ACUTE AND CHRONIC PANCREATITIS. I ABUZEID.ppt

Postgraduate lecture on acute and chronic pancreatitis

1. PANCREATITISPANCREATITIS
Prof. I AbuzeidProf. I Abuzeid

2. ANATOMY AND FUNCTIONS OF ANATOMY AND FUNCTIONS OF
THE PANCREASTHE PANCREAS
ExocrineExocrine
Secretes pancreatic juice Secretes pancreatic juice
which helps in digestion of which helps in digestion of
proteins, carbohydrates and proteins, carbohydrates and
fats. fats. (Proteases, Amylase & Lipase)(Proteases, Amylase & Lipase)
EndocrineEndocrine
β cells of islets secrete insulin.β cells of islets secrete insulin.
α cells secrete glucagon.α cells secrete glucagon.
δδ cells secrete somatostatin cells secrete somatostatin

3. Acute PancreatitisAcute Pancreatitis

4. Acute PancreatitisAcute Pancreatitis

reversible acute inflammation of the pancreasreversible acute inflammation of the pancreas

usually associated with severe acute upper usually associated with severe acute upper
abdominal pain and elevated blood levels of abdominal pain and elevated blood levels of
pancreatic enzymes pancreatic enzymes

may involve the pancreatic tissue or peripancreatic may involve the pancreatic tissue or peripancreatic
tissues and distant organstissues and distant organs

worldwide, the annual incidence may range from 5 worldwide, the annual incidence may range from 5
to 50 per 100 000.to 50 per 100 000.
DefinitionDefinition

5. EtiologyEtiology

Major causesMajor causes

Biliary calculi 50 - 75%Biliary calculi 50 - 75%

Alcoholism 25%Alcoholism 25%

Idiopathic 15%Idiopathic 15%

6. PATHOGENESISPATHOGENESIS

Acute pancreatitis occurs as a consequence Acute pancreatitis occurs as a consequence
of premature intracellular trypsinogen of premature intracellular trypsinogen
activation, releasing proteases which digest activation, releasing proteases which digest
the pancreas and surrounding tissue. the pancreas and surrounding tissue.

Triggers for this are many, including Triggers for this are many, including
alcohol, gallstones and pancreatic duct alcohol, gallstones and pancreatic duct
obstructionobstruction

Acute pancreatitis is often self-limiting, but Acute pancreatitis is often self-limiting, but
in some patients with severe disease, local in some patients with severe disease, local
complications, such as necrosis, pseudocyst complications, such as necrosis, pseudocyst
or abscess, occur, as well as systemic or abscess, occur, as well as systemic
complications that lead to multi-organ complications that lead to multi-organ
failure.failure.

7. Clinical PresentationClinical Presentation

SymptomsSymptoms

Pain is the cardinal symptom [ epigastric but may be Pain is the cardinal symptom [ epigastric but may be
localized to either upper quadrant or felt diffusely localized to either upper quadrant or felt diffusely
throughout the abdomen]throughout the abdomen]

The pain is usually sever and persistentThe pain is usually sever and persistent

The pain radiate to back and bending forward The pain radiate to back and bending forward
provides some reliefprovides some relief

Nausea, repeated vomiting and retching Nausea, repeated vomiting and retching

8. 
SignsSigns

Tachycardia / HypotensionTachycardia / Hypotension

Severe Abdominal TendernessSevere Abdominal Tenderness

Peritoneal SignsPeritoneal Signs

Abdominal DistensionAbdominal Distension

Respiratory DistressRespiratory Distress

Cullen’s, Grey-Turner’s, Fox’s SignCullen’s, Grey-Turner’s, Fox’s Sign

If severeIf severe: marked tenderness, guarding, distension, : marked tenderness, guarding, distension,
signs of shock, jaundice, fever, respiratory signs of shock, jaundice, fever, respiratory
findingsfindings
Clinical PresentationClinical Presentation

9. CLASSIFICATIONCLASSIFICATION

Mild acute pancreatitis:Mild acute pancreatitis:
● ● no organ failure; ● no local or systemic complications.no organ failure; ● no local or systemic complications.

