Acute _Pancreatitis

1. Acute
pancreatitis
PRESENTED BY: IRFAN UL HAQ
MBBS FINAL YEAR.
GMC SRINAGAR.

2. Definition
 Acute pancreatic inflammation associated with little or
no fibrosis.
 It ranges from a mild self-limiting inflammation
of the pancreas to critical disease characterized by infected
pancreatic necrosis, multiple organ failure and a high risk of mortality.

3. Pancreas with biliary tree

4. Epidemiology
 Worldwide annual incidence of acute pancreatitis may range from 5 to 50 per 100,000 with
highest incidence in Finland and US.
 The disease may occur at any age , with peak in young men and older women.
 Smoking is an independent risk factor for acute pancreatitis.

5. Aetiology
 There are two major causes of acute pancreatitis which are
 Gallstones and
 Alcohol abuse.
 Gallstone pancreatitis is seen in 50-70% of cases whereas due to alcohol
abuse it is 25%.
 The other possible causes of acute pancreatitis are:
 Biliary tract disease
 Hyperlipidemia
 Hereditary
 Hypercalcemia

6. Aetilogy (contd…)
 Trauma:
 External
 Surgical
 Endoscopic retrograde cholangiopancreatography.
 Ischemia:
 Hypoperfusion
 Atheroembolic
 Vasculitis
 Pancreatic duct obstruction:
 Neoplasms
 Pancreas divisum
 Ampullary and duodenal lesions
 Infections.
 Venom.
 Drugs.
 Idiopathic.

7. Pathophysiology
 Acute pancreatitis occurs in various degrees of severity, the
determinants of which are multifactorial.
 The generally prevalent belief today is that pancreatitis begins with the activation
of digestive zymogens inside acinar cells, which cause acinar
cell injury.
 Studies suggest that the ultimate severity of the
resulting pancreatitis may be determined by the events that
occur subsequent to acinar cell injury.
 These include inflammatory cell recruitment and activation, as well as generation
and release of cytokines and other chemical mediators of inflammation.

8. Pathogenesis (contd….)

9. Clinical features
 The most common symptoms and signs include:
 Severe epigastric pain radiating to the back, relieved by leaning forward.
 Nausea, vomiting, diarrhea and loss of appetite.
 Fever/chills.
 Hemodynamic instability, including shock.
 In severe case may present with tenderness, guarding, rebound .

10. Clinical features(contd…)
 Signs which are less common, and indicate severe disease,
include:
 Grey-Turner's sign (hemorrhagic discoloration of the flanks)
 Cullen's sign (hemorrhagic discoloration of the umbilicus)
 Abdominal examination reveals distention due to ileus or more rarely, ascites
with shifting dullness.
 A mass can develop in epigastrium due to inflammation.
 A pleural effusion is present in 10-20% of patients.

11. Cullen’s sign

12. Grey-Turner’s Sign

13. Investigations
 Full blood count: neutrophil leukocytosis.
 Electrolyte abnormalities include hypokaemia, hypocalcemia.
 Elevated LDH in biliary disease.
 Glycosuria ( 10% of cases).
 Blood sugar: hyperglycaemia in severe cases.
 Ultrasound look for stones in biliary tract diseases.
 Abdominal CT scan may reveal phlegmon (inflammatory mass), pseudocyst or
abscess(complications of acute pancreatitis).

14. Investigations(contd…)
Amylase and lipase :
 Elevated serum amylase and lipase levels, in combination with
severe abdominal pain, often trigger the initial diagnosis of acute
pancreatitis.
 Serum lipase rises 4 to 8 hours from the onset of symptoms
and normalizes within 7 to 14 days after treatment.
 Marked elevation of serum amylase level during first 24 hours
 Reasons for false positive elevated serum amylase include
salivary gland disease (elevated salivary amylase) and
macroamylasemia.
 If the lipase level is about 2.5 to 3 times that of Amylase, it is
an indication of pancreatitis due to Alcohol or gallstone
 The degree of amylase/lipase elevation does not correlate
with severity of acute pancreatitis.

15. Assesment of severity of AP.
 Different scoring systems have been applied to asses the severity and prognosis of acute
pancreatitis viz:
 Ranson Score.
 APACHE II Score.
 Balthazar Score.

16. Ranson score

17. Ranson Score(contd…)

18. APACHE II Score(Acute Physiology And Chronic
Health Evaluation)
Score 0 to 2 : 2% mortality. Score 3 to 4 : 15% mortality.
Score 5 to 6 : 40% mortality. Score 7 to 8 : 100% mortality.
1) Hemorrhagic peritoneal fluid.
2) Obesity.
3) Indicators of organ failure.
4) Hypotension (SBP <90 mmHG) or tachycardia > 130 beat/min.
5) PO2 <60 mmHg.
6) Oliguria (<50 mL/h) or increasing BUN and creatinine.
7) Serum calcium < 1.90 mmol/L (<8.0 mg/dL).
8) Serum albumin <33 g/L (<3.2.g/dL).

19. Balthazar scoring

20. Complications
 Immediate:
 Shock.
 DIVC.
 ARDS.
 Late:
 Pancreatic pseudocyst.
 Pancreatic abscess.
 Pancreatic necrosis.
 Pancreatic jaundice.
 Persistant duodenal ileus.
 G I bleed.
 Pancreatic ascites.

21. Management
 IV fluid replacement (normal saline).
 Bowel rest (NG tube, NPO) in severe case.
 Administration of meperidine/pethidine as pain killer.
 Antiemetic if necessary.
 Monitor & correct electrolytes.
 Prevent infection by antibiotic prophylaxis.
 Determine & treat specific etiology(avoid alcohol).
 Indication to surgery if pancreatitis not respond to treatment.