Your SlideShare is downloading. ×
Pancreatitis (acute and chronic )
Upcoming SlideShare
Loading in...5

Thanks for flagging this SlideShare!

Oops! An error has occurred.

Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

Pancreatitis (acute and chronic )


Published on

Lecture By Dr.Wael Alsadani …

Lecture By Dr.Wael Alsadani
ER Resident.

Published in: Education

  • Be the first to comment

No Downloads
Total Views
On Slideshare
From Embeds
Number of Embeds
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

No notes for slide


  • 2. 1-Manage severe acute pancreatitis► A 34-year-old woman► is evaluated for continued severe mid-epigastric pain that radiates to the back-nausea-vomiting………5 days after being hospitalized for acute alcohol-related pancreatitis► She has not been able eat or drink and has not had a bowel movement since being admitted► On physical examination the temperature is 38.2 °C -blood pressure is 132/84 mm Hg-pulse rate is 101/min-respiration rate is 20/min-no scleral icterus or jaundice-abdomen is distended and diffusely tender with hypoactive bowel sounds
  • 3. ► CT scan of the abdomen shows a diffusely edematous pancreas with multiple peripancreatic fluid collections, and no evidence of pancreatic necrosisWhich of the following is the most appropriate next step in the management of this patient?A- Enteral nutrition by nasojejunal feeding tubeB-Intravenous imipenemC-Pancreatic débridementD-Parenteral nutrition
  • 4. ► Enteral feeding is the preferred route of providing nutrition in patients with severe acute pancreatitis► This patient has moderate to severe acute pancreatitis and after 5 days remains febrile, continues to be in pain, and cannot take in any oral nutrition► The patient will likely have an extended period before being able to take in oral nutrition► Two routes are available for providing nutrition in patients with severe acute pancreatitis enteral nutrition-parenteral nutrition► Enteral nutrition is provided through a feeding tube ideally placed past the ligament of Treitz so as not to stimulate the pancreas► Parenteral nutrition is provided through large peripheral or central intravenous line► Enteral nutrition is preferred over parenteral nutrition because of its lower complication rate……..especially a lower infection rate► Enteral nutrition is associated with a significantly lower incidence of infections-reduced surgical interventions to control complications of pancreatitis-reduced length of hospital stay-faster attenuation of inflammation-fewer septic complications
  • 5. ► Imipenem therapy is only helpful in acute pancreatitis when there is evidence of pancreatic necrosis► Pancreatic necrosis is diagnosed by contrast-enhanced CT scan……….that shows nonenhancing pancreatic tissue► In patients with noninfected pancreatic necrosis, prophylactic antibiotics may↓incidence of sepsis-↓systemic complications (for example, respiratory failure)-↓local complications (for example, infected pancreatic necrosis or pancreatic abscess)► antibiotic use in acute pancreatitis of mild to moderate severity shown no benefit from-but may lead to development of nosocomial infections with resistant pathogens► Similarly pancreatic débridement is recommended only in infected pancreatic necrosis
  • 6. 2-Diagnose pancreatic necrosis► A 44-year-old man with a long history of alcohol abuse is evaluated on the sixth day of hospitalization for acute pancreatitis► On admission to the hospital he was afebrile-blood pressure was 150/88 mm Hg- pulse rate was 90/min-respiration rate was 16/min► Abnormal findings were limited to the abdomen, which was flat and tender to palpation -without peritoneal signs-Bowel sounds were normal► Plain abdominal and chest radiographs were normal► Abdominal ultrasonography revealed a diffusely enlarged, hypoechoic pancreas -without evidence of gallstones or dilated common bile duct► He was treated with aggressive intravenous hydration and opioid analgesia► For the past 2 days, the patient has had repeated febrile episodes-persistent severe abdominal pain-increasing shortness of breath
  • 7. ► On physical examination T 38.6 °C -BP 98/60 mm Hg - pulse rate is 112/min- RR 22/min-oxygen saturation is 92% with the patient breathing oxygen 3 L/min-Breath sounds are decreased at the base of both lungs-The abdomen is distended and diffusely tender with hypoactive bowel sounds► Laboratory studies reveal leukocyte count of 19,800/µL-creatinine 1.4 mg/dL -amylase 388 U/L-lipase 842 U/L.► Which of the following is the most appropriate next step in the evaluation of this patient?A- CT scan of the abdomen with intravenous contrastB-Endoscopic retrograde cholangiopancreatographyC-Endoscopic ultrasonographyD-Stool chymotrypsin
  • 8. ► CT scan of the abdomen with intravenous contrast is the most sensitive test to diagnose pancreatic necrosis► Pancreatic necrosis should be suspected in a patient with severe acute pancreatitis ………..whose condition is not improving or is worsening after 5 days or more of treatment► Pancreatic necrosis on CT scan can be identified as unenhanced areas of the pancreas► pancreatic necrosis in the setting of acute pancreatitis cannot detect by endoscopic retrograde cholangiopancreatography or endoscopic ultrasonography
