Acute pancreatitis
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  • 1. ACUTE PANCREATITIS CHAIR OF FACULTY SURGERY # 2 FIRST MOSCOW STATE MEDICAL UNIVERSITY NATROSHVILI A.G.
  • 2. ANATOMY AND PHYSIOLOGY • DIGESTIVE ENZYMES • HORMONES microscopic view of pancreatic acini pancreatic duct duodenum
  • 3. ANATOMY AND PHYSIOLOGY trypsinogen trypsin chymotrypsin elastase phospholipase carboxypeptidase enterokinase chymotrypsinogen proelastase prophospholipase procarboxypeptidase duodenal lumen Normal Enzyme Activation
  • 4. ANATOMY AND PHYSIOLOGY Exocrine Stimulation • THE MORE PROXIMAL THE NUTRIENT INFUSION…THE GREATER THE PANCREATIC STIMULATION (DOG STUDIES) • STOMACH – MAXIMAL STIMULATION • DUODENUM – INTERMEDIATE STIMULATION • JEJUNUM – MINIMAL / NEGLIGIBLE STIMULATION • ELEMENTAL FORMULAS TEND TO CAUSE LESS STIMULATION THAN STANDARD INTACT FORMULAS • INTACT PROTEIN > OLIGOPEPTIDES > FREE AMINO ACIDS • INTRAVENOUS NUTRIENTS (EVEN LIPIDS) DO NOT APPEAR TO STIMULATE THE PANCREAS
  • 5. ANATOMY AND PHYSIOLOGY Protection • COMPARTMENTALIZATION - DIGESTIVE ENZYMES ARE CONTAINED WITHIN ZYMOGEN GRANULES IN ACINAR CELLS • REMOTE ACTIVATION - DIGESTIVE ENZYMES ARE SECRETED AS INACTIVE PROENZYMES WITHIN THE PANCREAS • PROTEASE INHIBITORS – TRYPSIN INHIBITOR IS SECRETED ALONG WITH THE PROENZYMES TO SUPPRESS ANY PREMATURE ENZYME ACTIVATION • AUTO “SHUT-OFF” – TRYPSIN DESTROYS TRYPSIN IN HIGH CONCENTRATIONS
  • 6. ACUTE PANCREATITIS Definition • ACUTE INFLAMMATORY PROCESS INVOLVING THE PANCREAS • USUALLY PAINFUL AND SELF-LIMITED • ISOLATED EVENT OR A RECURRING ILLNESS • PANCREATIC FUNCTION AND MORPHOLOGY RETURN TO NORMAL AFTER (OR BETWEEN) ATTACKS
  • 7. ACUTE PANCREATITIS Etiology Gallstones 45% Alcohol [ПРОЦЕНТ] Idiopathic 10% Other 10%
  • 8. ACUTE PANCREATITIS Associated conditions • CHOLELITHIASIS • ETHANOL ABUSE • IDIOPATHIC • MEDICATIONS • HYPERLIPIDEMIA • ERCP • TRAUMA • END-STAGE RENAL FAILURE • PENETRATING PEPTIC ULCER
  • 9. ACUTE PANCREATITIS Pathogenesis Acinar cell injury Premature enzyme activation Failed protective mechanisms Audodigestion of pancreatic tissue Local vascular insufficiency Activation of white blood cells Release of enzymes into the circulation Local complications Distant organ failure
  • 10. ACUTE PANCREATITIS Pathogenesis • STAGE 1: PANCREATIC INJURY • EDEMA • INFLAMMATION • STAGE 2: LOCAL EFFECTS • RETROPERITONEAL EDEMA • ILEUS • STAGE 3: SYSTEMIC COMPLICATIONS • HYPOTENSION/SHOCK • METABOLIC DISTURBANCES • SEPSIS/ORGAN FAILURE SEVERITY Mild Severe
