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Acute pancreatitis
 

Acute pancreatitis

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Acute pancreatitis Acute pancreatitis Presentation Transcript

  • Acute Pancreatitis Int.Thanit Prasoppokakorn
  • Pancreatitis Acute Pancreatitis - Acute Inflammation of pancreas - Non bacterial infection - Autodigest of pancreas by its own enzymes - Pancreas can be recovery after inflammation resolves Chronic Pancreatitis - Many recurrent of acute pancreatitis - Exocrine and endocrine function will decrease
  • Acute Pancreatitis1) Edematous pancreatitis- Mild form- Swelling of tissue and fat necresis- No pancreatitic necrosis2) Hemorrhagic pancreatitis/Necrotizing pancreatitis- Severe form- Large area of necrosis- Hemorrhage in pancreas- Loss endocrine and exocrine function
  • FunctionExocrine functionProduce enzyme thatbreakdown carbohydrate,protein and fatEndocrine functionProduce several importanthormones such as Insulin,Glucagon
  • CauseBiliary Disease ; Gall stoneEthanol Abuse ; Chronic AlcoholismOther cause ; Steroid, Thaizide diuretic, Furosemide, Familial pancreatitis,Traumatic cause, HyperTG, HyperCaPost operative pancreatitisIdiopathic
  • Clinical ManifestationSevere to persistent epigastric painRadiated pain to the backPain after mealNausea/Vomitting
  • Abdominal ExaminationTenderness at epigastriumGuardingDecreased or absent bowel soundCullen’s signGrey Turner’s sign
  • Grey Turner’s SignHemorrhagic discoloration of flank
  • Cullen’s SignSuperficial edema and bruising in the subcutaneous fattytissue around the umbilicus
  • Lab investigationSerum amylase- rising 2.5 times in 6 hours and constant for 3 days- biliary pancreatitis -> amylase > 1000 iu/dlSerum lipase- more specificity and sensitivity than amylase- increased sensitivity in alcohol-induced pancreatitis
  • Lab investigationUrine amylase- > 5,000 iu/24 hr elevated for 7-14 dayALT- elevate in gall stone pancreatitisC-reactive protein- elevated in necrotic pancreatitisElectrolytes- Hyperglycemia, Hypocalemia
  • Radiological FindingAcute Abdomen Series Film- Sentinel loop -> dilatation of bowel near pancreas;duodenum, jejunum, transverse colon- Colon cutoff sign -> absent of shadow of ascending colon-transverse colon from colon spasm- Minimal pleural effusion in CXR
  • Sentinel loop
  • Colon cutoff sign
  • Radiological FindingUltrasound- edematous, swollen pancreas, peripancreatic fluid collection,pseudocyst- gall stoneCT scanERCP
  • Ranson’s Criteria Mortality 0-2 = 2% 3-4 = 15% 5-6 = 40% 7-8 = 100% or use APACHE II scoring system
  • Treatment
  • TreatmentIV fluid resuscitation-> third space lossImproved electrolytes imbalance-> hypokalemia from vomitting-> hypocalemia-> hypomagnesium in alcoholic patient-> metabolic alkalosis
  • TreatmentNPO-> decreared secretion from pancreas-> ileusOxygen support-> hypoxia, monitor blood gasAntibiotic
  • AntibioticThe proper role of antibiotics in acute pancreatitis remainscontroversialNo antibiotics are indicated in mild casesInfectious complications are an important concern in severecases, especially cases of pancreatic necrosisa recent randomized trial failed to demonstrate differences inoutcomeSome centers use antifungal therapy, but this practice has notbeen validated by randomized trials.
  • AntibioticIndication for antibiotic1) Infection associated - necrosis of gland > 50% - FNA find organisms2) Immunocompromised host3) Biliary pancreatitis4) Complication pancreatic abscess, infected pseudocyst
  • AntibioticImipenemQuinolone (Ciprofloxacin) + MetronidazoleThird genaration cephalosporin (Cef-3, Cefotaxime)+ Metronidazole
  • SurgeryIndication for surgery- Cannot exclude from other surgical condition- Not better after conservative for 24-48 hour- Biliary pancreatitis- Complication: pancreatitic abscess, pseudocyst- Pancreatic necrosis > 50% or have severe infection
  • Surgical InterventionDifferentiate between sterile and infected necrosis-> CT- or ultrasonography-guided fine-needle aspiration(FNA) of pancreatic or peripancreatic necrosisInfected necrosis pancreatitis- Mortality rate > 30% with risk of multiple organ failure- Surgery decreased mortality to < 20%Sterile necrosis pancreatitis- Conservative approach- Some have role of surgery
  • Surgical InterventionMortality rates of up to 65 % have been described with earlysurgery in severe pancreatitisProspective and randomized clinical trial comparing early(within 48 to 72 hr of symptoms) versus late (at least 12 daysafter onset) debridement in patients with severe pancreatitis,mortality rates were 56 %and 27 %Except patient with severe complications such as massivebleeding or bowel perforation, early surgery must beperformed