Moderately severe acute pancreatitis:Moderately severe acute pancreatitis:
● ● organ failure that resolves within 48 hours (transient organ failure); and/ororgan failure that resolves within 48 hours (transient organ failure); and/or
● ● local or systemic complications without persistent organ failurelocal or systemic complications without persistent organ failure

Severe acute pancreatitis:Severe acute pancreatitis:
● ● persistent organ failure (>48 hours) – single or multiple organ failure &/orpersistent organ failure (>48 hours) – single or multiple organ failure &/or
● ● infected pancreatic necrosisinfected pancreatic necrosis

10. DiagnosisDiagnosis

No single test, but clinical picture and investigationsNo single test, but clinical picture and investigations

Serum amylase or more specific serum lipase three times or Serum amylase or more specific serum lipase three times or
more above normal. [Normal level dose not exclude AP]more above normal. [Normal level dose not exclude AP]

Serum lipase more specific than amylase.Serum lipase more specific than amylase.

CBCCBC

RFTRFT

LFT’s – ALT >150 IULFT’s – ALT >150 IU

Serum calcium level.Serum calcium level.

UrinalysisUrinalysis

ABGABG

11. DiagnosisDiagnosis

X ray chest and abdomenX ray chest and abdomen

USSUSS

CT with Contrast – standard technique, CT with Contrast – standard technique,
used in ALL with unclear diagnosis or in used in ALL with unclear diagnosis or in
severe disease.severe disease.

MRCPMRCP

ERCPERCP
Investigations in acute pancreatitis should be aimed at answering three Investigations in acute pancreatitis should be aimed at answering three
questions: questions:
Is a diagnosis of acute pancreatitis correct? Is a diagnosis of acute pancreatitis correct?
How severe is the attack? How severe is the attack?
What is the aetiology?What is the aetiology?

12. Contrast-enhanced axial computed tomographic section of the upper abdomen
showing peripancreatic and retroperitoneal edema. Large non-enhancing areas of
necrosis are visible in the body and neck of the pancreas (arrows)

13. ASSESSMENT OF SEVERITYASSESSMENT OF SEVERITY

14. 
Scoring: CT grade + NecrosisScoring: CT grade + Necrosis

CT GradeCT Grade

A = normal pancreas (0)A = normal pancreas (0)

B = edematous pancreas (1)B = edematous pancreas (1)

C = B + mild extrapancreatic changes (2)C = B + mild extrapancreatic changes (2)

D = severe extrapancreatic changes and one fluid D = severe extrapancreatic changes and one fluid
collection (3)collection (3)

E = multiple or extensive fluid collections (4)E = multiple or extensive fluid collections (4)
Computed Tomography Severity Computed Tomography Severity
IndexIndex

15. 
Necrosis ScoreNecrosis Score

None (0)None (0)

<1/3 (2)<1/3 (2)

>1/3 but <1/2 (4)>1/3 but <1/2 (4)

>1/2 (6)>1/2 (6)
Computed Tomography Severity Computed Tomography Severity
IndexIndex

16. 
CT Severity Index score CT Severity Index score >>5 correlated with 5 correlated with
prolonged hospitalization and higher rates of prolonged hospitalization and higher rates of
mortality and morbidity.mortality and morbidity.

CT Severity Index score CT Severity Index score >>5 associated with a 5 associated with a
mortality rate 15 times higher than in those with mortality rate 15 times higher than in those with
a score of less than 5 a score of less than 5
Computed Tomography Severity Computed Tomography Severity
IndexIndex

17. ManagementManagement

For mild attack a conservative approach is indicated: For mild attack a conservative approach is indicated:

IVFIVF

Frequent, but non-invasive, observation. Frequent, but non-invasive, observation.

