Pancreatitis - Acute & Chronic - Types, C/F & Mgt

This topic is very important for an MBBS Students as it is one of the common cases a Medical Officer will come across during their Surgical Postings. Moreover it is always a Debate in treating the patient either an Physician or a Surgeon...Always it is one of the Devastating conditions of abdomen...

1. Prof. U.Murali.
Pancreatitis

2. Pancreatitis
Acute & Chronic
Prof. U.Murali.

3. Acute Pancreatitis

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Learning Objectives - AP
•Introduction
•Definition
•Aetiology
•Classification
•Pathophysiology
•Clinical presentation
•Scoring
•Investigations
•D/D & Complications
•Treatment

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•Acute pancreatitis [AP] refers to acute
inflammation of the pancreas.
•More than 75% of cases of AP are due
to either gallstones (or) alcohol.
•The disease may occur at any age, with
a peak in young men and older
woman.
•Incidence is about 5 - 50 per 100,00
population per year.
•80-85% have mild disease, while 15-
20% death occurs due to its
complications.
Introduction

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Physiological
•Acute pancreatitis (AP) is an acute
inflammation of the prior normal
gland parenchyma which is usually
reversible with raised pancreatic
enzyme levels in blood and urine.
Clinical [2 of 3 criteria]
•Characteristic abdominal pain.
•Elevation of pancreatic
enzymes > 3 times of upper
normal limit – amylase (or) lipase.
•Characteristic finding in CECT.
Definition

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Etiology
•P ancreatic divisum / Parasites
•A lcohol – 25%
•N eoplasm – Pancreatic cancer
•C ystic fibrosis / Calcium ↑
•Rx – Drugs (azathioprine, thiazides, valproic acid,
sulphonamides, tetracyclines, 5-ASA, oestrogens)
•E RCP – Post procedure – 1-3%
•A utoimmune
•T rauma (blunt abd. trauma)
•I nfections – Mumps, Coxsackie, CMV
•T riglycerides ↑
•I diopathic
•S tones – Gall [50-70%] / Scorpion venom / Surgeries

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Classification – Acute Pancreatitis
Revision of Atlanta {2012-13 / 1992}
•Early
Lasts for 1 week with
variable degree of edema &
ischemia.
•Late
Protracted course of many
weeks to months with local
complications & organ
failure.
•Mild
No organ failure.
No local (or) systemic complications.
•Moderately severe
Organ failure that resolves in 48hours.
Local (or) systemic complications without
persistent organ failure.
•Severe
Persistent organ failure (>48 hours) – can be
single (or) MOF.
•Interstitial Pancreatitis:
Localized mild inflammatory
changes in peripancreatic
tissues.
•Necrotizing Pancreatitis:
Inflammation associated with
pancreatic parenchymal
necrosis and/or
peripancreatic necrosis.
•Types •Phases •Severity

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Pathogenesis
The inflammation in acute pancreatitis is
typically caused by backflow (due to
obstruction) [or] hypersecretion of exocrine
digestive enzymes, which results in
autodigestion of the pancreas.

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•Severe epigastric pain radiating to back
– may be relieved by leaning forward.
•Low grade fever with nausea &
vomiting.
•FO – shock & dehydration.
•Mild jaundice & tachypnoea.
•Tenderness with mild distension.
•Epigastric guarding & rigidity.
•Reduced bowel sounds.
•Characteristic signs ……
Clinical Features

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Severity / Prognostic Score
[Score - 3 or More – 48 hours – Severe]

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Severity / Prognostic Score

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Sr. Amylase / D|D / Complications

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•FBC – Leukocytosis / CP / Platelet count
•Blood glucose - ↑
•Sr. electrolytes – ↓Na / K
•Sr. Ca. - ↓ [worst prognostic indicator]
•Sr. Amylase - ↑[less specific]
•Sr. Lipase - ↑[more specific & sensitive]
•LFT / RFT
•ABG – to assess pulm. insufficiency
•Urinary amylase / lipase estimation
•CRP - > 150 mg/L at 48 hours
Investigations - Hematological

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Investigations – Plain X-Ray
Sentinel Loop Sign
Colon-Cut Off Sign

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Investigations – U/S + ERCP
U/S Abdomen
ERCP

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Investigations – CT-Scan

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Treatment - Medical
•Other Measures

