ACUTE AND CHRONIC PANCREATITIS AND ITS MANAGEMENT pptx

presentation of pancreatitis with the learning objectives of pancreas anatomy and physiology, acute and chronic pancreatitis definition their clinical features and sign and symptom, its pathophysiology ,their diagnostic criteria like ranson criteria, glasgow scale, REVISED ATLANTA CLASSIFICATION SYSTEM
,BALTHAZAR COMPUTED TOMOGRAPHY SEVERITY INDEX ( CTSI ) , a case and its differential diagnosis like pancreatitis, cholecystitis, peptic ulcer disease, mesenteric ischemia, myocardial infarction , gastro intestinal reflux disease GERD , intestinal obstruction and biliary colic.. it is then followed by management if its mild pancreatitis and it is severe pancreatitis , and then management of chronic pancreatitis both medical and surgical management also the indication of surgical management of chronic pancreatitis , and then lastly the complications of acute pancreatitis , both systemically like shock arrythmia metabolic and local complications like peri pancreatic fluid collection , pseudocyst , pancreatic necrosis , pancreatic fistula , pancreatic ascites , pancreatic pleural effusion , splenic vein thrombosis and arterial complication , their diagnostic criteria and treatment options are also there.

1. PANCREATITIS By : Dr Komal Fatima House officer in S1 Lyari General Hospital

2. What will you learn: Anatomy and Physiology of the Pancreas Types of Pancreatitis Etiology Pathophysiology Clinical features Diagnosis / Investigation Differential Diagnosis Management and Treatment Complications

3. ANATOMY: It is retroperitoneal organ with weight of 80 gm and length of 15cm. It is located in the upper abdomen, behind the stomach, and stretches horizontally across the body. It is Triangular-shaped organ divided into head, body, and tail. Blood Supply:

4. Venous Drainage : Anterior and posterior arcades (the superior and inferior pancreaticoduodenal veins) drain head and the body. Splenic vein drains the body and tail. Ultimately, ends into Portal Vein by joining superior mesenteric Nervous Supply: Parasympathetic Innervation: Originates from the vagus nerve (cranial nerve X).These fibers travel to the pancreas and other abdominal organs. Sympathetic Innervation: Originates from the greater and lesser splanchnic nerves, typically from thoracic levels T5 to T12.These fibers synapse at the celiac ganglion and superior mesenteric plexus before projecting onto the pancreas.

5. Parts of pancreas

6. HEAD Occupies 30% of gland Lies within the curve of duodenum , overlying the body of 2 nd lumbar vertebra and inferior vena cava. Uncinate process is the projection from side of head , passing to the left and behind the sup mesenteric vein.

7. NECK: Behind the neck , lies the aorta and the sup mesenteric vessels. And near its upper border the sup mesenteric vein joins the splenic vein to form the portal vein.

8. BODY AND TAIL: They both make 70% of gland. Body is related post to aorta , sup mesenteric artery , left kidney , renal artery and renal vein. The tip of pancreas extend up to splenic hilum.

9. Pancreas has 2 ducts: Main pancreatic duct , it join the common bile duct and empties in to major duodenal papilla or ampulla of vater in the 2nd part of duodenum. Accessory Pancreatic duct which empties in to minor duodenal papillae .

10. EXOCRINE FUNCTION >95% Of pancreatic tissues Amylase> carbohydrates Lipase>fatty acids and glycerol. Proteases (Trypsin, Chymotrypsin)>proteins Controlled by hormonal signals and neural inputs to optimize digestion based on food intake.

11. ENDOCRINE FUNCTION Insulin>uptake of glucose .Glucagon> Apposition to insulin, release of stored glucose from the liver into the bloodstream Somatostatin>insulin and glucagon to maintain balanced blood sugar levels. Pancreatic Polypeptide>regulating pancreatic secretions and appetite.

12. TYPES OF PANCREATITIS: 1, Acute Pancreatitis : Acute condition presenting with abdominal pain, a threefold or greater rise in the serum levels of pancreatic enzymes or characteristic findings of pancreatic inflammation on contrast enhanced CT. It has two types Mild ( Interstitial edematous) pancreatitis 80% of acute pancreatitis Interstitial edema of gland and minimal organ dysfunction. Mortality of 1%. Severe ( necrotizing ) pancreatitis Pancreatic necrosis severe systemic inflammatory response and multi organ failure. Mortality rate of 20-50% Within 1 st week > multi organ failure ( early phase) After 1 st week > septic complication (late phase)

13. TYPES OF PANCREATITIS: 2, Chronic Pancreatitis : Continuing inflammatory disease of pancreas characterized by irreversible morphological changes typically causing pain and permanent loss of function.