A brief period of fasting may be sensible in a patient who is nauseated A brief period of fasting may be sensible in a patient who is nauseated
and in pain and in pain

Antibiotics are not indicated. Antibiotics are not indicated.

Apart from analgesics and anti-emetics, no drugs or interventions are Apart from analgesics and anti-emetics, no drugs or interventions are
warrantedwarranted

CT scanning is unnecessary unless there is evidence of deterioration. CT scanning is unnecessary unless there is evidence of deterioration.

For a severe attack a more aggressive approach is required, For a severe attack a more aggressive approach is required,
with the patient being admitted to ICU and monitored with the patient being admitted to ICU and monitored
invasivelyinvasively..

18. management of severe acute pancreatitismanagement of severe acute pancreatitis..

19. Complications of acute pancreatitisComplications of acute pancreatitis

20. Chronic PancreatitisChronic Pancreatitis

Chronic pancreatitis is a chronic inflammatory disease Chronic pancreatitis is a chronic inflammatory disease
characterised by fibrosis and destruction of pancreatic characterised by fibrosis and destruction of pancreatic
tissues. Diabetes mellitus occurs in advanced cases tissues. Diabetes mellitus occurs in advanced cases
because the islets of Langerhans are involved.because the islets of Langerhans are involved.

There is persistent abdominal pain of pancreatic origin There is persistent abdominal pain of pancreatic origin
combined with evidence of exocrine and endocrine combined with evidence of exocrine and endocrine
insufficiency and marked pathologically by irreversible insufficiency and marked pathologically by irreversible
parenchymal destruction. parenchymal destruction.

21. Aetiolgy Aetiolgy [Tigar-O Classification System][Tigar-O Classification System]

Toxic-metabolicToxic-metabolic

Alcoholic Alcoholic

Tobacco smoking Tobacco smoking

Hypercalcemia Hypercalcemia

Hyperlipidemia Hyperlipidemia

Chronic renal failure Chronic renal failure

IdiopathicIdiopathic

Early onset Early onset

Late onset Late onset

TropicalTropical

22. Aetiolgy Aetiolgy [Tigar-O Classification System][Tigar-O Classification System]

GeneticGenetic

Hereditary pancreatitis Hereditary pancreatitis

Cationic trypsinogen gene Cationic trypsinogen gene
PRSSPRSS
11
PRSSPRSS
22

CFTR mutations CFTR mutations

SPINK1 mutationsSPINK1 mutations

AutoimmuneAutoimmune

Isolated autoimmune chronic pancreatitis Isolated autoimmune chronic pancreatitis

Autoimmune chronic pancreatitis associated with Sjögren's syndrome Autoimmune chronic pancreatitis associated with Sjögren's syndrome

Inflammatory bowel disease Inflammatory bowel disease

Primary biliary cirrhosisPrimary biliary cirrhosis

23. Aetiolgy Aetiolgy [Tigar-O Classification System][Tigar-O Classification System]

Recurrent and Severe Acute PancreatitisRecurrent and Severe Acute Pancreatitis

Postnecrotic (severe acute pancreatitis) Postnecrotic (severe acute pancreatitis)

Recurrent acute pancreatitis Recurrent acute pancreatitis

PostirradiationPostirradiation

ObstructiveObstructive

Pancreas divisum Pancreas divisum

Sphincter of Oddi disorders (controversial) Sphincter of Oddi disorders (controversial)

Duct obstruction (e.g., tumor) Duct obstruction (e.g., tumor)

Posttraumatic pancreatic duct scarsPosttraumatic pancreatic duct scars

24. PathogenesisPathogenesis

The pathogenesis of this process of fibrosis involves The pathogenesis of this process of fibrosis involves
the activation of periacinar stellate cells of the pancreas the activation of periacinar stellate cells of the pancreas
which are converted to myofibroblast like cells which are converted to myofibroblast like cells
following an insult to the pancreas. These cells following an insult to the pancreas. These cells
synthesize and secrete type I and III collagen leading to synthesize and secrete type I and III collagen leading to
subsequent fibrosis.subsequent fibrosis.

