Acute pancreatitis / Epigastric pain

ACUTE PANCREATITIS- EPIGASTRIC PAIN
#surgicaleducator #epigastricabdominalpain #acutepancreatitis #usmle #babysurgeon #surgicaltutor
• Dear Viewers,
• Greetings from “Surgical Educator”
• Today I have uploaded a video on Acute Pancreatitis- a didactic lecture. I have already uploaded 2 more videos on the same topic, one in case based learning of abdominal pain and another one in image based questions for Hepato-biliary- pancreatic pathologies.
• It is one of the common surgical problems you see in surgical wards.
• I have discussed the various causes for Epigastric pain, etiology, pathology, clinical features, investigations, scoring systems, complications and treatment of Acute Pancreatitis.
• I have also included a mind map and a treatment algorithm for Acute Pancreatitis.
• I hope the video will be very useful and you will enjoy it.
• You can watch all my surgical teaching videos in the following link:
• youtube.com/c/surgicaleducator
• Thank you for watching the video.

1. ACUTE PANCREATITIS EPIGASTRIC PAIN AN OVRVIEW Dr.B.Selvaraj MS;Mch;FICS ; “Surgical Educator” Malaysia

2. ACUTE PANCREATITIS Different causes for epigastric pain Epidemiology Classifications and definitions Etiology Pathology Clinical features Investigations Assessment of severity Treatment Complications Mindmap Treatment Algorithm

3. ACUTE PANCREATITIS D/D for Epigastric Pain

4. ACUTE PANCREATITIS -Epidemiology Pancreatitis is inflammation of the pancreas . It is one of the most devastating conditions in the abdomen. More than 75% of cases of acute pancreatitis are due to either gallstones or alcohol . 80% to 85% of patients have mild and self-limiting Pancreatitis, while 15% to 20% of patients have severe Acute Pancreatitis complicated by shock, sepsis, and MODS. The overall mortality for AP is approximately 10% , but in its most severe form , it can increase to 20% to 30 % . The disease may occur at any age, with a peak in young men and older women. In the United States, more than 200,000 patients are hospitalized annually with acute pancreatitis It is the principal cause of approximately 3,200 deaths per year Infection of pancreatic and peripancreatic necrosis complicates 30% to 70% of cases of acute necrotizing pancreatitis and occurs during the second to third weeks after onset of disease.

5. ACUTE PANCREATITIS CLASSIFICATIONS AND DEFINITIONS Atlanta classification of acute pancreatitis(1992) Mild acute pancreatitis: ● no organ failure; ● no local or systemic complications. Moderately severe acute pancreatitis: ● organ failure that resolves within 48 hours (transient organ failure); and/or ● local or systemic complications without persistent organ failure. Severe acute pancreatitis: ● persistent organ failure (>48 hours); ● single organ failure ● multiple organ failure.

6. ACUTE PANCREATITIS -ETIOLOGY Nemonic : “I GET SMASHED”: Idiopathic Gallstones Ethanol Trauma Scorpion bite Mumps (viruses) Autoimmune Steroids Hyperlipidemia ERCP Drugs like Azathioprine,Thiazide.Valproic acid and Sulfasalazine.

7. ACUTE PANCREATITIS -PATHOLOGY Underlying Pathology: intrapancreatic activation of proteolytic enzymes

8. ACUTE PANCREATITIS -Clinical Features Severe epigastric pain radiating straight to the back This pain is relieved on bending forwards Anorexia, nausea and vomiting Low grade fever Mid-epigastric tenderness & fullness (paralytic ileus) Cullen’s sign ( peri-umbilical discoloration) Grey Turner’s sign (discoloration of flanks) Fox’s sign ( discoloration around inguinal ligament) Epigastric guarding Pleural effusion SYMPTOMS SIGNS

9. ACUTE PANCREATITIS -INVESTIGATIONS WBCs: ↑ Hct : ↑ (in dehydration)/ ↓ (in hemorrhage) ABG: metabolic & respiratory acidosis + hypoxia Urinary amylase: ↑ LAB INVESTIGATIONS Serum Lipase: ↑↑ (more specific & sensitive) Amylase: ↑↑↑ (less specific) BUN, creatinine: ↑ Liver enzymes, bilirubin: ↑ Inflammatory markers (CRP, IL-6, IL-8): ↑ Glucose: ↑ Ca2+: ↓

10. ACUTE PANCREATITIS -INVESTIGATIONS IMAGING INVESTIGATIONS- AXR Sentinel loops Colon cut-off sign

11. ACUTE PANCREATITIS -INVESTIGATIONS IMAGING INVESTIGATIONS- USG Pancreatitis with edema and Peripancreatic effusion

12. ACUTE PANCREATITIS -INVESTIGATIONS IMAGING INVESTIGATIONS- CECT Dual phase CT scan is useful initial investigation to look for necrosis (however, necrosis may not appear in initial 48 – 72 hrs)- If necrosis, won’t get “light up”

13. ACUTE PANCREATITIS -INVESTIGATIONS IMAGING INVESTIGATIONS- ERCP

14. ACUTE PANCREATITIS ASSESSMENT OF SEVERITY RANSON SCORING At Admission “GA LAW (Georgia law)”: Glucose >200 Age > 55 LDH > 350 AST > 250 WBC > 16,000 After 48 hrs “ C HOBBS (Calvin and Hobbes)”: Calcium <8 mg/dL Hct drop of >10% O2 <60 (PaO2) Base deficit >4 Bun >5 increase Sequestration >6 L Score 0 to 2: 2% mortality Score 3 to 4: 15% mortality Score 5 to 6: 40% mortality Score 7 to 8: 100% mortality

15. ACUTE PANCREATITIS ASSESSMENT OF SEVERITY GLASGOW-IMRIE SCORING Out of 8 criteria if more than 3 are positive it is severe

16. ACUTE PANCREATITIS ASSESSMENT OF SEVERITY BALTHAZAR CT SCORING

17. ACUTE PANCREATITIS ASSESSMENT OF SEVERITY BISAP SCORING

18. ACUTE PANCREATITIS TREATMENT Admission to HDU/ICU Analgesia  Opioid analgesia Aggressive fluid rehydration Supplemental oxygen Invasive monitoring of vital signs, central venous pressure, urine output, blood gases Frequent monitoring of haematological and biochemical parameters (including liver and renal function, clotting, serum calcium, blood glucose) Nasogastric drainage (only initially) Antibiotics if cholangitis suspected; prophylactic antibiotics can be considered CT scan essential if organ failure, clinical deterioration or signs of sepsis develop ERCP within 72 hours for severe gallstone pancreatitis or signs of cholangitis Supportive therapy for organ failure if it develops (inotropes, ventilatory support, haemofiltration , etc.) If nutritional support is required, consider enteral (nasogastric) feeding Early management of severe acute pancreatitis.

19. ACUTE PANCREATITIS TREATMENT Indications for surgery  Definitive diagnosis cannot be made  Pancreatic necrosis  Pancreatic abscess Surgical management of severe acute pancreatitis.

20. ACUTE PANCREATITIS COMPLICATIONS

21. ACUTE PANCREATITIS MINDMAP

22. ACUTE PANCREATITIS TREATMENT ALGORITHM

23. Peripheral Arterial Diseases(PAD)