  • 11. • MILD AP (NO NECROSIS) – 0%  Sterile necrosis – 10%  Infected necrosis – 25% ACUTE PANCREATITIS
  • 12. ACUTE PANCREATITIS Clinical presentation • ABDOMINAL PAIN • EPIGASTRIC • RADIATES TO THE BACK (“BELT PAIN” • WORSE IN SUPINE POSITION • NAUSEA AND VOMITING • FEVER • LABORATORY • ELEVATED AMYLASE OR LIPASE • > 3X UPPER LIMITS OF NORMAL • LIPASE HAS SLIGHTLY HIGHER SENSITIVITY AND SPECIFICITY AND GREATER OVERALL ACCURACY THAN AMYLASE (EVIDENCE CATEGORY A) • RADIOLOGY • ABNORMAL SONOGRAM OR CT • DIFFERENTIAL DIAGNOSIS • CHOLEDOCHOLITHIASIS • PERFORATED ULCER • MESENTERIC ISCHEMIA • INTESTINAL OBSTRUCTION • ECTOPIC PREGNANCY
  • 13. ACUTE PANCREATITIS Clinical presentation Mild: edema, inflammation, fat necrosis Severe: phlegmon, necrosis, hemorrhage, infection, abscess, fluid collections Retroperitoneum, perirenal spaces, mesocolon, omentum, and mediastinum Adjacent viscera: ileus, obstruction, perforation Cardiovascular: hypotension Pulmonary: pleural effusions, ARDS Renal: acute tubular necrosis Hematologic: disseminated intravascular coag. PANCREATIC PERIPANCREATIC SYSTEMIC
  • 14. ACUTE PANCREATITIS Predictors of severity • WHY ARE THEY NEEDED? • APPROPRIATE PATIENT THERAPY • COMPARE RESULTS OF STUDIES OF THE IMPACT OF THERAPY • WHEN ARE THEY NEEDED? • OPTIMALLY, WITHIN FIRST 24 HOURS (DAMAGE CONTROL MUST BEGIN EARLY) • WHICH IS BEST?
  • 15. ACUTE PANCREATITIS Scoring systems • RANSON AND GLASGOW CRITERIA (1974) • BASED ON CLINICAL & LABORATORY PARAMETERS • SCORED IN FIRST 24-48 HOURS OF ADMISSION • POOR POSITIVE PREDICTORS (BETTER NEGATIVE PREDICTORS) • APACHE SCORING SYSTEM • CAN YIELD A SCORE IN FIRST 24 HOURS • APACHE II SUFFERS FROM POOR POSITIVE PREDICTIVE VALUE • APACHE III IS BETTER AT MORTALITY PREDICTION AT > 24 HOURS • COMPUTED TOMOGRAPHY SEVERITY INDEX • MUCH BETTER DIAGNOSTIC AND PREDICTIVE TOOL • OPTIMALLY USEFUL AT 48-96 HOURS AFTER SYMPTOM ONSET
  • 16. ACUTE PANCREATITIS Scoring systems: Ranson criteria for alcoholic pancreatitis AT ADMISSION 1. AGE > 55 YEARS 2. WBC > 16,000 3. GLUCOSE > 200 4. LDH > 350 IU/L 5. AST > 250 IU/L WITHIN 48 HOURS 1. HCT DROP > 10 2. BUN > 5 3. ARTERIAL PO2 < 60 MM HG 4. BASE DEFICIT > 4 MEQ/L 5. SERUM CA < 8 6. FLUID SEQUESTRATION > 6L Number Mortality <2 1% 3-4 16% 5-6 40% 7-8 100%
  • 17. ACUTE PANCREATITIS Scoring systems: CT severity index appearance normal enlarged inflamed 1 fluid collection 2 or more collections grade A B C D E score 0 1 2 3 4 necrosis none < 33% 33-50% > 50% score 0 2 4 6 score morbidity mortality 1-2 4% 0% 7-10 92% 17% Balthazar et al. Radiology 1990.
