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Acute and Chronic Pancreatitis

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Acute and Chronic Pancreatitis

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Acute and Chronic Pancreatitis

  1. 1. Acute & Chronic Pancreatitis Marcos Machado, M.D. Heedong Park, M.D. November 8, 2006
  2. 2. Anatomy
  3. 3. Physiology <ul><li>Endocrine (20%) </li></ul><ul><ul><li>Islets of Langerhans </li></ul></ul><ul><ul><ul><li>Insulin (beta) </li></ul></ul></ul><ul><ul><ul><li>Glucagon (alpha) </li></ul></ul></ul><ul><ul><ul><li>Somatostatin (delta) </li></ul></ul></ul><ul><li>Exocrine (80%) </li></ul><ul><ul><li>Digestive enzymes (pro-enzymes) </li></ul></ul><ul><ul><ul><li>Trypsinogen </li></ul></ul></ul><ul><ul><ul><li>Chymotrypsinogen </li></ul></ul></ul><ul><ul><li>Controlled by </li></ul></ul><ul><ul><ul><li>Gastrin </li></ul></ul></ul><ul><ul><ul><li>CCK </li></ul></ul></ul><ul><ul><ul><li>Secretin </li></ul></ul></ul>
  4. 4. Pathophysiology – Acute <ul><li>Initiating event </li></ul><ul><li>Injury to acinar cells impairs release of proenzymes (in zymogen granules) </li></ul><ul><li>Premature activation of enzymes </li></ul><ul><li>Autodigestion </li></ul>
  5. 5. Pathophysiology – Acute Normal Pancreatitis
  6. 6. AP: Causes – The Big Ones <ul><li>Biliary Tract Disease (40%) </li></ul><ul><li>Alcohol (35%) </li></ul><ul><ul><ul><ul><li>Usually Acute on Chronic </li></ul></ul></ul></ul><ul><li>Idiopathic (10-30%) </li></ul><ul><ul><ul><ul><li>Most (70%): likely occult microlithiasis </li></ul></ul></ul></ul><ul><li>Post-ERCP (4%) </li></ul><ul><li>Trauma (1.5%) </li></ul><ul><li>Drugs (1.4%) </li></ul><ul><ul><ul><li>Azathioprine, sulfa, sulindac, valproic acid, tetracycline, methyldopa, estrogens, lasix, corticosteroids, octreotide </li></ul></ul></ul><ul><ul><ul><li>Poss: HCTZ, flagyl, nitrofurantoin, procainamide, cimetidine, other chemo drugs </li></ul></ul></ul>
  7. 7. AP: Other Causes – Each <1% <ul><li>Infection </li></ul><ul><ul><ul><ul><ul><li>Viral (EBV, VZV, cocksackie), Bact (M. pneumo, Salmonella, Campy, TB), ascariasis </li></ul></ul></ul></ul></ul><ul><li>Hereditary </li></ul><ul><ul><ul><ul><ul><li>AD – mutation of trypsinogen gene, premature activation </li></ul></ul></ul></ul></ul><ul><li>Hypercalcemia </li></ul><ul><li>Developmental Abn Pancreas </li></ul><ul><ul><ul><ul><ul><li>Annular pancreas, pancreas divisum, SOD dysfunction) </li></ul></ul></ul></ul></ul><ul><li>Hypertriglyceridemia (>1000) </li></ul><ul><li>Tumor ( obstruction of ducts) </li></ul><ul><li>Toxin (scorpion, pesticide) </li></ul><ul><li>Post-Op </li></ul>
  8. 8. Pathophysiology – Chronic <ul><li>Progressive inflammatory changes </li></ul><ul><li>Chronic irreversible inflammation </li></ul><ul><li>Fibrosis with calcification </li></ul><ul><li>Loss of pancreatic function </li></ul>
  9. 9. Causes - CP <ul><li>Alcohol (60%) </li></ul><ul><ul><ul><ul><li>Genetic predisposition? </li></ul></ul></ul></ul><ul><li>Genetic Causes (CF, hered pancreatitis) </li></ul><ul><li>Ductal Obstruction </li></ul><ul><ul><li>Trauma, pseudocysts, stones, tumors) </li></ul></ul><ul><li>Systemic Dz – SLE, high TG </li></ul><ul><li>Autoimmune </li></ul><ul><li>Idiopathic </li></ul>
  10. 10. Symptoms – Acute & Chronic <ul><li>Acute </li></ul><ul><ul><li>Dull, boring midepigastric, radiates to back </li></ul></ul><ul><ul><li>Usually sudden onset </li></ul></ul><ul><ul><li>Nausea/vomiting </li></ul></ul><ul><li>Chronic </li></ul><ul><ul><li>mid upper abd pain – chronic, intermittently severe, may rad to back </li></ul></ul><ul><ul><li>Diarrhea, wt loss </li></ul></ul><ul><ul><li>Steatorrhea, diabetes </li></ul></ul>
