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1. Pancreatitis

2. Overview
• Pancreatitis is an inflammation of the gland parenchyma
of the pancreas.
• It is divided into acute and chronic pancreatitis for
clinical purpose.

3. Acute Pancreatitis
 A disorder of exocrine pancreas, associated with reversible pancreatic
parenchyma cell injury with local and systemic inflammatory
responses.
 Acute nonbacterial inflammatory condition caused by activation,
interstitial liberation and auto-digestion of pancreas presenting as
abdominal pain, associated with raised pancreatic enzyme levels in the
blood or urine as a result of pancreatic inflammation.
 Mild or severe
• Mild acute pancreatitis is characterized by interstitial edema of the
gland and minimal organ dysfunction. The mortality from which is
around 1%.
• Severe acute pancreatitis is characterized
by pancreatic necrosis, a severe systemic
inflammatory response and often multi-
organ failure. The mortality varies from
20-50%.

4. Aetiology of Acute Pancreatitis

5. Pathogenesis
• Autodigestion results from inappropriate release and
activation of pancreatic enzymes is the final common
pathway leading to pancreatitis.

7. Clinical Presentation
• Pain is the cardinal symptom.
S- Diffuse, upper abdominal pain
O- Sudden
C- Boring pain
R- Radiation of pain to the back and chest
A- Nausea, vomiting, retching and hiccoughs
T- Pain often rapidly escalated in intensity, peaking within
about 10-20 min of onset and persists for hours/ days
E- Aggravated by breathing with increased chest expansion;
relieved by sitting or leaning forward (Muhammedan Prayer Sign) due to
shifting forward of abdominal contents and taking pressure off from
inflamed pancreas
S- Depending on severity, patients may present with shock

8. Clinical Presentation
• Tachypnea, tachycardia and hypotension- features of shock
• Normal body temperature or low grade fever- seen in infective
pancreas
• Jaundice – infrequently occur due to edema of the head of
pancreas
• Cyanosis – improper lung perfusion
• Mild icterus- biliary obstruction in gallstones pancreatitis
• Erythematous skin nodules – due to subcutaneous fact necrosis
• Abdominal findings:
- Abdominal tenderness, guarding and distension
- Mass in epigastrium
- Cullen’s sign ( bluish discolouration of the umbilicus)
- Grey Turner’s sign (bluish discolouration of the flanks)

10. Ranson’s and Glasgow’s Criteria
• Used to predict severity of acute pancreatitis.
• It is classified as severe when 3 or more factors are present.

11. Acute Physiology and Chronic
Health Evaluation (APACHE II)

12. Diagnostic criteria
• Most often established by the presence of two of the three following
criteria:
(i) abdominal pain consistent with the disease,
(ii) serum amylase and/or lipase greater than three times
the upper limit of normal, and/or
(iii) characteristic findings from abdominal imaging.
• CT and/or MRI of the pancreas should be reserved for patients
 in whom the diagnosis is unclear(typical pain with normal enzymes)
 who fail to improve clinically within the first 48–72 h after hospital
admission (e.g., persistent pain, fever, nausea, unable to begin oral
feeding)
 to evaluate complications

14. Management of Mild Acute
Pancreatitis
• Conservative Approach
• Admit in general ward
• Non invasive monitoring
• IV fluid administration
• A brief period of fasting in patient who is nauseated and in pain; oral
fluids, soft diet by 3-4 days once pain and ileus settle down
• Analgesia and anti-emetics
• Monitoring for any signs of early organ failure
• Oxygen supplementation for hypoxemia
• CT scan when there is evidence of deterioration
• Admission to ICU/HDU when the stable patient meets the prognostic
criteria for severe attack of pancreatitis
*No antibiotics