Fibrosis lead to obstuction of the pancreatic duct with Fibrosis lead to obstuction of the pancreatic duct with
subsequent dilatation and stone formation.subsequent dilatation and stone formation.

25. Clinical FeaturesClinical Features

Pain in epigastric regionPain in epigastric region, persistent and severe, which radiates to back. This , persistent and severe, which radiates to back. This
pain is due to irritation of retropancreatic nerves, or due to ductal pain is due to irritation of retropancreatic nerves, or due to ductal
dilatation and stasis, or due to chronic inflammation itself.dilatation and stasis, or due to chronic inflammation itself.

Exocrine dysfunctionExocrine dysfunction: : Diarrhoea, asthenia, loss of weight and appetite, Diarrhoea, asthenia, loss of weight and appetite,
steatorrhoea (signifies severe pancreatic insufficiency), malabsorption.steatorrhoea (signifies severe pancreatic insufficiency), malabsorption.

Endocrine dysfunctionEndocrine dysfunction: : Diabetes mellitus.Diabetes mellitus.

Mild jaundice Mild jaundice is due to narrowing of retropancreatic bile duct and is due to narrowing of retropancreatic bile duct and
cholangitis.cholangitis.

Mass per abdomenMass per abdomen, just above the umbilicus, tender, nodular, hard, felt on , just above the umbilicus, tender, nodular, hard, felt on
deep palpation, not moving with respiration, not mobile, resonant on deep palpation, not moving with respiration, not mobile, resonant on
percussionpercussion..
Chronic pancreatitis can lead to carcinoma pancreas.Chronic pancreatitis can lead to carcinoma pancreas.

26. InvestigationsInvestigations

Plain X-ray shows calcification in 65% of patients.Plain X-ray shows calcification in 65% of patients.

CT scan can show CT scan can show calcification, ductal stones, duct calcification, ductal stones, duct
stricture and dilatation, vasculature, fibrosis, stricture and dilatation, vasculature, fibrosis,
surrounding structures, CBD status.surrounding structures, CBD status.

ERCP (pancreatography) is diagnosticERCP (pancreatography) is diagnostic

MRCPMRCP is noninvasive method to see ductal anatomy.is noninvasive method to see ductal anatomy.

27. CT - chronic pancreatitisCT - chronic pancreatitis

29. TreatmentTreatment
ConservativeConservative

Avoid alcohol.Avoid alcohol.

Low fat, high protein, high carbohydrate diet; small and more Low fat, high protein, high carbohydrate diet; small and more
frequent meals.frequent meals.

Pancreatic enzyme supplements, vitamins and minerals, medium Pancreatic enzyme supplements, vitamins and minerals, medium
chain fatty acids.chain fatty acids.

For pain—analgesics, splanchnic nerve or coeliac plexus block.For pain—analgesics, splanchnic nerve or coeliac plexus block.

Control of diabetes by oral hypoglycaemics or insulin.Control of diabetes by oral hypoglycaemics or insulin.

Somatostatin and its analogues. Somatostatin and its analogues.

30. TreatmentTreatment
Surgical TreatmentSurgical Treatment

Celiac plexus block (<30% long lasting benefit)Celiac plexus block (<30% long lasting benefit)

Thoracoscopic splachnicectomy Thoracoscopic splachnicectomy

Ampullary procedures (sphincterotomy)Ampullary procedures (sphincterotomy)

Limited applicationLimited application

Pts with focal obstruction at the ampullary orificePts with focal obstruction at the ampullary orifice

Ductal drainage proceduresDuctal drainage procedures

Puestow procedure Puestow procedure
(side to side pancreatico-jejunostomy)(side to side pancreatico-jejunostomy)

(pancreatic duct >1cm.)(pancreatic duct >1cm.)

