Management and
Complications of Acute
Pancreatitis
Simrat Kaur
MANAGEMENT
 In most patients (85-90%) with mild acute pancreatitis,
the disease is self-limited and subsides spontaneousl...
SEVERE ATTACK
 Markers of severity within 24 hours are
-SIRS, Hct>44%,BUN>22mg%
 Admit the patient to ICU, Give Analgesi...
 Antibiotic prophylaxis can be considered (imipenem,
cefuroxime). The overall rate of infected necrosis is
20%.
 CT scan...
 ERCP within 36-72 hours for severe gallstone
pancreatitis or signs of cholangitis.
 Supportive therapy for organ failur...
SYSTEMIC COMPLICATIONS
 (More common in the first week)
 Cardiovascular Shock
 Arrhythmias Pulmonary
 ARDS
Renal failu...
LOCAL COMPLICATIONS
 Usually develops after the first week.
 A CT scan should be performed where clinical resolution
doe...
 Pancreatic necrosis is a Diffuse or focal area of non-viable
parenchyma in the pancreas and can be identified by an
abse...
 If the area involved is the head of pancreas midline laprotomy
should be carried out. The duodenocolic and gastrocolic
l...
 This is a circumscribed collection of pus, and may be an
acute fluid collection or a pseudocyst that has become
infected...
 Bleeding may occur into the gut, into the
retroperitoneum or into the peritoneal cavity. Possible
causes include bleedin...
 A pseudocyst is a extra pancreatic collection of amylase-rich
fluid enclosed in a wall of fibrous or granulation tissue....
Distinguishing a pseudocyst from a cystic
neoplasm
 History
 Appearance on CT and ultrasound
 FNA of fluid, preferably ...
Complications
Process Outcomes
Infection Abscess
Systemic sepsis
Rupture(prime cause of death)
into the gut
into the perit...
Management
 Pseudocysts that are thick-walled or large (over 6 cm in
diameter), have lasted for a long time (over 12 week...
Local Complications
 Acute fluid collection
 Sterile/Infected pancreatic necrosis
 Pancreatic Abscess
 Pancreatic asci...
Acute pancreatitis 1
Acute pancreatitis 1
Acute pancreatitis 1
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Acute pancreatitis 1

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Management of Acute Pancreatitis

