14. Alcohol
• 100-150 gm/day
• Acinar cell metabolism in oxidatiove and non
oxidative pathways
• Cause cell death , necroinflamation ,
autodigestive injury
• The stelleate cells are activated as
myofibroblasts
• Secretions of proinflamatory and cytokininis
15. • Spasm of spincter of oddi
• Ethanol inducted duct permability
• Protein content of pancreatic juice increase
• Decreaese in bicarbonate level , trypsin
inhibitor concentration
• Precipitation of pancreatic proteins and
formation of plugs leading to obstruction .
16.
17. Iatrogenic
Post ercp
Bile duct exploration
Splenectomy
Hepatic surgery
Distal gastrectomy
Major cardiac surgery
Haemorragic shock
18. Heridiatary
• PRSS 1 PRSS 2gene mutation – premature
activation
• SPINK 1 – Failure to express normal
trypsinogen inhibitor gene
• Claudin 2 mutation – abnormal location of
acinar cells and ducts
24. Clinical manifestaion
• Continous Epigastric pain radiating to mid
back
• Nausea and vomiting does not relieved by
pain
• Dehydration , tachycardia , hypotention
• Altered mental status
29. • On xray abd eretct we can notice colon cut off
sign , calcified gall stones , calcified pancreas
can be seen
• Cxr can show any pleural effusion or ARDS .
• USG ABDOMEN is of no value except to find
out a swollen pancreas , it is use to rule out
any gall stones or to do a diferential diagnosis
.
30. • The purpose of CT is to check for local
complications and can also be use full for
percutaneosus drainage in case of any
collection
• Mri is more superior to detect any solid
content with in the collection .
• Arterial phase CT can detect any
pesodoanerysm or bleeding or haematoma .
31. • Ct is use full only in case of dig uncertanity , to
distinguish between interstitial from
necrotising pancreatitis .
• In case of MODS , sepsis , or in case to find out
any local complications .
36. Management
• Admit in icu
• Analgesia
• Fluid rehydration
• Bp/ptr , i/o ,cvp , electrolytes
• NG tube
• Haemotological and biochemical management
• Prophylctic management
• Ct scan if any organ failure or signs of sepsis
37. • Ercp in case of gall stone pancreatitis
• Supportive therapy for MODS
• Nutritional support
38. Pain management
• With NSAIDS and opoid analegesia.
• Never use morphine as this increase the
spinter od oddi spasm .
39. iv.Fluids
• Vigrous fluid therapy with 5-10 ml /kg per
hour in first 24 hrs
• More ideally RL is more prefered as this may
reduce systemic inflamatatory response .
• Caution over the renal failure cases and
cardiac cases .
40. NPO ?NG TUBE?ANTIBIOTICS ?
• IT IS NO LONGER ACCEPETABLE TO “REST THE
PANCREAS “by avoiding nurtitional support
• Now mainstay is nutritional support .
• If patient is not tolerating foods and has
severe vomiting 48 to 72 hrs of NPO can be
considered .
• Later oral diet can be initiated if tolerated or
NG tube feeding can be given
41. • Never consider oral diet untill adequeate
resuscitaion is done this may lead to non
occlusive mesentric ischemia .
• Delay in enteral feeding ,may cause paralytic
ileus
• In mild acute pancreatiis oral diet is delayed
untill the abd pain decrease , once serum
amalyase levels are decreased patient
controlled nutrition can be given .
42. • Ng tube may be value oly in case of severe
vomiting .
• Antbiotics may be started the rationale is to
prevent local and systemic complications .
43. Ercp
• Can be use full in case of gall stone
pancreatitis or in case of severe jaundice ,
colangitis or dilate d CBD
• ERCP may reduce complications but not
mortalitity
• But ERCP has risk of increaasing pancreatitis ,
bleeding , colangitis and perforation .
• If persistent cholestasis perform MRCP then
proceed to ERCP .
44.
45. Systemic complications
• A multi disciplinary team support is required .
• In case of organ failure we appropriate line of
management with ionotropes , ventilatory
support and Dialysis etc to be used .
46. Local complications and there
management
• Acute peri pancreatic fluid collection :
• Large collections – pressure effect –
percutaneous drainage – CT, EUS , USG guided
.
47. Sterile infected pan necrosis
• Necrosis means non viable parenchyma with
lysis of near by fat
• This is acute necrtioc collection which in over
4 wweeks develop a wall hence called as
walled of necrosis .
• Sterile necrotic material should not be
touched untill needed .
• Necrosectomy &debridement can be done
48. • Can be done via laprotomy or with laproscopy
• Closed continous drainage , closed drainage ,
ope packing , closure and relaprotomy can be
considered.
49. Pancreatic abcess
• Collection of pus close to pancreas and WON
can be infected .
• Percutaneous drainage and drain are kept .
50. Pancreatic ascitis
• Wide bore drainage
• Parentral and jejunal feeding , octerotide can
supress pancreatic secretion .
• Ercp may demonstrate a disrupted duct and
placemnt of a panreatic stent may be done .
51. Pancreatic effusion
• Encaplulated fluid collection in pleural cavity
due to pancreatic ascitis and communication
with intra abdominal collection
• Percutaneous drainage can be done .
52. Haemorrhage
• Can occur into retroperitonium , gut ,
peritoeal cavity , or into the pesudocyst cavity
from a pesudo anerysm or from a major
pancreatic vessel .
• Mr or ct angiography can be done followed by
selective embolisation .
53. Portal or splenic vein thrombosis
• It is often silent and marked platet increase
• Portal htn , varieces can pressnt
• Conservative management with antiplatelets ,
anticougulants may be used.
54. Pesodocyst
• It is collection of amaylase rich fluid enclosed in
well defined wall of fibrosis and granulation
tissue
• Mostly the pesudocyst may resolve itself , if in
case of any complications surgical option may be
considered .
• Percutaneous drainage , percutaneous
transgastric cyctogastotomy , endoscopic guideed
drainage , EUS guided drainage , open or
laproscopic cyctogastrotomy are surgical options .