  11. 11. Signs – Acute & Chronic <ul><li>Acute </li></ul><ul><ul><li>Fever (76%), tachy (65%) </li></ul></ul><ul><ul><li>Abd tenderness, guarding (68%), hypoactive BS </li></ul></ul><ul><ul><li>± jaundice </li></ul></ul><ul><ul><li>Severe: hemodynamic instability, hematemesis </li></ul></ul><ul><li>Chronic </li></ul><ul><ul><li>± epigastric tender mass or fullness (pseudocyst) </li></ul></ul><ul><ul><li>Advanced: malnutrition, decreased subcut fat </li></ul></ul>
  12. 12. DDx – Acute & Chronic <ul><li>Acute </li></ul><ul><ul><li>Cancer (pancreatic, colon) </li></ul></ul><ul><ul><li>Cholangitis </li></ul></ul><ul><ul><li>Cholecystitis, Choledocholithiasis, Cholelithiasis </li></ul></ul><ul><ul><li>Colonic Obstruction </li></ul></ul><ul><ul><li>Ulcers </li></ul></ul><ul><ul><li>IBS </li></ul></ul><ul><ul><li>MI </li></ul></ul><ul><li>Chronic </li></ul><ul><ul><li>Cancer (pancreatic, ampullary) </li></ul></ul><ul><ul><li>Cholangitis </li></ul></ul><ul><ul><li>Cholecystitis </li></ul></ul><ul><ul><li>Crohn’s Dz </li></ul></ul><ul><ul><li>Chronic Gastritis </li></ul></ul><ul><ul><li>Bowel perforation </li></ul></ul><ul><ul><li>Mesenteric Ischemia </li></ul></ul><ul><ul><li>MI </li></ul></ul><ul><ul><li>PUD </li></ul></ul>
  13. 13. Labs – Acute & Chronic <ul><li>Acute </li></ul><ul><ul><li>Amy/lip: 3x above Nl to be diagnostic. Lipase has longer T1/2 and is more specific </li></ul></ul><ul><ul><li>Gallstone panc: ALP, Tbili, AST, ALT </li></ul></ul><ul><ul><li>Ca, cholesterol, TG </li></ul></ul><ul><ul><li>CBC – hemoconc-might be severe </li></ul></ul><ul><li>Chronic </li></ul><ul><ul><li>CBC, LFTs Chem Nl </li></ul></ul><ul><ul><li>Amy/Lip: Nl to slightly high </li></ul></ul><ul><ul><li>Compression of duct: high bili and ALP </li></ul></ul><ul><ul><li>AI: high ESR, RF, ANA </li></ul></ul><ul><ul><li>Adv: low serum trypsin, steatorrhea </li></ul></ul><ul><ul><li>Poss: high Ca, high TG </li></ul></ul>
  14. 14. Labs – cont. <ul><li>Other causes of elevated amylase </li></ul><ul><ul><li>SBO </li></ul></ul><ul><ul><li>Mesenteric ischemia </li></ul></ul><ul><ul><li>Tubo-ovarian dz </li></ul></ul><ul><ul><li>Renal insuff </li></ul></ul><ul><ul><li>Parotitis </li></ul></ul>
  15. 15. Imaging <ul><li>When to obtain imaging </li></ul><ul><ul><li>uncertain diagnosis </li></ul></ul><ul><ul><li>Severe disease </li></ul></ul>
  16. 16. Imaging <ul><li>Choice </li></ul><ul><ul><li>U/S – most useful initial test, TOC in gallstone </li></ul></ul><ul><ul><ul><li>Sensitivity 70-80% </li></ul></ul></ul><ul><ul><li>CT abd – if severe acute pancreatitis </li></ul></ul><ul><ul><ul><li>Good for assessing complications </li></ul></ul></ul>
  17. 17. Imaging <ul><li>Choice </li></ul><ul><ul><li>ERCP, MRCP – duct obstruction </li></ul></ul><ul><ul><ul><li>MRCP is safer, noninvasive and faster than ERCP but less sensitive </li></ul></ul></ul><ul><ul><ul><li>ERCP only if 2 ° to choledocholithiasis </li></ul></ul></ul>
  18. 18. Imaging <ul><li>Choice </li></ul><ul><ul><li>Abd xray – limited role </li></ul></ul><ul><ul><ul><li>Calcifications 30% of chronic panc </li></ul></ul></ul><ul><ul><ul><li>Free air–perforation </li></ul></ul></ul>
  19. 19. Medical Treatment <ul><li>Acute Pancreatitis </li></ul><ul><ul><li>NPO </li></ul></ul><ul><ul><li>IVF </li></ul></ul><ul><ul><li>Pain relief </li></ul></ul><ul><ul><li>Antibiotics </li></ul></ul><ul><ul><ul><li>If infected pancreatic necrosis </li></ul></ul></ul><ul><ul><ul><li>Antibiotic prophylaxis in severe pancreatitis is controversial </li></ul></ul></ul>
