Acute pancreatitis

Acute Pancreatitis general surgery undergraduate MBBS Medical School Complication of Acute Pancreatitis Ranson Criteria Alcohol Pancreatitis Gallstone Cullen sign Grey turner sign Increased serum amylase ERCP

1. Acute Pancreatitis

2. Outline of Presentation Anatomy of Pancreas Aetiology Pathophysiology Clinical Approach – History and Physical Examination Differential Diagnosis Investigation Assessment of Severity Management of Acute Pancreatitis Complications

3. ANATOMY OF PANCREAS

4. Anatomy Retroperitoneal organ In adults- 15cm long & 70-100 weighs 3 portions- head, body and tail Relations: Head Neck Uncinate Body Tail

5. Main pancreatic duct- Wirsung duct Acessory duct – Santorini duct

6. Incidence 3 % of all cases of abdominal pain Hospital admission rate for is 9.8 per 100 000 population anually Worldwide, 50 per 100 000 cases anually . The disease may occur at any age , with a peak in young men and older women.

7. Etiology Two major causes are : biliary calculi (50–70%) alcohol abuse (25%) The remaining cases may be due to rare causes or be idiopathic

8. Gallstone Pancreatitis Transient blockage of common bile duct  reflux of bile into pancreatic duct and impair flow of normal pancreatic juice  premature activation of pancreatic enzymes within duct system.

9. Alcohol Pancreatitis High risk in : 1. Long standing alcohol intake for at least 2 years or single session of heavy drinking Consumption >80g/day What Happened ? Direct toxic effect of alcohol in genetically predisposed individuals Viscid secretion of pancreatic juice  formation of protein plugs and impairment of flow

10. Pathophysiology Premature activation of pancreatic enzymes within the pancreas, leading to a process of autodigestion . Anything that injures the acinar cell and impairs the secretion of zymogen granules , or damages the duct epithelium and thus delays enzymatic secretion, can trigger acute pancreatitis. Once cellular injury has been initiated, the inflammatory process can lead to pancreatic oedema, haemorrhage and, eventually, necrosis . As inflammatory mediators are released into the circulation, systemic complications can arise.

11. ACUTE PANCREATITIS History and Physical Examination

12. Purpose of History Taking Pain Causes Complications

13. History Taking 1) Abdominal Pain - Remember SOCRATES! Site: Diffuse, upper abdominal pain Onset : Sudden Character : Boring Pain Radiation : Radiates to the back Associated factor : Nausea, vomiting, dyspnea Timing : Pain escalates in intensity and peaks within 10-20 minutes of onset.

14. Aggravating and relieving factor : Aggravated by breathing with increased chest expansion and relieved by leaning forward. Severity : Depending on severity, patient may present in shock

15. 2) History of underlying causes ‘I GET SMASHED’ Idiopathic (10%) Gallstone (45%) Ethanol ( 35%) Trauma (10%) Steroids Mumps Autoimmune Scorpion / Snake Hyperlipidemia ERCP Drugs (10%)

16. 3) History of Complications Systemic : ARDS Renal Failure Shock, arrythmias Metabolic: hypocalcemia , hyperglycemia Encephalopathy

17. Local : Mostly develop silently Pancreatic abscess – high grade fever Pseudocyst Pancreatic effusion

18. Physical Examination: Acute Pancreatitis Elevation of body temperature is often is acute pancreatitis

19. Abdominal Examination Inspection: abdominal distension Palpation : Hepatomegaly Tenderness Cullen sign Gray turner sign Peritoneal signs Rigidity Guarding

20. Percussion : Dullness suggesting ascites Auscultation: auscultate the abdomen for hypoactive or an absent bowel sounds or an abdominal bruit. Ileus is common in pancreatitis. Ausculation of lungs: 10-20% of patients have pulmonary findings, commonly left sided findings. Basilar rales Atelectasis Pleural effusion

21. Presented by Siti Nur Rifhan Kamaruddin DIFFERENTIAL DIAGNOSIS INVESTIGATIONS SEVERITY SCORING

22. Differential Diagnosis For Mild Acute Pain For Severe Acute Pain Acute Cholecystitis Fecal Peritonitis due to Perforated Colon Peptic Ulcer Disease Ruptured Abdominal Aortic Aneurysm Inferior Myocardial Infarction Ruptured Ectopic Pregnancy Acute Appendicitis Massive Bowel Infarction

23. INVESTIGATIONS

24. Investigations The diagnosis if made on basis of clinical presentation, an elevated serum Amylase level and characteristic Imaging features. Biological : - Serum Amylase increase 3x than normal or more than 1000IU/mL (Peak within the first 24hours after onset of Symptom) - Serum Lipase has longer half life thus more useful in delayed cases. - Serum Lipase: more sensitive & specific for Pancreatitis than Amylase