  • 18. ACUTE PANCREATITIS Severe pancreatitis • SCORING SYSTEMS • 3 RANSON CRITERIA • 8 APACHE II POINTS • 5 CT POINTS • ORGAN FAILURE • SHOCK (SBP < 90 MMHG) • PULMONARY EDEMA / ARDS (PAO2 < 60 MMHG) • RENAL FAILURE (CR > 2.0 MG/DL) • LOCAL COMPLICATIONS • FLUID COLLECTIONS PSEUDOCYSTS • NECROSIS (MORTALITY 15% IF STERILE, 30-35% IF INFECTED) • ABSCESS
  • 19. ACUTE PANCREATITIS Additional diagnostic tests: Ultrasonography • LITTLE PART IN THE DIAGNOSIS OF THE ACUTE PANCREATITIS DUE TO BOWEL DILATATION MAIN SIGNS: ENLARGED HYPOECHOGENIC PANCREAS, POSSIBLE FLUID COLLECTIONS • ROLE IN BILIARY PANCREATITIS • STONES IN GALLBLADDER • COMMON BILE DUCT DILATION US FINDINGS SHOULD BE EXAMINED IN ALL PATIENTS WITH POSSIBLE ACUTE PANCREATITIS ON ADMISSION (EVIDENCE CATEGORY B)
  • 20. ACUTE PANCREATITIS Additional diagnostic tests: CT-scan • HIGHLY INFORMATIVE • NORMAL • HOMOGENEOUS ENHANCEMENT OF THE WHOLE PANCREAS • ABNORMAL • NON-VISUALIZATION OF A PART OF THE PANCREAS • SENSITIVITY OF 90-95% • SPECIFICITY – 100% • ROUTINE USE OF CT SCAN WITHIN 24-48 HOURS OF ADMISSION (EVIDENCE CATEGORY C) • A DYNAMIC CT SCAN SHOULD BE PERFORMED IN ALL (PREDICTED) SEVERE CASES BETWEEN 3 AND 10 DAYS AFTER ADMISSION (EVIDENCE CATEGORY B)
  • 21. ACUTE PANCREATITIS Additional diagnostic lab tests • AMYLASE AND LIPASE • PLASMA LEVEL PEAK WITHIN 24 HOURS • T1/2 OF AMYLASE << LIPASE Sensitivity Specificity Amylase 67-100 85-98 Lipase 82-100 86-100 • AMYLASE/ LIPASE • DEGREE OF ELEVATION SHOWS LITTLE CORRELATION WITH DISEASE SEVERITY AND PROGNOSIS • MAY HAVE AN INVERSE RELATIONSHIP WITH SEVERITY • TRYPSINOGEN 2 • EXCRETED INTO THE URINE • USED AS A SCREENING TEST FOR ACUTE PANCREATITIS
  • 22. ACUTE PANCREATITIS Additional diagnostic lab tests • ACUTE PHASE REACTANT • SYNTHESIZED BY THE HEPATOCYTES • SYNTHESIS IS INDUCED BY THE RELEASE OF INTERLEUKIN 1 AND 6 • PEAK IN SERUM IS THREE DAYS AFTER THE ONSET OF PAIN • MOST POPULAR SINGLE TEST SEVERITY MARKER USED TODAY • GOLD STANDARD FOR THE PREDICTION OF THE NECROTIZING COURSE OF THE DISEASE • ACCURACY OF 86% • READILY AVAILABLE C-REACTIVE PROTEIN (CRP) Isenmann et al Pancreas 1993;8:358-61
  • 23. ACUTE PANCREATITIS Initial management of acute pancreatitis • PANCREATIC REST & SUPPORTIVE CARE • FLUID RESUSCITATION* – MAY REQUIRE 5-10 LITERS/DAY • CAREFUL PULMONARY & RENAL MONITORING – ICU • MAINTAIN HEMATOCRIT OF 26-30% • PAIN CONTROL – PCA PUMP • CORRECT ELECTROLYTE DERANGEMENTS (K+, CA++, MG++) • PROTON PUMP INHIBITORS • SANDOSTATINE • RULE-OUT NECROSIS • CONTRASTED CT SCAN AT 48-72 HOURS • PROPHYLACTIC ANTIBIOTICS IF PRESENT • SURGICAL DEBRIDEMENT IF INFECTED • NUTRITIONAL SUPPORT
