ACUTE PANCREATITIS AND GALL STONESS.pptx

This is a slide that contains important information on the inflammation of the pancreas which is responsible for the production of bile. It also involves the etiological factors, the signs and symptoms manifestations, investigations and treatment approach.

1. ACUTE PANCREATITIS & GALL STONES GROUP SEVEN(7) SCHOOL OF CLINICAL SCIENCIES MAKENI DEPT: OF INTERNAL MEDICINE HOD:DR SHERIFF& DR MARTIN

2. GROUP MEMBERS MOHAMED LAHAI MARRAH(LEADER)……………….22065 SIMEON KOROMA……………………………………………..22061 ABDULAI M.S .MANSARAY………………………………..22063 BINTU MARRAH…………………………………………………22066 RAMATULAI SALL……………………………………………….22068 ADAMA MURANA………………………………………………22067 PETER S. SAMURA SALIFU L.SAMURA……………………………………………..22070

3. Objectives Introduction Definition Epidemiology Aetiology & Pathogenesis Signs & Symptoms Investigations Management Complications Mortality

4. Pancreatitis Inflammation of the pancreatic parenchyma. Types: Acute: Emergency condition. Chronic: Prolonged & frequently lifelong disorder resulting from the development of fibrosis within the pancreas.

5. Acute Pancreatitis Definition: Acute condition of diffuse pancreatic inflammation & autodigestion , presents with abdominal pain, and is usually associated with raised pancreatic enzyme levels in the blood & urine. Reversible inflammation of the pancreas Ranges from mild to severe.

6. Epidemiolog y Acute pancreatitis accounts for 3% of all cases of abdominal pain among patients admitted to hospital world wide Affect 2 – 28 per 100 000 of population. It may occur at any age, peak incidence is between 50 and 60 years. Women are affected more the men, but men are more likely to suffer recurrent attacks.

7. E tiology 80% of the cases are due to gallstones & alcohol. The remaining 20 % of cases are due to: Congenital: Pancreatic divisum Metabolic: Hyperlipidemia, Hypercalcemia. Toxic: Scorpion venom Infective: Mumps, Coxsackie B, EBV, CMV.

8. Drugs: Azathioprine, Sulfonamides, Steroids, Thiazides, Estrogens. V ascular: Ischemia, V asculit i s (SLE, PAN). Autoimmune: Hereditary pancreatitis. Traumatic. Miscellaneous: CF, Hypothermia, Periampullary Tumors. Idiopathic.

9. Mnemonic for the causes of Acute Pancreatitis: ‘I get smashed‘ I diopathic G allstones E thanol T rauma S teroids M umps A u t oimmu n e S corpion / S nakes H yperlipidaemia / H ypercalcaemia E RCP (endoscopic retrograde cholangiopancreatography D rugs

10. Biliary Pancreatitis: Is a type of acute pancreatitis caused by the presence of gall stones in the bile ducts

11. Alcoholic Pancreatitis: Direct toxic effect on the pancreatic acinar cells Stimulation of the pancreatic secretion Constriction of the sphincter of Oddi

12. S ym p t oms Upper Abdominal pain, sudden onset, sharp, severe, continuous, radiates to the back, reduced by leaning forward. Generalized abdominal pain, radiates to the shoulder tips. Patient lies very still. Nausea, non-projactile vomiting, retching Anorexia Fever, weakness

13. Signs Distressed, moving continuously, or sitting still Pale, diaphoretic. Confusion Low grade fever Tachycardia, Tachypnea Shallow breathing Hypotension Mild icterus Abdominal distension (Ileus, Ascites) Grey Turner’s sign, Cullen’s sign, Fox’s sign Rebound tenderness, Rigidity Shifting dullness, reduced bowel sounds

14. Cullen’s Sign Grey Turner’s Sign Fox’s Sign

15. Panniculitis Subcutaneous nodular fat necrosis Tender red nodules Usually measures 0.5 – 2 cm Usually over the extremities

16. Investigations Should be aimed at answering three questions: Is a diagnosis of acute pancreatitis correct ? How severe is the attack ? What is the aetiology ?

17. I n v e s ti g a tion s Blood tests: Complete Blood Count Serum amylase & lipase C-reactive Protein Serum electrolytes Blood glucose Renal Function Tests Liver Function Tests LDH Coagulation profile Arterial Blood Gas Analysis

18. Serum Amylase: Sensitivity: 72% Specificity: 99% Released within 6-12 hours of the onset, & Remains elevated for 3-5 days . Elevation ˃ 3X normal is significant. Undergoes renal clearance. After its serum levels decline, its urinary level remains elevated. Its level doesn't correlate with the disease activity.

19. Serum Lipase: More pancreatic-specific than s. Amylase. Sensitivity: about 100% Specificity: 96% Remains elevated longer than amylase (up to week). Useful in patients presenting late to the physician. S. Amylase tends to be higher in gallstone pancreatitis S. Lipase tend to be higher in alcoholic pancreatitis

20. Plain x-ray abdomen It may show gall stones, sentinel loop, colon cut off sign, features of paralytic ileus, left pleural effusion or collapsing of lung CT scan Useful in detecting large pancreas, pseudocyst, abscess, hemorrhagic pancreas Presence of gas bubbles indicate abscess Ultrasound To detect gallstone and biliary obstruction and serial assessment of pseudocysts, although in the earlier stages the gland may not be grossly swollen and may be missed on US. investigations

21. investigations Acute exudative pancreatitis CT scan Acute necrotizing pancreatitis CT scan