25. Other Causes of Increased Serum Amylase : Renal Failure Liver Cirrhosis Peritonitis GIT Inflammation Ruptured Ectopic Pregnancy/ Salphingitis Salivary Gland Inflammation ( Parotitis )

26. Other Blood Tests.. Full Blood Count Elevated Leucocytes count for Ranson’s Criteria and to predict prognosis LFT To asses cause of Pancreatitis/obstructive jaundice BUSE To determine level of dehydration Random Blood Glucose Damage to beta cells interferes with insulin production causing Hyperglycemia (in severe cases) Serum Calcium Hypocalcaemia suggests saponification

27. Role of Imaging in Acute Pancreatitis To clarify diagnosis when the clinical picture is confusing To determine possible causes To assess severity (Balthazar Score) and thus to determine prognosis To detect complications

28. Imaging : Ultrasound Trans abdominal USG : Does not establish a diagnosis. USG should be performed within 24 hours in ALL patients To detect gallstones To rule out Acute Cholecystitis To determine whether the common bile duct is dilated T o evaluate change on pancreas i.e. edema, mass in Pancreas

29. Transverse Transbadominal Ultrasound shows a swollen pancreatic body with ill-defined heterogeneous hypoechoic pattern.

30. ERCP Diagnostic and therapeutic To look for Gallstones, CBD stones or CBD dilatation In patient with severe acute gallstone pancreatitis & signs of on going biliary obstruction and cholangitis – an urgent ERCP should be sought.

31. ERCP : Gallstone Pancreatitis

32. Plain Abdominal X-Ray Plain erect chest & abdominal X-ray are not diagnostic of Acute Pancreatitis but are useful in differential diagnosis. Non specific findings in Pancreatitis : Generalized or local ileus (Sentinel Loop), a colon cut off sign, and calcified gallstones. Erect CXR. Look for pleural effusion. In severe cases, a diffuse alveolar shadowing (Acute Respiratory Distress Syndrome)

33. A focal dilated proximal jejunal loop in the left upper quadrant. A focal area of adynamic ileus close to an intraabdominal inflammatory process . The sentinel loop sign may aid in localizing the source of inflammation. Sentinel Loop in upper abdomen may indicate Pancreatitis

34. Colon Cut-off Sign describes gaseous distension seen in proximal colon Associated with narrowing of splenic flexure in cases of Acute Pancreatitis This Appearance results from inflammatory process extending from Pancreas into the phrenicolic ligament via transverse mesocolon

35. CT Scan Not necessary for all patients. May reveal pseudo cyst or abscess (complication of acute pancreatitis ) A contrast-enhanced CT is indicated in following : If there is diagnostic uncertainty In Pt. with severe acute Pancreatitis to distinguish interstitial from necrotizing pancreatitis. In Pt. with organ failure, signs of sepsis or progressive clinical deterioration When a localized complication is suspected I.e. fluid collection, pseudo cyst.

36. CT Anatomy Pancreatic Level

37. CT shows significant swelling & Inflammation of the Pancreas

38. Morphologic Types of Acute Pancreatitis THE REVISED ATLANTA CLASSIFICATION Interstitial Edematous Pancreatitis Necrotizing Pancreatitis Parenchymal necrosis Peripancreatic necrosis Combined Type

39. Interstitial Edematous Pancreatitis Pancreatic Enlargement due to edema Pancreatic Parenchyma shows relatively homogenous enhancement & peripancreatic fat stranding Outcome : Symptoms usually resolve within first week

40. - Inflammation associated pancreatic parenchymal necrosis orperipancreatic necrosis - Cause impairment of pancreatic perfusion - Impairment evolve over several days - Early CECT may underestimate extent of disease Necrotizing Pancreatitis (5-10%)

41. Pancreatic Fluid Collection : Revised Atlanta 2012 85% 15%

42. Local Complications should be suspected if : Persistence or recurrence of abd . pain Secondary increases in Serum Pancreas activity Increasing organ dysfunction Development of clinical signs of Sepsis i.e. fever, leucocytosis Prompt CECT to be done in these cases. Pancreatic Fluid Collection : REVISED ATLANTA 2012 Acute Peripancreatic Fluid Collection (APFC) Pancreatic Pseudocyst (PP) Acute Necrotic Collection (ANC) Walled-off Necrosis (WOPN)

43. 1) Acute Peripancreatic Fluid Collection (APFC) Peripancreatic Fluid associated with IEP with no necrosis Usually seen within first 4 weeks Homogenous collection of fluid Usually resolve spontaneously When a localised APFC persists > 4 weeks – develop into a Pseudocyst

