ACUTE PANCREATITIS- EPIGASTRIC PAIN #surgicaleducator #epigastricabdominalpain #acutepancreatitis #usmle #babysurgeon #surgicaltutor • Dear Viewers, • Greetings from “Surgical Educator” • Today I have uploaded a video on Acute Pancreatitis- a didactic lecture. I have already uploaded 2 more videos on the same topic, one in case based learning of abdominal pain and another one in image based questions for Hepato-biliary- pancreatic pathologies. • It is one of the common surgical problems you see in surgical wards. • I have discussed the various causes for Epigastric pain, etiology, pathology, clinical features, investigations, scoring systems, complications and treatment of Acute Pancreatitis. • I have also included a mind map and a treatment algorithm for Acute Pancreatitis. • I hope the video will be very useful and you will enjoy it. • You can watch all my surgical teaching videos in the following link: • youtube.com/c/surgicaleducator • Thank you for watching the video.

1. ACUTE
PANCREATITIS
EPIGASTRIC PAIN
AN OVRVIEWDr.B.Selvaraj MS;Mch;FICS;
“Surgical Educator”
Malaysia

2. ACUTE PANCREATITIS
 Different causes for epigastric pain
 Epidemiology
 Classifications and definitions
 Etiology
 Pathology
 Clinical features
 Investigations
 Assessment of severity
 Treatment
 Complications
 Mindmap
 Treatment Algorithm

3. ACUTE PANCREATITIS
D/D for Epigastric Pain

4. ACUTE PANCREATITIS
-Epidemiology
 Pancreatitis is inflammation of the pancreas .
It is one of the most devastating conditions in
the abdomen.
 More than 75% of cases of acute pancreatitis
are due to either gallstones or alcohol.
 80% to 85% of patients have mild and self-
limiting Pancreatitis, while 15% to 20% of
patients have severe Acute Pancreatitis
complicated by shock, sepsis, and MODS.
 The overall mortality for AP is approximately
10% , but in its most severe form , it can
increase to 20% to 30 % .
 The disease may occur at any age, with a
peak in young men and older women.
 In the United States, more than 200,000
patients are hospitalized annually with acute
pancreatitis
 It is the principal cause of approximately
3,200 deaths per year
 Infection of pancreatic and peripancreatic
necrosis complicates 30% to 70% of cases of
acute necrotizing pancreatitis and occurs
during the second to third weeks after onset
of disease.

5. ACUTE PANCREATITIS
CLASSIFICATIONS AND DEFINITIONS
Atlanta classification of acute pancreatitis(1992)
 Mild acute pancreatitis:
● no organ failure;
● no local or systemic complications.
 Moderately severe acute pancreatitis:
● organ failure that resolves within 48 hours
(transient organ failure); and/or
● local or systemic complications without
persistent organ failure.
 Severe acute pancreatitis:
● persistent organ failure (>48 hours);
● single organ failure
● multiple organ failure.

6. ACUTE PANCREATITIS
-ETIOLOGY
Nemonic: “I GET SMASHED”:
 Idiopathic
 Gallstones
 Ethanol
 Trauma
 Scorpion bite
 Mumps (viruses)
 Autoimmune
 Steroids
 Hyperlipidemia
 ERCP
 Drugs like Azathioprine,Thiazide.Valproic acid
and Sulfasalazine.

7. ACUTE PANCREATITIS
-PATHOLOGY
Underlying Pathology: intrapancreatic activation of proteolytic enzymes

8. ACUTE PANCREATITIS
-Clinical Features
 Severe epigastric pain radiating
straight to the back
 This pain is relieved on bending
forwards
 Anorexia, nausea and vomiting
 Low grade fever
 Mid-epigastric tenderness &
fullness (paralytic ileus)
 Cullen’s sign ( peri-umbilical
discoloration)
 Grey Turner’s sign (discoloration
of flanks)
 Fox’s sign ( discoloration around
inguinal ligament)
 Epigastric guarding
 Pleural effusion
SYMPTOMS SIGNS

9. ACUTE PANCREATITIS
-INVESTIGATIONS
 WBCs: ↑
 Hct: ↑ (in dehydration)/ ↓ (in
hemorrhage)
 ABG: metabolic & respiratory
acidosis + hypoxia
 Urinary amylase: ↑
LAB INVESTIGATIONS
Serum
 Lipase: ↑↑ (more specific &
sensitive)
 Amylase: ↑↑↑ (less specific)
 BUN, creatinine: ↑
 Liver enzymes, bilirubin: ↑
 Inflammatory markers (CRP,
IL-6, IL-8): ↑
 Glucose: ↑
 Ca2+: ↓

10. ACUTE PANCREATITIS
-INVESTIGATIONS
IMAGING INVESTIGATIONS- AXR
Sentinel loops Colon cut-off sign

11. ACUTE PANCREATITIS
-INVESTIGATIONS
IMAGING INVESTIGATIONS- USG
Pancreatitis with edema and Peripancreatic effusion

12. ACUTE PANCREATITIS
-INVESTIGATIONS
IMAGING INVESTIGATIONS- CECT
Dual phase CT scan is useful initial investigation to look for necrosis (however, necrosis may
not appear in initial 48 – 72 hrs)- If necrosis, won’t get “light up”

13. ACUTE PANCREATITIS
-INVESTIGATIONS
IMAGING INVESTIGATIONS- ERCP

14. ASSESSMENT OF
SEVERITY
RANSON SCORING
At Admission
“GA LAW (Georgia law)”:
Glucose >200
Age > 55
LDH > 350
AST > 250
WBC > 16,000
After 48 hrs
“C HOBBS (Calvin and Hobbes)”:
Calcium <8 mg/dL
Hct drop of >10%
O2 <60 (PaO2)
Base deficit >4
Bun >5 increase
Sequestration >6 L
Score 0 to 2: 2% mortality Score 3
to 4: 15% mortality
Score 5 to 6: 40% mortality
Score 7 to 8: 100% mortality

15. ASSESSMENT OF
SEVERITY
GLASGOW-IMRIE SCORING
 Out of 8 criteria if more than 3 are
positive it is severe

16. ASSESSMENT OF
SEVERITY
BALTHAZAR CT SCORING

17. ASSESSMENT OF
SEVERITY
BISAP SCORING

18. ACUTE PANCREATITIS
TREATMENT
 Admission to HDU/ICU
 Analgesia Opioid analgesia
 Aggressive fluid rehydration
 Supplemental oxygen
 Invasive monitoring of vital signs, central
venous pressure, urine output, blood gases
 Frequent monitoring of haematological and
biochemical parameters (including liver and
renal function, clotting, serum calcium,
blood glucose)
 Nasogastric drainage (only initially)
 Antibiotics if cholangitis suspected;
prophylactic antibiotics can be considered
 CT scan essential if organ failure, clinical
deterioration or signs of sepsis develop
 ERCP within 72 hours for severe gallstone
pancreatitis or signs of cholangitis
 Supportive therapy for organ failure if it
develops (inotropes, ventilatory support,
haemofiltration, etc.)
 If nutritional support is required, consider
enteral (nasogastric) feeding
Early management of severe acute pancreatitis.

19. ACUTE PANCREATITIS
TREATMENT
 Indications for surgery
Definitive diagnosis cannot be made
Pancreatic necrosis
Pancreatic abscess
Surgical management of severe acute pancreatitis.

20. ACUTE PANCREATITIS
COMPLICATIONS

21. ACUTE PANCREATITIS
MINDMAP

22. ACUTE PANCREATITIS
TREATMENT ALGORITHM

23. Peripheral Arterial Diseases(PAD)