Ablative proceduresAblative procedures

PancreatectomiesPancreatectomies

31. PSEUDOCYST OF PANCREASPSEUDOCYST OF PANCREAS

It is localized collection of sequestered pancreatic fluid,It is localized collection of sequestered pancreatic fluid,
usually 3 weeks after an attack of acute pancreatitis.usually 3 weeks after an attack of acute pancreatitis.

It can occur after trauma and recurrent chronic It can occur after trauma and recurrent chronic
pancreatitis.pancreatitis.

Collection usually occurs in the lesser sac in relationCollection usually occurs in the lesser sac in relation
to stomach, but can occur in relation with duodenum,to stomach, but can occur in relation with duodenum,
jejunum, colon, splenic hilum.jejunum, colon, splenic hilum.

About 50% of acute pancreatitis leads to pseudocystAbout 50% of acute pancreatitis leads to pseudocyst
formation, but among that 20-40% will resolveformation, but among that 20-40% will resolve
spontaneously.spontaneously.

32. Clinical FeaturesClinical Features

A swelling in the epigastric region which is hemispherical, smooth, soft, not moving with respiration,A swelling in the epigastric region which is hemispherical, smooth, soft, not moving with respiration,
not mobile, upper margin is diffuse but lower marginnot mobile, upper margin is diffuse but lower margin
well defined, resonant or impaired resonant onwell defined, resonant or impaired resonant on
percussion, with transmitted pulsation.percussion, with transmitted pulsation.

If it is infected, it will be tender mass and patient willIf it is infected, it will be tender mass and patient will
be toxic with fever and chills.be toxic with fever and chills.

33. InvestigationsInvestigations

USS reveals the size and thickness of the USS reveals the size and thickness of the
pseudocyst. Size less than 6 cm indicates that pseudocyst. Size less than 6 cm indicates that
one can wait for spontaneous resolution. one can wait for spontaneous resolution.

CT scan is the study of choice. It is two timesCT scan is the study of choice. It is two times
more sensitive than U/S. It demonstrates size, more sensitive than U/S. It demonstrates size,
shape, number, wall thickness, contents, shape, number, wall thickness, contents,
pancreatic duct size.pancreatic duct size.

MRCP delineates the ductal anatomy and itsMRCP delineates the ductal anatomy and its
abnormality.abnormality.

ERCP can be done to find out the ERCP can be done to find out the
communication.communication.

34. ComplicationsComplications

Obstruction: gastric outlet, biliaryObstruction: gastric outlet, biliary

HemmorhageHemmorhage

InfectionInfection

RuptureRupture

35. TreatmentTreatment
Cysto-gastrostomyCysto-gastrostomy
CystojejunostomyCystojejunostomy

36. Pancreatic abscessPancreatic abscess

Pancreatic abscess is collection of pus in lesser sac (intraabdominal) in Pancreatic abscess is collection of pus in lesser sac (intraabdominal) in
relation to pancreatic surface which contains mainly pus with only less relation to pancreatic surface which contains mainly pus with only less
or no necrotic pancreas. or no necrotic pancreas.

It may slough off the pancreatic/ splenic vessel wall to cause torrential It may slough off the pancreatic/ splenic vessel wall to cause torrential
haemorrhage.haemorrhage.

Abscess may be single or multiple . It is commonly in head/body or Abscess may be single or multiple . It is commonly in head/body or
tail. But often entire gland may be involved . tail. But often entire gland may be involved .

Abscess may rupture into viscera or extend into other part of the Abscess may rupture into viscera or extend into other part of the
abdomen.abdomen.

Features of sepsis, tender palpable mass in the epigastrium with Features of sepsis, tender palpable mass in the epigastrium with
leukocytosis are observed.leukocytosis are observed.

It is treated by antibiotics, percutaneous U/S or CTIt is treated by antibiotics, percutaneous U/S or CT
guided aspiration or open drainage.guided aspiration or open drainage.

37. Thank YouThank You