  20. 20. Medical Treatment <ul><li>Chronic Pancreatitis </li></ul><ul><ul><li>Behavior modification </li></ul></ul><ul><ul><ul><li>Cessation of EtOH and tobacco use will help pain relief in early stages, not in late </li></ul></ul></ul><ul><ul><li>Pain control </li></ul></ul><ul><ul><li>Restoration of digestion and absorption </li></ul></ul><ul><ul><ul><li>enzyme replacement </li></ul></ul></ul><ul><ul><li>± insulin </li></ul></ul>
  21. 21. Complications <ul><li>Pseudocyst </li></ul><ul><li>Abscess formation </li></ul><ul><li>Pancreatic necrosis </li></ul>
  22. 22. Surgical Treatment <ul><li>Pseudocysts </li></ul><ul><ul><li>Peripancreatic fluid collections for >4wks </li></ul></ul><ul><ul><li>Intervention if: </li></ul></ul><ul><ul><ul><li>>7cm and rapidly expanding </li></ul></ul></ul><ul><ul><ul><li>Symptomatic (pain, bleeding, infection) </li></ul></ul></ul>
  23. 23. Surgical Treatment <ul><li>Pseudocysts </li></ul><ul><ul><li>Percutaneous aspiration </li></ul></ul><ul><ul><ul><li>Very large fluid collections </li></ul></ul></ul><ul><li>Pancreatic abcess </li></ul><ul><ul><li>Also responds to percut drainage </li></ul></ul>
  24. 24. Surgical Treatment <ul><li>Pseudocysts </li></ul><ul><ul><li>Transpapillary drainage </li></ul></ul><ul><ul><ul><li>If pancreatic duct communicates with pseudocyst, can place stent </li></ul></ul></ul>
  25. 25. Surgical Treatment <ul><li>Pseudocysts </li></ul><ul><ul><li>Transmural enterocystostomy </li></ul></ul><ul><ul><ul><li>Endoscopic if distance between lumen and pseudocyst is <1cm </li></ul></ul></ul>
  26. 26. Surgical Treatment <ul><li>Pseudocysts </li></ul><ul><ul><li>Transmural enterocystostomy </li></ul></ul>
  27. 27. Surgical Treatment <ul><li>Infected pancreatic necrosis </li></ul><ul><ul><li>Abx not enough </li></ul></ul><ul><ul><li>Surgical debridement and drainage </li></ul></ul>
  28. 28. Surgical Treatment <ul><li>Stones </li></ul><ul><ul><li>If evidence of biliary obstruction (jaundice, bile duct dilation), may benefit from ERCP </li></ul></ul>
  29. 29. Surgical Treatment <ul><li>Pancreatic Duct distruption </li></ul><ul><ul><li>ERCP can provide dx and tx </li></ul></ul><ul><ul><ul><li>Transpapillary stent placement </li></ul></ul></ul><ul><ul><li>For distal leaks (tail of pancreas) </li></ul></ul><ul><ul><ul><li>Distal pancreatectomy </li></ul></ul></ul>
  30. 30. Surgical Treatment <ul><li>Pancreatic Duct distruption </li></ul><ul><ul><li>Proximal leaks (head of pancreas) </li></ul></ul><ul><ul><ul><li>Whipple </li></ul></ul></ul>
  31. 31. Prognosis <ul><li>Acute Pancreatitis </li></ul><ul><ul><li>Overall mortality – 15%, severe dz – 30% </li></ul></ul><ul><ul><li>Ranson’s Criteria </li></ul></ul><ul><li>Chronic Pancreatitis </li></ul><ul><ul><li>Poor prognostic factors: young, smoker, cont to use EtOH, +liver cirrhosis </li></ul></ul><ul><ul><li>Overall mortality 30% @ 10yrs, 55% @ 20yrs </li></ul></ul><ul><ul><li>4% risk of developing pancreatic CA @ 20yrs </li></ul></ul>
  32. 32. Prognosis <ul><li>Ranson’s Criteria </li></ul><ul><ul><li>Admission </li></ul></ul><ul><ul><ul><li>>55yo, WBC>16, BG>200, LDH>350, AST>250 </li></ul></ul></ul><ul><ul><li>@ 48 hrs </li></ul></ul><ul><ul><ul><li>HCT drops 10%, BUN increases by 5, Ca < 8, pO2 <60, Base deficit>4, fluid sequestration > 6L </li></ul></ul></ul><ul><li>Scoring </li></ul><ul><ul><li>0-2 = minimal mortality </li></ul></ul><ul><ul><li>3-5 = 10-20% </li></ul></ul><ul><ul><li>>5 = >50% mortality </li></ul></ul><ul><li>APACHE II scoring is best validated, but cumbersome </li></ul>
  33. 33. References <ul><li>http://www. emedicine .com </li></ul><ul><li>http://hopkins- gi.nts.jhu.edu/pages/latin/templates/index.cfm? pg=disease4&organ=4&disease=24&lang_id=1 </li></ul><ul><li>http://www.uptodate.com </li></ul>

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