  • 9. ► Stool chymotrypsin can be measured when chronic pancreatitis is suspected……… help evaluate for decreased pancreatic function► Pancreatic necrosis is the most important predictor of poor outcome in acute pancreatitis► Patients who develop pancreatic necrosis should be given antibiotic prophylaxis, usually with imipenem► The necrosis should be sampled for the presence of infection………….and if infection is present, surgical débridement is recommended
  • 10. 3-Manage gallstone pancreatitis► A 55-year-old woman► is evaluated in the hospital for a 2-day history of epigastric abdominal pain - nausea and vomiting - anorexia► The patient has no significant medical history► takes no medications► On physical examination temperature is 38.0 °C - blood pressure is 124/76 mm Hg - pulse rate is 99/min - respiration rate is 16/min - There is scleral icterus and a slight yellowing of the skin - mid-epigastric and right upper quadrant tenderness - no palmar erythema, spider angiomata, or other evidence of chronic liver disease
  • 11. ► Abdominal ultrasonography shows a biliary tree with a dilated common bile duct of 12 mm and cholelithiasis but no choledocholithiasis► Which of the following is the most appropriate next step in the management of this patient?A-CT scan of the abdomen and pelvis with pancreatic protocolB- Endoscopic retrograde cholangiopancreatographyC-Hepatobiliary iminodiacetic acid (HIDA) scanD-Magnetic resonance cholangiopancreatography
  • 12. ► In patients with gallstone pancreatitis and evidence of biliary obstruction, endoscopic retrograde cholangiopancreatography and stone removal will reduces morbidity and mortality………… reducing the risk of biliary sepsis► This patient has a classic presentation of acute pancreatitis with the acute onset of epigastric abdominal pain, nausea, and vomiting - associated with markedly elevated pancreatic enzymes► The presence of stones in the gallbladder- dilated bile duct - elevated aminotransferase levels…………….highly suggest gallstones as the cause of pancreatitis► The presence of scleral icterus – jaundice - elevated bilirubin level…….suggest continuing bile duct obstruction► Abdominal ultrasonography has a sensitivity of only 50% to 75% for choledocholithiasis► a common duct stone should be suspected in the correct clinical situation even when ultrasonography does not show a stone► Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and stone removal… the most appropriate procedure in patients with acute gallstone pancreatitis and with imaging and biochemical evidence of biliary obstruction from a common duct stone
  • 13. ► The procedure can document the diagnosis of choledocholithiasis and remove the gallstones………..which lessens the morbidity and mortality due to biliary sepsis.► CT scan acute pancreatitis and the presence of a common duct stone=sensitivities ranging from 80% to 100%► magnetic resonance cholangiopancreatography (MRCP) will show acute pancreatitis and the presence of a common duct stone=sensitivities ranging from 80% to 100%► ERCP = diagnosis of choledocholithiasis► Biliary scintigraphy may show obstruction of the cystic or common bile duct…..but will not determine the cause► However CT - biliary scintigraphy and MRCP………are not be therapeutic for bile duct stones
  • 14. 4-Evaluate acute pancreatitis► A 42-year-old woman► is evaluated in the emergency department for the acute onset of epigastric pain …that radiates to the back …and is associated with nausea and vomiting► The patient had previously been healthy► no history of alcohol or tobacco use► Her only medication is an oral contraceptive pill► On physical examination=temperature is 37.2 °C - blood pressure is 158/90 mm Hg - pulse rate is 101/min - respiration rate is 20/min - no scleral icterus or jaundice► The abdomen is distended with mid-epigastric tenderness - no rebound or guarding - hypoactive bowel sounds
  • 15. ► Radiography of the abdomen shows mild ileus► Which of the following is the most appropriate next step in the evaluation of this patient?A-CT scan of the abdomen and pelvisB-Endoscopic retrograde cholangiopancreatographyC-EsophagogastroduodenoscopyD- Ultrasonography of the abdomen
  • 16. ► Gallstones=most common cause of acute pancreatitis in the United States - diagnosed with abdominal ultrasonography► The diagnosis of pancreatitis relies heavily on the serum amylase and lipase…….which are elevated in 75% to 90% of patients► Serum lipase is more specific and stays elevated longer than amylase► The two most common causes of acute pancreatitis in the United States are alcohol and gallstones► this patient who does not consume alcohol , so gallstones are the most likely cause of acute pancreatitis as shown by the pattern of liver enzymes► Abdominal ultrasonography is the most sensitive test for detecting the presence of gallstones and ductal dilation - can provide indirect evidence for the presence of a retained common duct stone - Ultrasonography = has no risk + widely available + inexpensive