14. ETIOLOGY for acute pancreatitis: Idiopathic Gallstone Ethanol Trauma Steroids Mumps Autoimmune Scorpion venom Hyper lipidemia Hereditary ERCP induced Drugs ( Azathioprine, thiazides ,estrogen, valproic acid, estrogens , corticosteroids)

15. RISK FACTORS for chronic pancreatitis: Alcohol Trauma On going acute pancreatitis Cigarette smoking Hyperlipidemia Hypercalcemia Idiopathic Hereditary pancreatitis protein serene 1 gene mutation SPINK 1 Mutation Tropical pancreatitis Autoimmune Pancreatitis

16. PATHOPHYSIOLOGY Defective intracellular transport and secretion of pancreatic zymogens Reflux of infected bile or duodenal contents into pancreatic duct (sphincter of Oddi dysfunction) Hyperstimulation of Pancreas (alcohol, triglycerides) Pancreatic duct obstruction (common bile duct stones, tumors) Pro- enzyme Activated proteolytic enzymes Acute Pancreatitis

17. SIGN AND SYMPTOMS of ACUTE PANCREATITIS STMPTOMS Constant epigastric pain Pain is severe constant refractory to analgesic Sitting forward may relieve pain Pain radiates to back in 50 % of patients Nausea vomiting and retching are usually marked . SIGNS Tachycardia, tachypnea and hypotension Muscle guarding in upper abdomen Jaundice > gallstone Swinging pyrexia > cholangitis Cullen sign > peri umbilical ecchymosis Grey turner sign > flank ecchymosis .

18. CLINICAL FEATURES of CHRONIC PANCREATITIS Abdominal pain > dull ,recurrent and severe associated with weightless. Head of pancreases > epigastric and right subcostal pain Body and tail > left subcostal and back pain Jaundice and cholangitis > due to fibrosis of distal common bile duct Duodenal obstruction > due to extensive scarring of head of pancreas. Features of Exocrine insufficiency > anorexia and weightloss ( due to protein malabsorption) , steatorrhea ( due to fat malabsorption) Features of Endocrine insufficiency > insulin dependent diabetes mellites , infection related to dm.

19. DIAGNOSIS of ACUTE PANCREATITIS Enzyme levels : Serum Amylase peaks in 1-2 hours to normal in 4-8 days. Persistent elevation > 10 days > complications. Serum Lipase > sensitive and specific for AP start in 4-8 hours , peaks in 24h and remain high for 7-14 days. Abdominal Xray: Ultrasonography and CT scan. Ultrasound to rule out biliary etiology. Contrast CT > best single imaging investigation CT indications: Diagnostic uncertainty To distinguish interstitial from necrotizing pancreatitis. Clinical deterioration , sign of sepsis and multi organ failure. Suspected local complications . E.g. pseudocyst

20. DIAGNOSIS of ACUTE PANCREATITIS: To Monitor condition: CBC CRP LFT BUN Glucose IL-6 & 8 Serum Calcium

21. RANSON SCORE:

22. MODIFIED GLASGOW SCORE: (<60 mmHg)

23. BALTHAZAR COMPUTED TOMOGRAPHY SEVERITY INDEX ( CTSI )

24. REVISED ATLANTA CLASSIFICATION SYSTEM

25. DIAGNOSIS of CHRONIC PANCREATITIS Abdominal x ray shows pancreatic calcifications. CT scan shows: Dilated pancreatic duct Parenchyma atrophy Pancreatic calcification Peri pancreatic fluid and focal pancreatic enlargement ERCP Accurate way for anatomy of duct Dilated chains of lakes > sacculation with intervening short strictures. Function test: Fecal elastase test Test for steatorrhea

26. CASE & DIFFERENTIAL DIAGNOSIS: Case Presentation: Zaid, a 45-year-old male come with Chief Complaint of Severe abdominal pain for 2 days. History of Present Complaint : Zaid presents to the emergency department with sudden onset severe upper abdominal pain radiating to his back, which started 2 days ago. The pain is constant, rated 8/10 in intensity, and worsens with eating. Associated symptoms include nausea and vomiting. Past Medical History : History of gallstones Chronic alcohol use (5-6 drinks/day for the past 15 years) Medications : No regular medications Social History: Smokes 1 pack of cigarettes per day No illicit drug use

