Acute pancreatitis

"Love is like pancreatitis; it starts off slow, then builds in intensity until you become consumed and develop violent cramps." Dana Gould

1. Dr Fawwaz Bin Shahab Post Graduate trainee, surgical Unit 4 Acute Pancreatitis

2. OVERVIEW Acute pancreatitis refers to an acute inflammatory process of the pancreas, usually accompanied by abdominal pain and elevations of serum pancreatic enzymes. This syndrome is usually a discrete episode, which may cause varying degrees of injury to the pancreas, and adjacent and distant organs.

3. TYPES OF ACUTE PANCREATITIS ACUTE INTERSTITIAL / EDEMATOUS PANCREATITIS 80 % The gland architecture is preserved but is edematous. Inflammatory cells and interstitial edema are prominent within the parenchyma. Usually self limited with transient clinical manifestation. ACUTE NECROTIZING / HEMORRHAGIC PANCREATITIS 20% Marked necrosis, hemorrhage of the tissue, and fat necrosis, along with vascular inflammation and thrombosis. Much higher morbidity and substantial mortality rates.

4. PATHOGENESIS

5. ETIOLOGY

6. SIGNS AND SYMPTOMS

7. CRITERIAS TO DETERMINE THE SEVERITY AND ASSOCIATED MORTALITY OF PANCREATITIS

8. GLASGOW SCALE

9. INVESTIGATIONS FOR ACUTE PANCREATITIS Bedside Vitals ( Pulse , BP, Saturation monitoring) ECG (if tachycardiac or deranged electrolytes)  Beta-HCG Blood Tests Amylase/lipase (Serum amylase or Lipase > 3 times above normal limit is diagnostic ) FBC UCE CRP LFT (including AST) LDH Serum glucose Lipids Arterial blood gas (used for scoring acute pancreatitis)

10. Imaging investigations: Ultrasound : used to demonstrate gallstones or a dilated common bile duct. The pancreas may be visualized . Computed tomography: used to confirm diagnosis when uncertainty remains and to exclude complications of disease.

11. Initial Management of Acute Pancreatitis SUPPORTIVE CARE VOLUME RESUSCITATION: Aggressive Fluid resuscitation to compensate for third-space losses, particularly in the first 24 hours, targeting urine output >o.5 ml/kg/ hr ADEQUATE ANELGESIA RESPIRATORY MONITORING AND ABGS: To access oxygenation and acid base status, since hypoxemia is common secondary to the aggressive fluid resuscitation and potential for development of sympathetic effusions.

12. Initial Management of Acute Pancreatitis GASTRIC REST WITH NUTRITIONAL SUPPORT In mild cases, a low fat diet may be reintroduced once tolerated by the patient (i.e. the pain has settled and they have an appetite).  Enteral feeding is preferred to total parenteral nutrition as it helps maintain the mucosa and prevent translocation of bacteria. Nasojejunal feeding is commonly used. Total parenteral nutrition should be used in patients with ileus or where nutritional requirements are not being met.  ANTIBIOTICS : Antibiotics are not routinely indicated in acute pancreatitis and they should not be used prophylactically.  Infection remains a significant cause of mortality in pancreatitis. Antibiotics should be commenced in patients with suspected infected pancreatic necrosis

13. INTERVENTIONAL AND SURGICAL TREATMENT: For developing pancreatic collection and necrosis SURGICAL OPTIONS FOR GALL STONE PANCREATITIS: Early lap cholecystectomy within same admission with operative cholangiogram , in mild acute pancreatitis. In patients with severe attack, early ERCP followed by delayed lap cholecystectomy. In patients with severe pancreatitis there is an 82.6% morbidity and 47.8% mortality from cholecystectomy if performed within the initial 48 hours. If deferred until the signs of pancreatitis have subsided, morbidity and mortality fall to 17.8% and 11.8% respectively.

14. INDICATIONS OF ERCP IN PATIENTS WITH ACUTE PANCREATITIS Preferred within 72 hours in patients with acute biliary pancreatitis or with signs of cholangitis

15. ALGORITHM OF MANAGEMENT OF BILIARY PANCREATITIS

16. INDICATIONS OF CT SCAN IN PANCREATITIS

17. CT SEVERITY INDEX / BALTHAZAR CRITERIA BASED ON IMAGING CHARACTERISTICS

18. Prognosis based on CTSI

19. COMPLICATIONS OF ACUTE PANCREATITIS LOCAL COMPLICATIONS (usually develop after the 1 st week) Acute fluid collections Sterile pancreatic necrosis Infected pancreatic necrosis Pancreatic abscesses Pseudocyst Pancreatic ascites Pleural effusion Portal/ splenic vein thrombosis Pseuodoaneurysm SYSTEMIC COMPLICATIONS (common in 1 st week) CVS: shock, arrhythmias Pulmonary: ARDS Renal failure DIC Metabolic: Hypo Ca , Hyper- lipidemia , Hyperglycemia GI: Ileus Neurological: Confusion, irritability , encephalopathy.