  • 17. ► CT scan is less sensitive than ultrasonography for the detection of cholelithiasis► CT with contrast is indicated in patients with moderate or severe pancreatitis = to confirm the diagnosis - to grade the severity of pancreatitis - to diagnose local complications such as pancreatic necrosis , pseudocyst & abscess► Magnetic resonance cholangiopancreatography is used if there is a contraindication to intravenous radiocontrast► Endoscopic retrograde cholangiopancreatography (ERCP) is the most sensitive test for choledocholithiasis - can provide direct treatment by removing common duct stones► ERCP is indicated in patients with - persisting pancreatitis - persistent elevation of aminotransferase levels - dilated bile ducts suggesting the presence of retained bile duct stones - can do stone extraction with biliary sphincterotomy so improves the outcome, prevents further attacks of acute biliary pancreatitis, and reduces pancreatitis► But in this patient there is not enough evidence yet that a common duct stone is still present to perform this more invasive test before ultrasonography► Upper endoscopy = no role in determining the cause of acute pancreatitis
  • 18. 5-Diagnose chronic pancreatitis► A 51-year-old man► is evaluated for an 8-month history of mid-epigastric pain that is worse after eating - six to eight bowel movements a day usually occurring after a meal - loss of 6.8 kg over the past 6 months► The patient drinks six to eight cans of beer a day► He takes no medications► On physical examination BMI 21 - normal bowel sounds - mid-epigastric tenderness - no hepatosplenomegaly or masses► Rectal examination reveals brown stool - negative occult blood► The remainder of the examination is normal► Plain radiograph of the abdomen shows a normal bowel gas pattern and is otherwise normal
  • 19. Which of the following tests is most likely to establish the diagnosis in this patient?A-ColonoscopyB- CT scan of the abdomenC-Measurement of serum antiendomysial antibodiesD-Stool for leukocytes, culture, ova, and parasite
  • 20. ► Patients with chronic pancreatitis=the three classic findings in chronic pancreatitis are abdominal pain that is usually mid-epigastric - postprandial diarrhea - and diabetes mellitus secondary to pancreatic endocrine insufficiency► This patient has chronic pancreatitis secondary to alcohol abuse………… SO has resulted in malabsorption► Malabsorption occurs in patients with chronic pancreatitis when approximately 80% of the pancreas is destroyed► because the damaged pancreatic gland is no longer producing the pancreatic exocrine enzymes to absorb food so malabsorption occurs that presents with diarrhea and steatorrhea - weight loss - deficiencies of fat- soluble vitamins► Patients with a typical presentation may not need additional testing► However, most patients with chronic pancreatitis have only nonspecific abdominal pain ………….so require diagnostic radiographic imaging studies
  • 21. ► The presence of pancreatic calcifications on radiographs confirms the diagnosis► Plain films of the abdomen will show pancreatic calcifications in approximately 30% of patients…………so confirms the diagnosis► But most patients require abdominal CT scans, which are able to detect pancreatic calcification in up to 90% of patients► CT scanning can also exclude other causes of pain► Radiographic evidence of pancreatic ductal dilation – pseudocysts - or mass lesions ………….may also help identify the cause of pain and determine the type of therapy► Antiendomysial antibodies are a marker for celiac disease ……….. but celiac disease is unlikely in this patient with an evident history of pancreatic malabsorption
  • 22. ► colonoscopy is indicated as a screening tool for asymptomatic patients beginning at the age of 50 years - and for patients with a change in bowel habits and weight loss► But this patient’s history suggests pancreatic malabsorption so colonoscopy is less likely than abdominal CT scan to confirm the diagnosis► Stool studies are appropriate fordetermining the cause of an acute infectious diarrhea……but this patient has had diarrhea for 8 months ………… infectious diarrhea is not usually associated with such a degree of weight loss
  • 23. 6-Diagnose chronic pancreatitis► A 42-year-old man► is evaluated in the hospital for a 1-year history of postprandial abdominal pain that radiates to the back -worse after eating - and is associated with nausea► He has no (vomiting -weight loss -change in bowel habits)► The patient has had at least five alcohol-containing drinks a day for 20 years► he has reduced his intake in the past year because of continued abdominal pain► On physical examination vital signs are normal - BMI is 24 - mild epigastric tenderness - no guarding or rebound - normal bowel sounds► Laboratory studies reveal normal complete blood count - normal fasting glucose - normal liver chemistry tests - amylase is 221 U/L and lipase 472 U/L.► esophagogastroduodenoscopy , AXR, ultrasonography, and CT scan of the abdomen are normal► Which of the following is the most appropriate next step in the evaluation of this patient?A-Biliary scintigraphyB-ColonoscopyC- Endoscopic retrograde cholangiopancreatographyD-easurement of stool elastase