27. Physical Examination: Vital Signs: BP 140/90 mmHg, HR 110 bpm, Temp 37.8°C, RR 20 breaths/min General : Appears in distress due to pain Abdomen : Epigastric tenderness with guarding, no rebound tenderness Skin : Mild jaundice Laboratory Results: Elevated serum amylase and lipase Mildly elevated liver enzymes Normal complete blood count (CBC)Elevated blood glucose Imaging: Abdominal ultrasound: Gallstones present, no bile duct dilation CT scan of the abdomen : Enlarged pancreas with inflammation and peripancreatic fluid CASE & DIFFERENTIAL DIAGNOSIS:

28. CASE & DIFFERENTIAL DIAGNOSIS: Differential Diagnosis: Acute Pancreatitis : Key Indicators : Elevated serum amylase and lipase, characteristic CT findings, history of alcohol use and gallstones. Diagnostic Tests : Serum amylase and lipase, CT scan. Cholecystitis : Key Indicators : Right upper quadrant pain, positive Murphy's sign ( absent), gallstones on ultrasound. Diagnostic Tests : Abdominal ultrasound.

29. Differential Diagnosis: Peptic Ulcer Disease: Key Indicators : Epigastric pain, often relieved by antacids or food. Diagnostic Tests : Endoscopy, H. pylori testing. Acute Myocardial Infarction (AMI): Key Indicators : Chest pain radiating to the back, ECG changes, elevated cardiac enzymes. Diagnostic Tests : ECG, cardiac enzyme levels CASE & DIFFERENTIAL DIAGNOSIS:

30. Differential Diagnosis: Gastroesophageal Reflux Disease (GERD): Key Indicators : Burning epigastric pain, regurgitation. Diagnostic Tests: Esophageal pH monitoring, endoscopy. Intestinal Obstruction: Key Indicators: Abdominal distension, vomiting, absent bowel sounds. Diagnostic Tests: Abdominal X-ray, CT scan. CASE & DIFFERENTIAL DIAGNOSIS:

31. Differential Diagnosis: Biliary Colic: Gallstones present .Intermittent rather than constant pain. Pain typically resolves within a few hours and is not associated with elevated pancreatic enzymes. Mesenteric Ischemia: Severe abdominal pain out of proportion to physical findings. Often associated with cardiovascular risk factors. Serum lactate levels and imaging would help in differentiation CASE & DIFFERENTIAL DIAGNOSIS:

32. MANAGEMENT & TREATMENT of ACUTE PANCREATITIS: Mild Pancreatitis: NPO Aggressive Iv fluids resuscitation Foleys catheterization & urine output monitoring Adequate analgesia Anti emetics Antibiotics are not indicated CT when sign of deterioration

33. MANAGEMENT & TREATMENT of ACUTE PANCREATITIS: Severe Pancreatitis Admission in HDU NPO & aggressive fluid rehydration Analgesic and anti emetics Supplementation oxygen to keep SaO2 > 95% Invasive monitoring of vitals, CVP, urine output, blood gases LFTs, RFTs , Serum Calcium , Blood glucose , Coagulation Profile ERCP within 72h of severe gallstone pancreatitis or sign of cholangitis Supportive therapy for organ failure

34. MANAGEMENT & TREATMENT of ACUTE PANCREATITIS: Severe Pancreatitis Antibiotics: Prophylactically to prevent local & septic complications Cefuroxime or Imipenem or Ciprofloxacin + metronidazole. Shouldn’t exceed 14 days. Nutritional Support: Vital in treatment of AP. Enteral feeding or total parental nutrition.

35. MANAGEMENT & TREATMENT of CHRONIC PANCREATITIS: Medical Management: Treat the addiction. Treatment of dm Pain control. Step wise analgesia Celiac axis block Dietary Modification. Low fat and high protein and carb Fat soluble vitamins and B12 Exocrine enzyme supplementation Micronutrient therapy Medium Chain triglycerides.