20. APFC (ACUTE PERIPANCREATIC FLUID COLLECTION) Occurs early in the course of pancreatitis No encapsulating wall. No intervention is required unless its a large collection with pressure effects , where percutaneous aspiration under us or CT guidance , or transgastric drainage under EUS guidance is an option. 45-year-old man with abdominal pain for 3 days due to acute pancreatitis. Axial contrast-enhanced CT scan shows diffuse parenchymal swelling of pancreas (arrowhead) and peripancreatic fat infiltration and small amount fluid collection without enhancing wall without necrosis

21. PANCREATIC NECROSIS Diffuse or focal area of non viable parenchyma. Initially sterile , but later often becomes infected This is associated with lysis of peripancreatic fat and is called ACUTE NECROTIC COLLECTION. Over 4 weeks, this becomes well defined inflammatory capsule and evolve into walled off necrosis (WON) 57-year-old man with abdominal pain for 2 days. Axial contrast-enhanced CT scan shows peripancreatic fluid collection (arrows) extending to Lt. anterior para renal space and swelling of pancreas (only visible body portion) with focal non-enhancing portion in tail of pancreas (arrowhead), indicative of necrosis.

22. 34-year and 57-year-old men with chronic abdominal pain . a) multifocal necrotic fluid collection with peripheral enhancement (arrows) in peripancreatic , omentum and small bowel mesentery, indicative of maturating fluid collection. b ) peripheral enhancing fluid collection with internal entrapped air bubbles (arrowhead) around tail of pancreas, indicative of infection.

23. Treatment options for pancreatic necrosis Conservative management. Percutaneous Aspiration of infected pancreatic necrosis under US or CT guidance Often repeated drainage and repeated insertion of wider drains Pancreatic necrosectomy (thorough debridement of dead tissue around the pancreas) If further necrotic tissue forms after a necrosectomy (MANAGEMENT OF POST NECROSECTOMY NECROTIC TISSUE), following options are present Closed continuous lavage (Of Berger ) Closed drainage Open packing Closure and relaparotomy

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25. PANCREATIC PSEUDOCYSTS: 39-year and 43-year-old men with acute pancreatitis and pseudocysts formation. a) Axial contrast-enhanced CT scan shows ovoid shape peripheral rim enhancing lesion (arrowhead), indicative of pseudocyst , in lesser sac and detectable peripancreatic fluid collection and fat infiltration (arrows). b) Axial contrast-enhanced (b) CT scan shows two pseudocysts (arrowhead) in head of pancreas and pancreaticoduodenal groove, respectively

26. TYPES OF PSEUDOCYST

27. MANAGEMENT OF PSEUDOCYST

28. Important facts regarding management of pseudocyst A pseudocyst should be differentiated from cystic mucinous neoplasms of pancreas by evaluating the cystic fluid aspirate for CEA , AMYLASE and Cytology. Percutaneous drainage should be mostly avoided , particularly if it’s a communicating pseudocyst (because of the development of pancreatico -cutaneous fistula), or unless one is absolutely certain that it is not neoplastic. Communicating pseudocysts can be treated by ERCP and placement of pancreatic stent across the ampulla to provide adequate drainage. Non Communicating pseudocysts mostly require Surgical or endoscopic drainage into the adjacent hollow viscus .

29. ANC AND SPLENIC VEIN THROMBOSIS 46-year-old man with abdominal pain due to necrotizing pancreatitis. Axial contrast-enhanced CT scan shows parenchymal necrosis in pancreas (*) and non-enhancing subtle heterogeneous peripancreatic fluid collection, indicative of acute necrotic collection (arrowheads). Splenic vein thrombosis (arrow) is also detectable.

30. The following physical examination findings may be noted, varying with the severity of the disease: Fever (76%) and tachycardia (65%) are common abnormal vital signs; hypotension may be noted Abdominal tenderness, muscular guarding (68%), and distention (65%) are observed in most patients; bowel sounds are often diminished or absent because of gastric and transverse colonic ileus; guarding tends to be more pronounced in the upper abdomen A minority of patients exhibit jaundice (28%) Some patients experience dyspnea (10%), which may be caused by irritation of the diaphragm (resulting from inflammation), pleural effusion, or a more serious condition, such as acute respiratory distress syndrome (ARDS) In severe cases, hemodynamic instability is evident (10%) and hematemesis or melena sometimes develops (5%); in addition, patients with severe acute pancreatitis are often pale, diaphoretic, and listless Occasionally, in the extremities, muscular spasm may be noted secondary to hypocalcemia

31. A 60 year old man presented to the OPD with symptoms suggestive of acute pancreatitis. He consumes high quantities of alcohol regularly. His symptoms started 4 days ago. But he continued to consume alcohol. He was admitted  for further evaluation. Presently, he has severe vomiting. He also complains of dizziness when standing. Examination revealed tenderness in the epigastrium and right hypochondrium . A reddish discoloration is noted in the flanks. Which of the following statements regarding the patient is most accurate? A. The patient should be evaluated for concomitant appendicitis B. USG is likely to demonstrate pseudocyst of pancreas C. Contrast CT scan of the abdomen will reveal severe necrotising pancreatitis D. Pancreatic calcification will be seen in X-ray abdomen

32. Correct answer :  C. Contrast CT scan of the abdomen will reveal severe necrotising pancreatitis.