  • 24. ► Endoscopic retrograde cholangiopancreatography is the most sensitive imaging test for chronic pancreatitis► diagnosis of chronic pancreatitis in a patient with early disease can be difficult► No blood or stool tests are currently available for the accurate diagnosis of early chronic pancreatitis► This patient’s pain is most likely secondary to chronic pancreatitis with minimally elevated pancreatic enzymes and a history of harmful drinking► The patient has no evidence of exocrine or endocrine insufficiency and thus likely has early chronic pancreatitis► Normal liver enzymes, normal upper endoscopy, and a normal abdominal ultrasonography and CT scan of the abdomen make biliary causes and peptic ulcer disease………less likely the cause of pain► Endoscopic retrograde cholangiopancreatography (ERCP) has a sensitivity of nearly 95% for chronic pancreatitis - can show ductal dilation,strictures and irregularity in both the main duct and its side branches
  • 25. ► CT scan of the abdomen =has a sensitivity of up to 90% for diagnosing chronic pancreatitis and should be ordered with thin cuts of the pancreas to improve sensitivity► Endoscopic ultrasonography=may also be used to diagnose chronic pancreatitis - sensitivities is equal to ERCP for moderate and advanced chronic pancreatitis - but with lower sensitivity and specificity for mild and early chronic pancreatitis► Magnetic resonance cholangiopancreatography does not have sensitivities or specificities that match ERCP in the diagnosis of mild and early chronic pancreatitis and cannot be routinely recommended► Biliary scintigraphy is used to diagnose acute cholecystitis - but does not have a role in diagnosing chronic pancreatitis► Stool elastase can be abnormal in patients with more advanced chronic pancreatitis=particularly those who have malabsorption - but stool elastase has poor sensitivity in patients with early chronic pancreatitis► Colonoscopy has a low yield in patients with upper abdominal pain
  • 26. 7-Treat chronic pancreatitis with pancreatic duct stones► A 38-year-old man is evaluated for a 2-month history of progressive mid-epigastric pain that is worse after eating - postprandial nausea - 4.6-kg weight loss► The patient has a 5-year history of chronic pancreatitis► has six alcohol-containing drinks a day► His medications are Amitriptyline - oral morphine - and pancreatic enzyme supplements► On physical examination BMI 20 - appears to be in mild distress - There is epigastric tenderness without rebound or guarding - The liver is slightly enlarged, but there are no palpable masses► Laboratory studies reveal normal complete blood count - serum amylase of 175 U/L - lipase of 333 U/L► CT scan of the abdomen and pelvis shows - multiple pancreatic calcifications - a calcified stone in the head of the pancreas within the main pancreatic duct - dilation of the duct in the body and tail of the gland► In addition to alcohol cessation, which of the following is the most appropriate management for this patient?A-Celiac nerve blockB- Endoscopic retrograde cholangiopancreatography with removal of stonesC-Increasing the dose of pancreatic enzymesD-Pancreatoduodenectomy
  • 27. ► Endoscopic treatment of pain in chronic pancreatitis is performed by removing pancreatic duct stones and placing stents in pancreatic duct strictures ….to decrease pancreatic duct pressure► Patients with chronic pancreatitis must avoid alcohol► Patients who continue to drink alcohol have an increase in painful attacks and mortality► Pain in chronic pancreatitis results from chronic inflammation - chronic noxious stimulation of the nerves to the pancreas - and increased pancreatic intraductal pressure secondary to pancreatic duct stones, calcifications, or strictures► Large stones in the pancreatic duct can be - crushed with extracorporeal shock wave lithotripsy - Then endoscopic retrograde cholangiopancreatography can remove the stones and place stents in pancreatic duct strictures to decrease pancreatic duct pressure…….so symptom improvement in 11% to 75% of patients and resolution of stricture in 10% to 50%
  • 28. ► A surgical pancreatoduodenectomy (Whipple procedure) can be performed to relieve pain - but is effective only in patients who have disease limited to the head of the pancreas and who have failed to respond to medical and endoscopic therapy► A surgical procedure to divert the pancreatic duct into the small intestine =The procedure involves removing pancreatic tissue that overlies the ductal system in the head of the pancreas - has been used widely in the treatment of patients with a chronic pancreatitis and is effective in many patients…..but a less invasive procedure is preferred to surgical intervention as the next management step► Celiac nerve block =has been used to treat chronic pancreatitis pain - but is considered by many experts to be an unproved therapy and even in patients who respond, pain returns in 2 to 6 months and significant procedural complications have been reported - Furthermore, it would not be the first procedure of choice in a patient with a pancreatic ductal stone and evidence of obstruction► Pancreatic enzyme supplements are not effective for pain control in chronic pancreatitis