36. MANAGEMENT & TREATMENT of CHRONIC PANCREATITIS: Surgical Management: Indicated in : Intractable pain Obstruction ( biliary , pancreatic duct , duodenal) Pseudocyst formation Inability of Rule of malignancy. GENRAL RULE OF SURGERY: Pancreatic duct dilation  decompressing procedure No pancreatic duct dilatation  Resectional procedure

37. MANAGEMENT & TREATMENT of CHRONIC PANCREATITIS: Surgical Management: ERCP Modified Puestow Procedure Freys Procedure Whipple Procedure Normal Pancreatic Duct Berger Procedure

38. COMPLICATIONS of ACUTE PANCREATITIS: Systemic Complication in 1 st week: Shock Arrythmia Acute respiratory distress syndrome Renal Failure DIC Paralytic ileus Encephalopathy Metabolic Hypocalcemia Hyperglycemia Hyperlipidemia

39. COMPLICATIONS of ACUTE PANCREATITIS: Local complications of acute pancreatitis (after 1 st week) Acute peri pancreatic fluid collection Pancreatic pseudocyst Pancreatic necrosis Pancreatic pleural effusion Pancreatic ascites Pancreatic fistula Splenic vein thrombosis Arterial complications

40. COMPLICATIONS of ACUTE PANCREATITIS: Local complications of acute pancreatitis Acute peri pancreatic fluid collection Diagnostic criteria : Its not infected fluid collection around pancreases with no walls. <4 weeks after acute interstitial edematous pancreatic attack. Normal enhancing pancreases. Treatment Asymptomatic  observation Symptomatic image guided drainage / US guided trans gastric drainage .

41. COMPLICATIONS of ACUTE PANCREATITIS: Local complications of acute pancreatitis Pancreatic pseudocyst Diagnostic criteria : It's walled off non-infected fluid collection around pancreases with no walls. >4 weeks after acute interstitial edematous pancreatic attack. Normal enhancing pancreases Amylase rich pancreatic fluid. Why pseudo ? Communicating pseudocyst Non communicating pseudocyst Complication Abscess Peritonitis Hemorrhage into cyst causing pain Sepsis obstructive jaundice GI bleeding Bowel Obstruction

42. COMPLICATIONS of ACUTE PANCREATITIS: Local complications of acute pancreatitis Pancreatic pseudocyst Indication for surgical treatment Causing pain Complication To differentiate btw pseudocyst and tumor Large and thicked walled > 6cm That lasted for > 12weeks Percutaneous Approach Endoscopic Approach Cystogastrostomy cystoduodenostomy Surgical appraoach Cystogastrostomy cystoduodenostomy

43. COMPLICATIONS of ACUTE PANCREATITIS: Local complications of acute pancreatitis Pancreatic necrosis Indicates acute necrotizing pancreatitis. Diagnosed by contrast enhanced CT Acute necrotic collections Walled off necrosis When suspect infected pancreatic necrosis Progressive clinical deterioration Prolonged fever Elevated wbc count Evidence of air within pancreatic necrosis seen on CT Gram stain + ve on FNA

44. COMPLICATIONS of ACUTE PANCREATITIS: Local complications of acute pancreatitis Pancreatic necrosis Management Sterile pancreatic necrosis  only supportive Infected pancreatic necrosis: Needle aspiration under CT or US. Surgical Management: Necrosectomy Closed Drainage Open Packing

45. COMPLICATIONS of ACUTE PANCREATITIS: Local complications of acute pancreatitis Pancreatic pleural effusion Imaged-guided percutaneous thoracocentesis. If no response → NPO, TPN, and octreotide. It is due to retroperitoneal leakage of pancreatic fluid (no due to pancreatic-pleural fistula)

46. COMPLICATIONS of ACUTE PANCREATITIS: Local complications of acute pancreatitis Pancreatic ascites Imaged-guided percutaneous paracentesis. If no response → NPO, TPN, and octreotide. It is due to retroperitoneal leakage of pancreatic fluid.

47. COMPLICATIONS of ACUTE PANCREATITIS: Local complications of acute pancreatitis Pancreatic fistula Observation (especially if < 200mL per day) If no response → NPO, TPN, octreotide If no response → ERCP, sphincterotomy + pancreatic stent.

48. COMPLICATIONS of ACUTE PANCREATITIS: Local complications of acute pancreatitis Splenic vein thrombosis It is mostly asymptomatic, first seen on CT. It is most common after CHRONIC pancreatitis, not acute. It should be suspected if there is marked rise in platelet. Treatment: Observation If portal HTN develops → banding, beta-blockers, sclerotherapy If gastric varices develops → splenectomy (bleeding gastric varices) Thrombocytosis → Aspirin

49. COMPLICATIONS of ACUTE PANCREATITIS: Local complications of acute pancreatitis Arterial complications Splenic artery pseudoaneurysm – most common

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