Acute Pancreatitis

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Acute Pancreatitis

  1. 1. Acute pancreatitis
  2. 2. <ul><li>Exocrine </li></ul><ul><li>-P roduces enzymes t hat break down breakdown of the carbohydrates , protein and fat </li></ul><ul><li>Endocrine </li></ul><ul><li>Producing several important hormones, including insullin , glucagon </li></ul>Function
  3. 3. <ul><li>Acute inflammation of the pancreas </li></ul><ul><li>Varying degree of regional tissue involvement and remote organ systems </li></ul><ul><li>Classified as acute unless there is evidence of chronic pancreatitis, otherwise considered as exacerbation of inflammation superimposed on chronic pancreatitis </li></ul>What is pancreatitis ?
  4. 4. <ul><li>Other ( 10 % ) => include </li></ul><ul><ul><li>Trauma </li></ul></ul><ul><ul><li>Postendoscopic retrograde cholangiopancreatography </li></ul></ul><ul><ul><li>Pancreatic malignancy , PUD ,IBD </li></ul></ul><ul><li>Medications </li></ul><ul><ul><li>Thizide Tetracycline Sulphonamid Croticosteroide </li></ul></ul><ul><ul><li>Metabolic </li></ul></ul><ul><ul><li>- Hypertriglyceridemia ,Hypercalcemia </li></ul></ul><ul><li>Infectious </li></ul><ul><ul><li>-Viral , Bacterial , Parasitic </li></ul></ul>Causes of Acute Pancreatitis <ul><li>Gall stone (45 % ) </li></ul><ul><li>Ethanol abuse (Alcohol ) </li></ul><ul><li>(35 %) </li></ul><ul><li>Idiopathic ( 10 % ) </li></ul>
  5. 5. Clinical Presentation <ul><li>Epigastric pain or Upper abdominal / Diffuse abdominal pain with radiation to back </li></ul><ul><li>Nausea & Vomiting </li></ul><ul><li>Fever </li></ul><ul><li>Nausea and V omiting </li></ul><ul><li>Tachycardia </li></ul>
  6. 6. <ul><li>Decreased or absent bowel sounds </li></ul><ul><li>Abdominal tenderness , Guarding </li></ul><ul><li>Jaundice if there’s obstruction of the bile duct </li></ul><ul><li>Cullen’s sign </li></ul><ul><li>Grey Turner’s Sign </li></ul>Abdominal Examination
  7. 7. <ul><li>Grey-Turner’s sign </li></ul><ul><li>( H emorrhagic d iscoloration of the flanks) </li></ul>
  8. 8. <ul><li>Cullen’s sign </li></ul><ul><li>( Hemorrhagic discoloration of the umbilicus ) </li></ul>
  9. 9. <ul><li>Physical examination </li></ul><ul><li>Investigation </li></ul>Pancreatitis Diagnosis
  10. 10. <ul><ul><li>Marker of pancreatitis injury </li></ul></ul><ul><ul><li>Serum amylase </li></ul></ul><ul><ul><li>Most accurate when at least twice the upper limit of normal; amylase levels and sensitivity decrease with time from onset of symptoms </li></ul></ul><ul><ul><li>Serum Lipase </li></ul></ul><ul><ul><li>Increased sensitivity in alcohol-induced pancreatitis; more specific and sensitive than amylase for detecting acute pancreatitis </li></ul></ul>Laboratory Investigation
  11. 11. <ul><li>Marker of biliary tract involvement </li></ul><ul><li>Alanine aminotransferase ( ALT ) </li></ul><ul><li>Elevate in gallstone pancreatitis </li></ul><ul><li>Other </li></ul><ul><li>- C - reactive protein (CRP ) </li></ul><ul><li>( Predictive of severity Late marker ) </li></ul><ul><li>H igh levels associated with pancreatic necrosis </li></ul>
