pancreatitis1970-160120092226265729.pptx

Pancreatitis

1. CLINICAL PROFILE OF ACUTE PANCREATITIS AND MANAGMENT PRSENTOR :DR MANIKANTA S G 2 ND YEAR RESIDENT MODERATOR:DR PRASHANTH DHANNUR ASSOCIATE PROFFESSOR GIMS GADAG

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

3. Pancreatitis Inflammation of the pancreatic parenchyma. Types: Acute: reversible pancreatic parenchymal changes Chronic: Prolonged & frequently lifelong disorder resulting from the development of fibrosis within the pancreas.

4. Acute Pancreatitis Definition: 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.

5. Epidemiology Acute pancreatitis accounts for 3% of all cases of abdominal pain among patients admitted to hospital Affect 2 – 28 per 100 000 of population. It may occur at any age, peak incidence is between 50 and 60 yrs.

6. Etiology Metabolic : 1)Alcohol 2)Hypercalcemia 3)Drugs –steroids, thiazide diuretics, sulfanamides , azathioprimes 4)Scorpion venom Mechanical: 1) Cholilithiasis (most common) 2)Pancreatic divisum 3)Post traumatic 4)Post ERCP 5)Pancreatic tumors and ascaris infestation

7. Vascular: 1)Periarteritis nodosa 2) Atheroembolism Infections : 1)Mumps 2)Coxsackie B 3)Cytomegalovirus 4)cryptococcus

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

9. Symptoms Upper Abdominal pain, sudden onset, sharp, stabbing type, severe, continuous, radiates to the back, reduced by leaning forward. Nausea, non-projectile vomiting, retching Fever, weakness

10. Signs General physical examination : Low grade fever Tachycardia, Tachypnoea Shallow breathing Hypotension Mild icterus Per abdomen: Abdominal distension (Ileus, Ascites) Grey Turner’s sign, Cullen’s sign, Fox’s sign Rebound tenderness, Rigidity, guarding Shifting dullness, reduced bowel sounds

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

12. Differential Diagnosis hollow viscus perforation Acute cholecystits , Biliary colic Renal colic Myocardial infarction Diabetic ketoacidosis

13. Investigations Blood tests: Complete Blood Count Serum amylase & lipase C-reactive Protein Serum electrolytes Blood glucose Renal Function Tests Liver Function Tests Coagulation profile Arterial Blood Gas Analysis

14. Serum Amylase: Sensitivity: 72% Specificity: 99% Normal 40-140 IU/l 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.

15. Serum Lipase: More pancreatic-specific than s. Amylase. Normal value 0-50 IU/L 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

16. Imaging Investigations: Plain erect x-ray abdomen and chest X-ray: not diagnostic on pancreatitis, but to rule out other D/D Pleural effusion, diffuse alveolar infiltrate (ARDS)

17. Sentinel Loop Sign

18. Colon cut-off sign

19. Ultrasound abdomen: 1)Diffusely enlarged, hypoechoic pancreas 2)Can detect gallstone in gallbladder and biliary tree 3)Bowel gas obscure the pancreas 4)Cannot identify necrosis and extrapancreatic spread

20. CECT Scan: not indicated in every patient Should be done after 72 hours of onset of symptoms CECT indicated in: Diagnostic uncertainty. Severe acute pancreatitis. Clinical deterioration, with multi-organ failure, sepsis, progressive deterioration. Local complications occurs (fluid collection, pseuodocyst , pseudo-aneurysm).

21. Axial CT Scan: Peripancreatic stranding (arrow) . Multiple gallstones in the gallbladder

22. Contrast-enhanced CT: acute necrotising pancreatitis. Pancreatic area of reduced enhancement, peripancreatic edema and stranding of the fatty tissue

23. Pancreatic pseudocyst occupying the head of the pancreas. The pancreatic duct ( arrow ) is dilated

24. CT Severity Index = Balthazar Grade + Necrosis Score

25. MRCP: CBD stones detection pancreatic duct ROLE OF EUS: To differentiate 1)Pseudocyst from cystic neoplasm of pancreas 2)Necrotising pancreatitis

26. Prognostic criteria: Score >3 severe pancreatitis 1) Ransons score : On admission: 1)Age >70 yrs 2)Tc >18,000 3)Sugars >220mg/dl 4)LDH>400 IU/l 5)AST>250 IU/100ml Within 48 hours 1)Haematocrit drop>10% 2)BUN rise >2 mg% 3)Serum calcium <8mg% 4)Base deficit>5meq/l 5)Fluid sequestration >4L

27. Goals of Treatment Aggressive supportive care Decrease inflammation Limit superinfection Identify and treat complications Treat cause if possible

28. Conservative Management Gain IV access, obtain blood sample, rapid fluid resuscitation & electrolytes replacement. Give analgesics Give Anti-emetics. Keep the patient NPO (until pain free/2-3 days). NGT insertion to relieve vomiting Urinary catheterization is done.

29. 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.

30. Role of Antibiotics Prophylactic use of antibiotics is not indicated indication for Antibiotics use: Gas in retroperitoneal space Needle aspiration of necrotic material confirms infection Sepsis CRP of ˃ 120 mg/L Peri -pancreatic fluid collection Organ dysfunction APACHE II Score of ˃ 6

31. Operative Management Surgery has no immediate role in acute pancreatitis. Aggressive surgical pancreatic debridement ( Necrosectomy ) should be undertaken soon after confirmation of the presence of infected necrosis. Pseudocyst : Cystogastrostomy , Cystodudenostomy , Roux-en-Y cystojejunostomy .

32. 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

33. Local Complications Acute fluid collection: Occurs early in the course of acute pancreatitis Located in or near the pancreas, the wall encompassing the collection is ill defined, the fluid is sterile. Most of such collections resolve, & no intervention is necessary unless a large collection causes symptoms or pressure effects, in which case it can be percutaneously aspirated under ultrasound or CT guidance. Transgastric drainage under EUS guidance is another option. An acute fluid collection that does not resolve can evolve into a pseudocyst or an abscess if it becomes infected .

34. Pancreatic Pseudocyst : Wall formed by granulation tissue & fibrosis typically presents as abdominal pain, abdominal mass, & persistent hyperamylasemia in a patient with prior pancreatitis. 4 weeks Rule of 6 1)size>6cm 2)>6 weeks 3)Wall thickness>6mm

35. Transgastric Endoscopic Pseudocyst Drainage

36. Sterile and infected pancreatic necrosis: Diffuse or focal area of non-viable parenchyma, typically associated with peripancreatic fat necrosis. These areas can be identified by an absence of contrast enhancement on CT. They’re sterile to begin with, but can become subsequently infected, due to the gut bacterial translocation. Sterile necrotic material should not be drained or interfered with. If the patient shows signs of sepsis, then one should determine whether the necrosis is infected. Nercosectomy done after 3 weeks

37. Mortality acute pancreatitis: Mortality rate of 1% Severe pancreatitis: Mortality rate 5% Sterile necrosis -15% Infected necrosis -30% First week of illness -> MODS Subsequent weeks -> infection

38. THANK YOU