22. CT Severity Index = Balthazar Grade + Necrosis Score

23. Management In most patients it is a mild disease that subsides spontaneously within several days. Withhold food and liquids by mouth, bed rest and in patients with severe pain and ileus nasogastric suction. Supportive treatment Bed rest NPO IV fluids ; saline or whole blood Nasogastric suctioning ; if severe nausea, vomiting or development of paralytic ileus Pethidine 3-4 hourly to control pain, avoid morphine Dopamine may be required for shock nonresponsive to fluid management

24. Injection Ranitidine 50 mg IV 8 hourly, or Omeprazole 40 mg IV BD. Somatostatin or octreotide (pancreatic secretions inhibitors). Respiratory support: oxygen supplementation, or Venti mask ICU admission if severe acute pancreatitis . Urinay catheterization is done Monitor vitals

25. Calcium gluconate IV only if hypocalcemia is associated with tetany Fresh frozen plasma for coagulopathy Serum albumin for hypoalbuminemia Insulin for hyperglycemia Total parenteral nutrition for severe cases Antibiotics ; prophylactic broad spectrum antibiotic is given even in sterile pancreatitis to prevent infection Imipenem 500mg IV 8 hourly or cefuroxime 1.5g IV 8 hourly ERCP ; when severe pancreatitis results from stone in biliary tract; particularly if there is jaundice or cholangitis ERCP with endoscopic sphincterotomy and stone extraction is indicated management

26. management

27. Surgery Cholecystectomy should be undertaken within 2 weeks of resolution of pancreatitis. Patients with necrotizing pancreatitis or abscess require urgent endoscopic or minimally invasive retroperitoneal pancreatic (MIRP) necrosectomy to debride all cavities of necrotic material. Pancreatic pseudocysts can be treated by draining into stomach, duodenum or jejunum. Performed after 6 weeks, once capsule matures, by surgery or endoscopic cystogastrostomy. management

28. Complications Systemic Complications: Cardiovascular: Shock, Arrhythmias, Pericardial effusion Pulmonary: Basal atelactasis, pleural effusion, ARDS Renal: ATN, Renal failure Haematological: DIC Metabolic: Hypocalcemia, Hyperglycemia, Hyperlipidemia GIT: Ileus Neurological: Confusion, Irritability, Encephalopathy Miscellaneous: Subcutaneous fat necrosis, Arthralgia

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30. Cholelithiasis

31. Introduction Calculous disease of the biliary tract is the general term applied to diseases of the gallbladder and biliary tree that are a direct result of gallstones. Gallstone disease is the most common disorder affecting the biliary system. The true prevalence rate is difficult to determine because calculous disease may often be asymptomatic. 

32. Definition “Cholelithiasis is the presence of stones in the gallbladder - chole - means "gall bladder", lithia meaning "stone", and -sis means "process". Cholelithiasis is the formation of gallstones, which are composed of cholesterol, calcium salts, and bile pigments.

33. Causes & Risk Factors Fair, fat, female, fertile of course. High fat diet Obesity Rapid weight loss Increases with age alcoholism. Diabetics have more complications Lack of Physical Activity Family History of Gallstones

34. signs and symptoms There are three stages of gallstones: asymptomatic, symptomatic, and with complications. Sixty to 80% of gallstones are asymptomatic, meaning that they cause no symptoms. If gallstones become symptomatic, the person may have the following symptoms: a feeling of abdominal bloating and excessive gas nausea and sometimes vomiting pain that is usually in the upper right or middle part of the abdomen radiation of the pain through to the back or into the shoulder worsening of the pain after a heavy or fatty meal

35. signs and symptoms If complications occur, the individual may develop further symptoms: · abnormally light- colored stools · blockage of the bowels · dark- colored urine · fever · itching · jaundice, or yellowing of the eyes and skin · severe, constant abdominal pain

36. Diagnosis History Taking Abdominal Examination Ultrasound - Ultrasounds are used to view internal organs of the abdomen such as the liver spleen, and kidneys and to assess blood flow through various vessels. cholangiography - x-ray examination of the bile ducts using an intravenous (IV) dye (contrast). percutaneous transhepatic cholangiography (PTC) - a needle is introduced through the skin and into the liver where the dye (contrast) is deposited and the bile duct structures can be viewed by x-ray.

37. Diagnosis Computed tomography scan - A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general x-rays. endoscopic retrograde cholangiopancreatography (ERCP) - a procedure that allows the physician to diagnose and treat problems in the liver, gallbladder, bile ducts, and pancreas. The procedure combines x-ray and the use of an endoscope - a long, flexible, lighted tube. The scope is guided through the patient's mouth and throat, then through the esophagus , stomach, and duodenum.

38. Treatment Surgery is the treatment of choice for gallbladder and biliary tract diseases and may include open or laparoscopic cholecystectomy, cholecystectomy with operative cholangiography and, possibly, exploration of the common bile duct. Stone dissolution: For patients who decline surgery or who are at high surgical risk ( eg , because of concomitant medical disorders or advanced age), gallbladder stones can sometimes be dissolved by ingesting bile acids orally for many months.

39. Treatment Other treatments such as low-fat diet to prevent attacks and vitamin K for itching, jaundice, and bleeding tendendes due to vitamin K deficiency. Treatment during an acute attack such as insertion of a nasogastric tube and an I.V.line and, possibly, antibiotic and analgesic administration. Another treatment for this disease is non surgical, it involves placement of a catheter through the percutaneous transhepatic cholangiographic route. Guided by fluoroscopy, the catheter is directed toward the stone. A basket is threaded through the catheter,opened , twirled to entrap the stone, closed, and withdrawn. This procedure can be performed endoscopically .

40. Laparoscopic Cholecystectomy

41. Complications Cholangitis , sepsis Pancreatitis Perforation (10%) Hepatitis Choledocholithiasis (Stone in Common Bile Duct)

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