  • 24. ACUTE PANCREATITIS Initial management of acute pancreatitis: ERCP • GALLSTONE PANCREATITIS • CHOLANGITIS • OBSTRUCTIVE JAUNDICE • RECURRENT ACUTE PANCREATITIS • STRUCTURAL ABNORMALITIES • NEOPLASM • BILE SAMPLING FOR MICROLITHIASIS • SPHINCTEROTOMY IN PATIENTS NOT SUITABLE FOR CHOLECYSTECTOMY • NOT INDICATED IN CASE OF MILD PANCREATITIS OF SUSPECTED OR PROVEN BILIARY ETIOLOGY IN THE ABSENCE OF THE BILIARY OBSTRUCTION (EVIDENCE A) Neoptolemos et al 1988; Fan NEJM 1993; Folsch NEJM 1997
  • 25. ACUTE PANCREATITIS Antibiotics • SEPSIS • ACCOUNTS FOR > 80% OF DEATHS • INTESTINAL FLORA • GRAM NEGATIVE BACTERIA • MECHANISM – TRANSLOCATION OF THE BACTERIA ACROSS THE GUT WALL • PROPHYLACTIC ANTIBACTERIAL TREATMENT IS STRONGLY RECOMMENDED IN SEVERE PANCREATITIS (EVIDENCE B) • NO EVIDENCE WHEN TO START PROPHYLACTIC TREATMENT OR HOW LONG TO CONTINUE THERAPY • APPROPRIATE ANTIBIOTICS ARE THOSE THAT ARE ACTIVE AGAINST IN PARTICULAR GRAM-NEGATIVE ORGANISMS • COMMENCE AS EARLY AS POSSIBLE AFTER THE IDENTIFICATION OF A SEVERE ATTACK
  • 26. ACUTE PANCREATITIS Pancreatic necrosis • STERILE NECROSIS – SYSTEMIC INFLAMMATORY RESPONSE SYNDROME (SIRS) (FIRST WEEK) • MORTALITY RATE OF 10-40% • STERILE PANCREATIC NECROSIS – SURGERY IN SELECTED CASES SELECTED CASES • MASSIVE PANCREATIC NECROSIS (>50%) WITH A DETERIORATING CLINICAL COURSE (EVIDENCE C) • PATIENTS WITH PROGRESSION OF ORGAN DYSFUNCTION • NO SIGNS OF THE IMPROVEMENT (GRADE B)
  • 27. ACUTE PANCREATITIS Pancreatic necrosis Infected necrosis – Sepsis (After 3 weeks) Mortality – 20-70% • US OR CT GUIDED FNA WITH GRAM STAIN AND CULTURE IS A CONFIRMATORY TEST (EVIDENCE A) SUSPECT IF: • EXACERBATION OF CLINICAL SIGNS • LABORATORY BLOOD TEST CHANGES • SHIFT TO IMMATURE CELLS • ELEVATION OF CRP • INCREASED APACHE II • POSITIVE BLOOD CULTURE • NECROSECTOMY IS INDICATED IN A CONFIRMED INFECTED PANCREATIC NECROSIS (EVIDENCE A)
  • 28. ACUTE PANCREATITIS Pancreatic necrosis Infected necrosis – Sepsis (After 3 weeks) Mortality – 20-70% • US OR CT GUIDED FNA WITH GRAM STAIN AND CULTURE IS A CONFIRMATORY TEST (EVIDENCE A) SUSPECT IF: • EXACERBATION OF CLINICAL SIGNS • LABORATORY BLOOD TEST CHANGES • SHIFT TO IMMATURE CELLS • ELEVATION OF CRP • INCREASED APACHE II • POSITIVE BLOOD CULTURE • NECROSECTOMY IS INDICATED IN A CONFIRMED INFECTED PANCREATIC NECROSIS (EVIDENCE A)
  • 29. ACUTE PANCREATITIS Algorithm Confirm acute pancreatitis Amylase/Lipase Trypsinogetn2 CT scan in atypical cases Initial management Severity stratification IV fluid/pain conrol Scoring systems C-reactive protein Mild acute pancreatitis Severe acute pancreatitis
  • 30. ACUTE PANCREATITIS Algorithm Mild acute pancreatitis Severe acute pancreatitis RECOMMENDED Admit to general ward Refeed when pain subsides NOT RECOMMENDED Antibiotics CT scan RECOMMENDED Admit to ICU Antibiotics CT-scan – day 3 NECROSIS Sterile – observe (CT, US) Infection suspected – fine needle aspiration/drainage under US or CT control Infected necrosis – necrosectomy Open drainage of abscesses, retroperitoneal space