate obstructive factors (duodenum, bile duct, pancreatic duct) ● Escalate analgesia in a stepwise fashion ● Refer to a pain management specialist ● For intractable pain, consider CT/EUS-guided coeliac axis block Nutritional and pharmacological measures

25. ● Diet: low in fat and high in protein and carbohydrates ● Pancreatic enzyme supplementation with meals ● Correct malabsorption of the fat-soluble vitamins and vitamin B12 ● Micronutrient therapy with methionine, vitamins C and E, selenium (may reduce pain and slow disease progression) ● Steroids (only in autoimmune pancreatitis, for relief of symptoms) ● Medium-chain triglycerides in patients with severe fat malabsorption (they are directly absorbed by the small intestine without the need for digestion) ● Reducing gastric secretions may help

26. Surgical management Endoscopic, radiological or surgical interventions are indicated mainly to relieve obstruction of the pancreatic duct, bile duct or the duodenum, or in dealing with complications Decompressing an obstructed pancreatic duct can provide pain relief in some patients Endoscopic pancreatic sphincterotomy might be benefcial in patients with papillary stenosis and a high sphincter pressure and pancreatic ductal pressure Patients with a dominant pancreatic duct stricture and upstream dilatation may beneft by placement of a stent across the stricture. The stent should be left in for no more than 4–6 weeks as it will block

27. Pancreatic duct stones may be extracted at ERCP The role of surgery is to overcome obstruction and remove mass lesions. Some patients have a mass in the head of the pancreas, for which either a pancreatoduodenectomy or a Beger procedure (duodenum-preserving resection of the pancreatic head) is appropriate. If the duct is markedly dilated, then a longitudinal pancreatojejunostomy or Frey procedure can be of value Patients with intractable pain and diffuse disease may plead for a total pancreatectomy in the expectation that removing the offending organ will relieve their pain. However, one should keep in mind that pancreatic function and quality of life are significantly impaired after this procedure, and the operative mortality rate is not trivial. Moreover, there is no guarantee of pain relief