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Treatment - Surgical
Indications for Surgical Intervention
1 Failure of Conservative treatment
2 Infected Pancreatic Necrosis
3 For Complications – Pseudocyst & Pancreatic abscess
Surgeries
1 Open Method – Necrosectomy – Wide debridement – Lavage –
Drainage
2 Closed Method – Beger’s Procedure
3 Laparoscopic Method

32. Chronic Pancreatitis

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Learning Objectives - CP
•Introduction
•Aetiology &
Classification
•Pathophysiology
•Clinical presentation
•Investigations
•D/D & Complications
•Treatment

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•Chronic pancreatitis [CP] is a persistent
progressive inflammatory disease in
which there is irreversible destruction
of pancreatic tissue.
•Its clinical course is characterized by
severe pain & in later stages – exo &
endocrine pancreatic insufficiency.
•Incidence ranges from 2-10 cases per
100,00 population per year.
•The disease occurs more frequently in
men [M:F-4:1] & the mean age is 40
yrs.
Introduction

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Etiology / Risk Factor Classification

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Pathogenesis

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•Mid epigastric pain – severe, persistent
& recurrent radiating to back.
•Diarrhea, steatorrhea, LOA & W.
•Mild jaundice & asthenia.
•Mass per abdomen – Can present.
•Mallet-Guys sign ……
Clinical Features

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D|D / Complications
•Ca. head of
pancreas.
•Retroperitoneal
tumour.
•Pancreatic
Pseudocyst, Ascites,
Fistula & Carcinoma.
•CBD stenosis.
•Duodenal stenosis.
•PHT – Splenic vein
thrombosis.
•Malnutrition –
Malabsorption.

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Investigations

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Treatment

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Endoscopic Procedures
1Pancreatic duct Sphincterotomy
2Main ductal stone extraction
3Main ductal stenting in Strictures
4ESWL of main duct stones
5Pseudocysts drainage

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References

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• Definition & Etiology.
• Classification.
• Pathogenesis.
• Clinical Features – Signs.
• Severity & Prognostic Scores.
• D/D & Complications.
• Investigations – Non-Imaging & Imaging.
• Treatment - Medical & Surgical Methods.
To Summarize – AP & CP

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• Define & Classify Acute pancreatitis [AP].
• List 5 etiological factors of AP.
• Write the pathogenesis of AP.
• Mention the conservative treatment for AP.
• Enumerate 5 complications of Chronic pancreatitis [CP].
• List 5 salient imaging findings of CP.
• Name the surgical drainage procedures of CP.
• Write the TIGAR-O classification of CP.
Question Time

59. A patient presents with a 10-day history of abdominal pain.
If the clinical features suggest acute pancreatitis, which of
the following investigations is most likely to confirm the
diagnosis? –
•a) Serum amylase.
•b) Amylase-creatinine clearance ratio.
•c) Contrast enhanced computerized tomography.
•d) E R C P.

60. The Gold standard investigation for Chronic pancreatitis is –
•a) MRI.
•b) ERCP.
•c) Pancreatic function tests.
•d) CT – scan.

61. Of the various local complications of acute pancreatitis, the
most definitive indication for surgery is –
•a) Large pleural effusion.
•b) Infected pancreatic necrosis.
•c) Peripancreatic fluid collection.
•d) Pancreatic ascites.

62. A 35-year-old male diagnosed to have chronic pancreatitis has
recurrent severe pain requiring injectable analgesic once a week.
This results in loss of work. Imaging shows a dilated main pancreatic
duct of diameter 8-9 mm. The appropriate treatment is –
•a) Continue with analgesics avoiding opioids.
•b) Endoscopic stenting of pancreatic duct.
•c) Resection of distal pancreas with drainage.
•d) Lateral pancreatico-jejunostomy.

63. Which one of the following does not correlate with the
severity of acute pancreatitis? –
•a) Serum glucose.
•b) Serum AST.
•c) Serum amylase.
•d) Serum albumin.

64. A chronic alcoholic presents with abdominal pain radiating to the back
that responds to analgesics. At evaluation, the pancreatic duct was
found to be dilated and stones were noted in the tail pf pancreas. The
most appropriate treatment is –
•a) Pancreatic tail resection.
•b) Pancreaticojejunostomy.
•c) Percutaneous removal of stone.
•d) Conservative management.

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77. Thank You