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Acute pancreatitis 1

  1. 1. Management and Complications of Acute Pancreatitis Simrat Kaur
  2. 2. MANAGEMENT  In most patients (85-90%) with mild acute pancreatitis, the disease is self-limited and subsides spontaneously, usually within 3-7 days.  However, a conservative (non-invasive) approach is indicated(1) analgesics for pain, (2) IV fluids and colloids to maintain normal intravascular volume, and (3) no oral alimentation.  A brief period of fasting may be sensible mainly in patients who are nauseated or in pain.
  3. 3. SEVERE ATTACK  Markers of severity within 24 hours are -SIRS, Hct>44%,BUN>22mg%  Admit the patient to ICU, Give Analgesic drugs and Aggressive fluid rehydration.  Oxygen masks may be applied and Invasive monitoring of vital signs, central venous pressure, urine output and blood gases should be carried out.  Frequent monitoring of haematological and biochemical parameters  Nasogastric drainage, it is not essential but may be of value in patients with vomiting.
  4. 4.  Antibiotic prophylaxis can be considered (imipenem, cefuroxime). The overall rate of infected necrosis is 20%.  CT scan(contrast enhanced) essential if organ failure, clinical deterioration or signs of sepsis develop. Its severity can be judged by Balthazar scoring system.
  5. 5.  ERCP within 36-72 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 instead of TPN.
  6. 6. SYSTEMIC COMPLICATIONS  (More common in the first week)  Cardiovascular Shock  Arrhythmias Pulmonary  ARDS Renal failure  Haematological DIC  Metabolic - Hypocalcaemia Hyperglycaemia Hyperlipidaemia  Gastrointestinal Ileus  Neurological Visual disturbances Confusion, irritability Encephalopathy  Miscellaneous Subcutaneous fat necrosis Arthralgia
  7. 7. LOCAL COMPLICATIONS  Usually develops after the first week.  A CT scan should be performed where clinical resolution does not take place and signs of of sepsis develop.  These complications carry a significant burden of mortality.
  8. 8.  Pancreatic necrosis is a Diffuse or focal area of non-viable parenchyma in the pancreas and can be identified by an absence of contrast enhancement on CT.  These are sterile to begin with, but can become subsequently infected, probably due to translocation of gut bacteria. Infected necrosis is associated with a mortality rate of up to 50%.  If the pancreatic fluid aspirate is purulent, percutaneous drainage of the infected fluid should be carried out. The tube drain inserted should have the widest bore possible.
  9. 9.  If the area involved is the head of pancreas midline laprotomy should be carried out. The duodenocolic and gastrocolic ligaments should be divided and the lesser sac opened. Thorough debridement of the dead tissue around the pancreas should be carried out.  If the body and tail of the gland are primarily involved, a retroperitoneal approach though a left flank incision may be more appropriate.  Laproscopy- A rigid laparoscope is inserted into the peripancreatic area through a retroperitoneal approach, and vigorous irrigation and suction is combined with a gradual nibbling away of the necrotic debris.
  10. 10.  This is a circumscribed collection of pus, and may be an acute fluid collection or a pseudocyst that has become infected. Percutaneous drainage with the widest possible drains should be done Pancreatic Ascites is a chronic, generalised, peritoneal, enzyme-rich effusion usually associated with pancreatic duct disruption. Paracentesis will reveal turbid fluid with a high amylase level. Pancreatic effusion is an encapsulated collection of fluid in the pleural cavity. Concomitant pancreatic ascites may be present, or there may be a communication with an intra-abdominal collection.
  11. 11.  Bleeding may occur into the gut, into the retroperitoneum or into the peritoneal cavity. Possible causes include bleeding into a pseudocyst cavity, or diffuse bleeding from a large raw surface.
  12. 12.  A pseudocyst is a extra pancreatic collection of amylase-rich fluid enclosed in a wall of fibrous or granulation tissue.  Disruption of Pancreatic ductal system is common, however the course may vary from spontaneous healing to tense ascites.  Cause – 90% pancreatitis 10% trauma  They are often single but, occasionally, patients will develop multiple pseudocysts.  A pseudocyst is usually identified on ultrasound or a CT scan. It is important to differentiate a pseudocyst from an acute fluid collection or an abscess and a cystic neoplasm.
  13. 13. Distinguishing a pseudocyst from a cystic neoplasm  History  Appearance on CT and ultrasound  FNA of fluid, preferably under EUS guidance and Cytology typically reveals inflammatory cells in pseudocyst fluid.  CEA (high level in mucinous tumours .400ng/ml) Amylase (level usually high in pseudocysts, but occasionally in tumours)
  14. 14. Complications Process Outcomes Infection Abscess Systemic sepsis Rupture(prime cause of death) into the gut into the peritoneum GI bleeding peritonitis Enlargement Pressure effects Obstructive jaundice from biliary compression Bowel obstruction Erosion into a vessel Haemorrhage into the cyst Haemoperitoneum ( A triad of findings-inc size of mass, localized bruise over mass and a sudden dec in Hb and Hematocrit without external blood loss)
  15. 15. Management  Pseudocysts that are thick-walled or large (over 6 cm in diameter), have lasted for a long time (over 12 weeks) are less likely to resolve spontaneously. 1. Percutaneous drainage to the exterior under radiological guidance should be avoided. It carries a very high likelihood of recurrence. 2. Endoscopic drainage usually involves puncture of the cyst through the stomach or duodenal wall under EUS guidance, and placement of a tube drain with one end in the cyst cavity and the other end in the gastric lumen. 3. Surgical drainage involves internally draining the cyst into the gastric or jejunal lumen. Pseudocysts that have developed complications are best managed surgically.
  16. 16. Local Complications  Acute fluid collection  Sterile/Infected pancreatic necrosis  Pancreatic Abscess  Pancreatic ascites or effusion  Portal/ splenic vein thrombosis  Pseudocyst

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