updated guidelies of acute pancreatitis .pptx

updated guidelines of mangement of acute pancreatitis 2024 and data concern anatomy and physiology of pancreas

1. Acute pancreatitis Dr Ahmed Mokhtar Ass. Lecturer of Gastroenterology, MFM

2. Anatomy of the pancreas The pancreas lies in the  abdomen, retroperitoneally . In adults, it is about 12–15 cm long ,  lobulated , and salmon-colored in appearance. Anatomically, the pancreas is divided into a head, neck, body, and tail . The  pancreas  is an  organ  of the  digestive system  and  endocrine system .

3. Duct system

4. Ventral pancreatic bud (VP) arises from hepatic diverticulum, and dorsal pancreatic bud (DP) arises from dorsal mesogastrium (A). During 7th gestational week, expansion of duodenum causes ventral pancreatic bud to rotate and pass behind duodenum from right to left and fuse with dorsal pancreatic bud (B-D). Ventral bud forms posterior head and uncinate process, whereas dorsal bud forms anterior head, body, and tail. Finally, ventral and dorsal pancreatic ducts fuse, and pancreas predominantly is drained through ventral duct, which joins common bile duct at level of major papilla and dorsal duct drains at level of minor papilla. Normal embryologic development of pancreas

5. Variations in configuration of pancreatic duct (A) Bifid configuration with dominant duct of Wirsung drainage, (B) bifid configuration with dominant duct of Santorini drainage without divisum , (C) rudimentary non-draining duct of Santorini (D) pancreas divisum , (E) ansa pancreatica

6. Annular pancreas Annular pancreas arises as a failed result of normal rotation of the ventral bud of the pancreas, causing it to elongate and encircle the second portion of the duodenum. Commonly, annular pancreas presents in the neonatal period and is manifest as duodenal atresia.

7. Acute pancreatitis (AP) Itis one of the principal gastrointestinal disorders that cause abdominal pain , associated with raised pancreatic enzymes , in the blood or urine because of pancreatic inflammation and autodigestion.

8. Epidemiology of acute pancreatitis 3% of all cases of abdominal pain . Hospital admission rate 9.8 per 100 000 population annually. It may occur at any age, with a peak incidence in young men and old women.

9. Etiology The most common etiologies of AP are: - gallstones (40-70%) alcohol (25-35%). Other causes are almost rare or idiopathic.

10. Gallstone pancreatitis This is caused by a gallstone blocking CBD  reflux of bile into pancreatic duct and impaired flow of normal pancreatic juice  premature activation of pancreatic enzymes within the duct system.

11. Acute pancreatitis (classification)

12. Acute pancreatitis (History taking) To assess: Pain Causes complications

13. Acute pancreatitis (Physical examination) General  Fever Abdominal ….

14. Acute pancreatitis (Investigations)

15. Other blood tests

16. Role of imaging in acute pancreatitis

17. 1- Ultrasound

18. 2- ERCP

19. ERCP: Gallstones

20. 3- Plain abdominal x-ray

21. Sentinel loop sign

22. Colon cut-off sign

23. 4- CT scan

24. CT anatomy pancreatic level

25. Local complications of AP

26. CT severity index

27. Assessment of AP severity

28. Ranson’s score

29. Glasgow score

30. APACHE II score (Acute physiology and chronic health evaluation)

31. AP Management

32. Mild AP

33. Severe AP

34. Severe AP (cont.)

35. American College of Gastroenterology Guidelines: Management of Acute Pancreatitis

36. 1- Diagnosis and Initial Assessment

37. Ultrasound Transabdominal ultrasound for patients with acute pancreatitis (AP) to evaluate for biliary pancreatitis. a report US if the initial examination is inconclusive.

38. Reserve CT for uncertain diagnosis failure to improve in 48-72 hours.

39. Risk factors for severe disease : 

40. Etiology

41. In absence of gallstones or ETOH use Evaluate serum triglyceride level (>1000 mg/dL more suggestive)  N.B. The most common etiologies of AP are - gallstones (40-70%) - alcohol (25-35%)

42. Pancreatic tumor Concern for pancreatic tumor is highest for those: - aged 40+ with no clear etiology of AP

43. Cholecystectomy is recommended in those with 2nd episode of AP with no cause.

44. Management

45. 1- Fluids

46. Monitor patient closely the first 6-12 hours while checking vitals, BUN/HCT to assess fluid needs.  ( LR preferred) Moderately aggressive hydration is most important the first 6-12 hours.  Moderately aggressive hydration is of little benefit after 24-48 hours ….. continue to monitor the patient closely during this time.

47. 2- Antibiotics

48. No antibiotics unless concern for infection.  If infected necrosis is suspected (typically after 10-14 days), use antibiotics that can penetrate:   (1) Carbapenems  (2) Quinolones  (3) Cephalosporins (4) Metronidazole 

49. 3- Feeding

50. In mild disease: Early oral feeding with low fat solid diet (within 24-48 hours) as tolerated.  Avoid parenteral nutrition if possible.

51. In moderately severe or severe disease: Consider NG for enteral feeding (NG>NJ preferred) Add small peptide-based medium chain TG oil for tolerance. Continuous feeding > cyclic or bolus

52. 4- Procedures and Surgery

53. ERCP ERCP within 24 hours if complicated by cholangitis. Consider rectal indomethacin, pancreatic duct stent, and hydration to avoid post ERCP pancreatitis

54. Cholecystectomy It is preferably before discharge in mild acute biliary pancreatitis

55. In stable pancreatic necrosis: Wait 4-6 weeks  for surgical, radiological, and/ or endoscopic interventions.

56. Thank You