  • Surgical InterventionTechniques of open pancreatic necrosectomy4 methods; necrosectomy combined with1) open packing2) planned, staged relaparotomies with repeated lavage3) closed continuous lavage of the lesser sac andretroperitoneum4) closed packing
  • Surgical Intervention
  • Surgical Intervention
  • Surgical InterventionOpen surgical debridement is the “goldstandard” fortreatment of infected pancreatic and peripancreatic necrosisNecrosectomy and subsequent closed continuous lavage ofthe lesser sac is the technique with the lowest morbidity.Consequently, it is the most commonly adopted technique
  • IAP GuidelinesRecommendation1) Mild acute pancreatitis is not an indication for pancreaticsurgery (recommendation grade B)2) The use of prophylactic broad spectrum antibiotics reducesinfection rates in CT-proven necrotizing pancreatitis but maynot improve survival (recommendation grade A)3) FNAB should be performed to differentiate between sterileand infected pancreatic necrosis inpatients with sepsissyndrome (recommendation grade B)
  • IAP Guidelines4) Infected pancreatic necrosis in patients with clinical signsand symptoms of sepsis is an indication for interventionincluding surgery and radiological drainage(recommendation grade B)5) Patients with sterile pancreatic necrosis (FNAB negative)should be managed conservatively and only undergointervention in selected cases (recommendation grade B)
  • IAP Guidelines6) Early surgery within 14 days after onset of the disease isnot recommended in patients with necrotizing pancreatitisunless there are specific indications (recommendation gradeB)7) Surgical and other forms of interventional managementshould favor an organ-preserving approach which involvesdebridement or necrosectomy combined with a postoperativemanagement concept that maximizes postoperativeevacuation of retroperitoneal debris and exudate(recommendation grade B)
  • IAP Guidelines8) Cholecystectomy should be performed to avoid recurrenceof gallstone-associated acute pancreatitis (recommendationgrade B)9) mild gallstone-associated acute pancreatitischolecystectomy should be performed as soon as the patienthas recovered and ideally during the same hospital admission(recommendation grade B)
  • IAP Guidelines10) severe gallstone-associated acute pancreatitis,cholecystectomy should be delayed until there is sufficientresolution of the inflammatory response and clinical recovery(recommendation grade B)
  • IAP Guidelines11) Endoscopic sphincterotomy is an alternative tocholecystectomy, in those who are not fit to undergo surgeryin order to lower the risk of recurrence of gallstoneassociatedacute pancreatitis. There is, however, a theoretical risk ofintroducing infection into sterile pancreatic necrosis(recommendation grade B).
  • 88 patients with necrotizing pancreatitis with suspected orconfirmed necrotic tissue to undergo primary opennecrosectomy or a step-up approach to treatmentstep-up approach consisted of percutaneous drainagefollowed, if necessary, by minimally invasive retroperitonealnecrosectomyThe primary end point was a composite of majorcomplications (new-onset multiple-organ failure or multiplesystemic complications, perforation of a visceral organ orenterocutaneous fistula, or bleeding) or death
  • The primary end point occurred in- 31 of 45 patients (69%) assigned to open necrosectomy- 17 of 43 patients (40%) assigned to the step-up approach(risk ratio with the step-up approach, 0.57; 95% confidence interval, 0.38 to 0.87;P=0.006)35% of step-up approach were treated with percutaneous drainage onlyNew-onset multiple-organ failure occurred less often in patients assigned to thestep-up approach than in those assigned to open necrosectomy(12% vs. 40%, P=0.002)The rate of death did not differ significantly between groups(19% vs. 16%, P=0.70)
  • ComplicationSystemic complicationLocal complication
  • Systemic complication NeuroPulmonary - Pancreatitic- Acelactasis encephalopathy- Pleural effusions- ARDS Metabolic - HypocalemiaCardiovascular - Hypokalemia- cardiogenic shock - Metabolic alkalosisRenal GI- Prerenal failure - Hemorrhage
  • Local complicationAcute fluid collection- early in acute pancreatitis- no specific therapyPancreatic Pseudocyst- Collection of pancreatic fluid walled off by granulationtissue after episode of acute pancreatitis- Develop more than 4week, detected by CT scan
  • Local complicationIntra-abdominal infection- within 1-3 weekPancreatic abscess- Infected pancreatic pseudocyst may develop to abscess in3-6 weekPancreatic necrosis