44. 2) Pancreatic Pseudo cyst Encapsulated collection of fluid with a well defined inflammatory wall usually outside the pancreas With minimal or no necrosis Usually round or oval Appears after 4 weeks of onset IEP Note the two round, homogenous fluid collection with a well defined borders White stars denote normal enhancing pancreas

45. 3) Acute Necrotic Collection (ANC) A collection containing of both fluid & necrosis < 4 weeks Occurs only in setting of NP Single or multiple heterogeneous collection No defined wall Note enhancement of entire pancreatic Parenchyma (Whitestars ) Note the heterogeneous, non-liquid component in retroperitoneum (White arrows pointing at the borders of ANC)

46. 4) Walled-off Necrosis (WON) A mature, encapsulated collection of pancreatic / peripancreatic necrosis that has developed a well-defined inflammatory wall Appears >4 weeks after onset of NP Heterogeneous with liquid & non-liquid density Note the Area of non-liquid components of high attenuation (black arrows) in the collection It has a well defined, enhancing wall (White arrows)

47. - Homogenous, low attenuation fluid density - NO solid component Pseudocyst (PC) vs. Walled-off Necrosis (WON) Heterogeneous with liquid and solid densities

48. SUMMARY: Local Complications of AP

49. CT Severity Index: Balthazar + Necrosis Score A B C D E

50. Assessment of Severity Ranson Score Glasgow Scale APACHE II Score

51. Severity: RANSON’S SCORE To predict severity of acute pancreatitis . On Admission (LEGAL) L – Leucocytes >16000 E – Enzyme AST > 250 G – Glucose > 200 A – Age > 55 L – LDH > 350 During Next 48 Hours (C.HOBBS) C – Calcium 8mg/dl H – Hematocrit fall of >10% O2 – Pa02 < 60mmHG B – Base deficit > 4mmol/L B – BUN rise > 5 S – Sequestration (Fluid) > 6 litres 3 or more factors present – SEVERE

52. Glasgow Scale 3 OR MORE FACTORS PRESENT - SEVERE

53. APACHE II SCORE Score > 8 : Severe Acute Pancreatitis

54. Management of Acute Pancreatitis Presented By Fariza Asilah Ahmad Rahim

55. Mild Acute Pancreatitis Nil by mouth Fluid resuscitation : 4 pints Analgesia : IM Tramal 50mg TDS Treat underlying cause No role for antibiotics

56. Severe Acute Pancreatitis Admission to intensive care or high-dependency unit Oxygen supplementation Analgesia Aggressive fluid rehydration 4. Monitor vital signs 5. Monitor haematological & biochemical parameters

57. 6. Nasogastric drainage 7. Antibiotic prophylaxis –imipenem, cefuroxime 8. CT scan 9. ERCP within 72 hours 10. Supportive therapy for organ failure 11. Nutritional support

58. Complications of Acute Pancreatitis

59. SYSTEMIC Cardiovascular - shock - arrhythmia Pulmonary - ARDS Renal failure Haematological - DIC Gastrointestinal - Ileus

60. SYSTEMIC Metabolic - Hypocalcaemia - Hyperglycaemia - Hyperlipidaemia Neurological - Visual disturbance - Confusion - Encephalopathy Miscellaneous - Arthralgia

61. Acute fluid collection Sterile pancreatic necrosis Infected pancreatic necrosis Pacreatic abscess Pseudocyst LOCAL

62. Pancreatic ascites Pleural effusion Portal or systemic vein thrombosis Pseudocyst LOCAL

63. Complications & their Management Acute fluid collection No intervention unless pressure effect Aspirate under US or CT guidance OR Transgastric drainage under EUS guidance Pancreatic necrosis No intervention

64. Infected pancreatic necrosis Aspirate under CT guidance Percutaneous drainage Prophylactic antibiotic

65. If patient deteriorates Necrosectomy Closed continuous lavage C losed drainage Open packing Closure and relaparotomy

66. Pancreatic abscess Percutaneous drainage Antibiotic cover Pancreatic ascites Drainage Parenteral or jejunal feeding

67. Pancreatic effusion Percutaneous drainage under CT guidance Portal or systemic vein thrombosis Aspirin in the early process

68. Pseudocyst Percutaneous transgastric cystogastrotomy and place double-pigtail drain Endoscopic under EUS guidance and place tube drain Surgical drainage – internal drainage into gastric or jejunum lumen

69. Cystogastrotomy

70. Reference BAILEY, H., LOVE, R. J. M., MANN, C. V., & RUSSELL, R. C. G. (1992). Bailey and Love's short practice of surgery. London, Chapman & Hall Medical. COLLEDGE, N. R., WALKER, B. R., RALSTON, S., & DAVIDSON, S. (2010). Davidson's principles and practice of medicine. Edinburgh, Churchill Livingstone/Elsevier.