  12. 12. <ul><li>Plain Films Abdomen & CXR </li></ul><ul><ul><li>Localized segment of small intestine (“sentinel loop”) </li></ul></ul><ul><ul><li>Generalize ileus </li></ul></ul><ul><ul><li>Calcifications (stones, or pancreas with chronic calcific pancreatitis) </li></ul></ul><ul><ul><li>Pneumobilia following stone passage and/or bilioenteric fistula formation </li></ul></ul><ul><ul><li>Severe ascites </li></ul></ul><ul><ul><li>Retroperitoneal gas (pancreatic abscess) </li></ul></ul><ul><ul><li>30% with CXR abnormalities (elevated hemidiaphragm, pleural effusion, basal atelectasis, pulmonary infiltrates) </li></ul></ul>Radiological Findings <ul><li>Abdominal ultrasound </li></ul><ul><ul><li>Cholelithiasis, biliary sludge, bile duct dilation, and pseudocysts </li></ul></ul><ul><li>CT of abdomen </li></ul><ul><li>MRCP </li></ul><ul><li>(Magnetic resonance cholangiopancreatography) </li></ul>
  13. 13. Other testing will reveal…… <ul><li>Urine amylase increased for 1-2 weeks </li></ul><ul><li>Elevated WBC </li></ul><ul><li>Decreased serum calcium </li></ul><ul><li>Elevated serum bilirubin, AST, ALT, LD, and alkaline phosphatase </li></ul><ul><li>Serum triglycerides >150mg/dl </li></ul>
  14. 14. <ul><li>Pulmonary </li></ul><ul><ul><li>Atelactasis </li></ul></ul><ul><ul><li>Pleural effusions </li></ul></ul><ul><ul><li>ARDS </li></ul></ul><ul><li>Cardiovascular </li></ul><ul><ul><li>Cardiogenic shock </li></ul></ul><ul><li>Neurologic </li></ul><ul><ul><li>Pancreatic encephalopathy </li></ul></ul><ul><li>Metabolic </li></ul><ul><ul><li>Metabolic acidosis </li></ul></ul><ul><ul><li>Hypocalcemia </li></ul></ul><ul><ul><li>Altered glucose metabolism </li></ul></ul><ul><li>Hematologic </li></ul><ul><ul><li>GI bleeding </li></ul></ul><ul><li>Renal </li></ul><ul><ul><li>Prerenal failure </li></ul></ul>Common Complications of Acute Pancreatitis
  15. 15. <ul><li>If not improve </li></ul><ul><li>If infected pancreatic necrosis </li></ul>Anti - inflammatory & Antisecretory agents drug Treatment . Mild Acute Pancreatitis Severe Pancreatitis (pancreatic necrosis or infected) Supportive Care Antibiotic iv <ul><ul><li>- I.V. fluid resuscitation </li></ul></ul><ul><ul><li>-Nutritional support </li></ul></ul><ul><ul><li>-Analgesia </li></ul></ul>Fine needle aspiration (FNA ) Percutaneous Drainage
  16. 16. Antibiotic in Acute Pancreatitis <ul><li>I mipenem-cilastin 500 mg iv 8 hr x 2 wks </li></ul><ul><li>Q uinolone group ( C iprofloxacin or O floxacin ) ร่วมกับ M etronidazole </li></ul><ul><li>T hird generation cephalosporin </li></ul><ul><li>( C efotaxime ) ร่วมกับ M etronidazole </li></ul>
  17. 17. <ul><li>M ild acute pancreatitis ไม่ได้เป็นข้อบ่งชี้ในการทำ surgery </li></ul><ul><li>ควรทำ FNA เพื่อใช้ในการแยกระหว่าง sterile และ infected pancreatic necrosis ในผู้ป่วยที่มีอาการ sepsis </li></ul><ul><li>การใช้ P rophylactic antibiotic สามารถลดอัตราการติดเชื้อแต่ไม่ลด survival </li></ul>Guideline for management of acute pancreatitis
  18. 18. <ul><li>Infected pancreatic necrosis ที่มีอาการของ sepsis เป็นข้อบ่งชี้ในการทำ surgery และ Radiological drainage </li></ul><ul><li>ผู้ป่วยที่เป็น sterile necrosis ( FNA negative) ควรได้รับการรักษาแบบ conservative </li></ul><ul><li>ไม่แนะนำให้ทำการผ่าตัดในช่วง 14 วันแรกหลังจากมีอาการในผู้ป่วย necrotizing pancreatitis </li></ul>

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