15. Management of Severe
Acute Pancreatitis
• Aggressive Approach
• Admit in HDU/ICU
• Analgesia
• Aggressive fluid rehydration
• Oxygenation
• Invasive monitoring of vital signs, central venous pressure, urine output, blood gases
• Frequent monitoring of hematological and biochemical parameters ( including liver
and renal function, clotting, serum calcium, blood glucose)
• Nasogastric drainage
• Antibiotic prophylaxis can be considered (imipenem, cefuroxime)
• 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)

17. Chronic pancreatitis
A continuing inflammatory disease
of the pancreas characterized by
irreversible morphological change
typically causing pain and/or
permanent loss of function.
Associated with recurrent inflammation, fibrosis, and
injury to the exocrine and endocrine tissues.
Painful exacerbation or completely painless.

18. Aetiology of Chronic
Pancreatitis

19. Pathogenesis of Chronic Pancreatitis

20. Clinical Presentation
• Pain is the outstanding symptom.
S- Diffuse, upper abdominal pain
O- Sudden
C- Often dull, gnawing, and boring pain
R- Radiation of pain to the left shoulder
and back with a postprandial component
A- Nausea, vomiting, loss of appetite, weight loss
T- Constant
E- Pain initially gets worse after a meal, or during the night;
can be relief by knee chest position (Jack-knife position)
S- Depends on the severity
• Steatorrhea
• DM

21. Medical Treatment
of Chronic
Pancreatitis

22. Endoscopic, Radiological or surgical
Interventions of Chronic Pancreatitis
• Indicated to relieve obstruction and remove mass lesion of the
pancreatic duct, bile duct or the duodenum, or in dealing with
complications.
• To provide pain relief by decompressing an obstructed
pancreatic duct.

23. Endoscopic, Radiological or surgical
Interventions of Chronic Pancreatitis
• Endoscopic pancreatic sphincterotomy- papillary stenosis, high sphincter pressure and
pancreatic ductal pressure
• Stent placement- pancreatic duct stricture and upstream dilatation
• Endoscopic retrograde cholangiopancreatography (ERCP)- pancreatic duct stones
• Percutaneous or transgastric drainage under endoscopic ultrasound (EUS) or CT
guidance-pseudocysts
• Pancreatoduodenectomy or Beger procedure (duodenum-preserving resection of the
pancreas head) - mass in the head of the pancreas
• Longitudinal pancreatojejunostomy or Frey procedure if the pancreatic is markedly
dilated.
• Distal pancreatectomy- disease limited to the tail of the pancreas
• Subtotal or total pancreatectomy- intractable pain and diffuse disease with nondilated
ducts
• Total pancreatectomy and islet autotransplantation- to avoid long-term morbidity
caused by diabetes ; involves harvesting the islets from the resected pancreas and
injecting them into the portal system, which then lodges them in the liver.

24. Differential Diagnosis of
Chronic Pancreatitis
• Ampullary Carcinoma
• Cholangitis
• Cholecystitis
• Chronic Gastritis
• Community-Acquired Pneumonia
• Crohn Disease
• Intestinal Perforation
• Mesenteric Artery Ischemia
• Myocardial Infarction
• Pancreatic Cancer
• Peptic Ulcer Disease

25. Q&A
1. Following are features of acute pancreatitis except
A. Shock
B. Cullen’s sign
C. Grey Turner’s sign
D. Kehr sign
2. The best surgical treatment for chronic pancreatitis with
dilated duct is
A. Frey’s operation
B. Whipple’s operation
C. Longitudinal pancreaticojejunostomy
D. Distal pancreatectomy

26. References
• Bailey & Love's short practice of surgery By: Williams,
Norman S., and C. J. K. Bulstrode. Hodder Arnold 2008
• Manipal manual of surgery By: Shenoy, K. Rajgopal.
CBS Publishers & Distributors, 2000
• Robbins and Cotran pathologic basis of disease By:
Robbins, Stanley L.. Saunders/Elsevier 2010
• http://annals.org/data/Journals/AIM/20218/tt2.png