3. Etiology80% - Gallstones or Alcohol related
Gallstone pancreatitis
• Female
• Common channel theory
• Ductal hypertension theory
• Sphincter incompetence theory
Alcoholic pancreatitis
• Male, alcoholic
• Direct toxicity
• Sphincter oddi spasm
• Viscosity theory
4. Diagnosis
• Clinical :
Abdominal pain
• Laboratory:
Serum Amylase/Lipase >3x
• Imaging :
proven (US/CT/MRI)
2
out
of
3
Previous
pancreatitis
Hx of Gallstones
Alcohol History
Drugs
Trauma
6. CT-SCAN
• Contrast CTWhat type?
• Diagnostic dilemma
• Failure to improve after 72 hr
• Suspicion of local complications
• Severity scoring Balthazar (CTSI)
• Guided FNAc
Why?
• After 72 hrWhen?
• Contrast allergy / Renal failure
• MRI
If
contraindicated?
7.
8.
9. ERCP
Most gallstones causing AP pass to the doudenum
Severe gallstone AP or AP with concurrent
cholangitis(persistent stone)
Within 72 hr of admission
Diagnostic / Therapeutic
Sphincterotomy
Reduce infective complications/mortality
EUS
Repeated idiopathic AP
Occult Biliary ds--- small stone/sludge
Exclude malignancy(5% of pancreatic ca. present as
AP)
Age>40 with prolonged/recurrent attack of AP
11. Modified Atlanta
Mild AP (80%)
• No local complication &
No organ failure
Moderate severe AP
• Local complications
with/without transient
organ failure(<48hr)
Severe AP
• Persistent(>48hr) organ
failure with/without local
complication
12.
13. Where to admit patients?
Mild pancreatitis Wards
Persistent SIRSICU
Moderate severe
pancreatitisICU
Severe pancreatitisICU
14. Management
Two distinct phases of APEarly phase (<
2wks)
Late phase (>
2wks)
Characterized by
SIRS+/-/organ failure
Severity assessed by
clinical scoring systems
Management – Medical
Characterized by Local
Cpxn.
Severity assessed by
Morphological scoring
system(baltazar)
Management– Medical
+/- Surgery
15. Fluid Resuscitation
Early aggressive fluid resuscitation
• Correction of volume depletion
• Prevent pancreatic necrosis
• Most beneficial over the first 24 hr
Ringer Lactate Ideal fluid
• (RCT) after 24hr of resuscitation with RL,
84% reduction in SIRS & significant reduction in
CRP
16. In severe volume depletion
• 30ml/kg over 30 min followed by
3-5ml/kg/hr for 12-24hr
Resuscitation Goals
HR <120/min
MAP = 65-85mmhg
Urine output = 0.5ml/kg/hr
Hct, creatinine, BUN
17. Prophylactic Antibiotic ????
Rational For:
Early unblinded trials prevent
infection of sterile necrosis
Rational Against:
(Meta analysis ) prophylactic antibiotics Vs
placebo in CT proven necrotizing AP concluded
No statistically significant
oReduction of mortality
oReduction in infection rate of the
pancreatic necrosis
18. Prospective RCT demonstrated prophylactic
antibiotic use
3 fold increase in incidence of local & systemic
fungal infection with candidia albicans(from 7%
to 22%)
Clostridial difficle colitis
Indications for Antibiotic include
Infected necrosis confirmed by FNA or CT
Carbapenems /flouroquinolones
/metronidazole/high dose cephalosporins
Extrapancreatic infections
Sterile necrosis >50%
Antifungal Rx?????????? NOT
RECOMMONDED
19. NUTRITION
Nil Per Oral : Traditional school of
thought
Rational For: prevent stimulation
of exocrine pancreas
Rational Against:
AP – inflammatory stress
Altered gut mucosal integrity
Increased chance of infection
20. Oral Feeding
May be difficult due to aggravation of pain with
intake
nausea & Recurrent
vomiting
ileus causing distention
In mild pancreatitis can be started
immediately if
No nausea & vomiting
Abdominal pain has resolved
Low fat diet is recommended
21. Total Parentral Nutrition
Rational For:
Maintenance of proper nutrition avoiding GI
cpxn.
Rational Against:
Increased chance of altered gut mucosal
integrity
Portal of infection introduction
High Cost
Nasogastric Vs Nasojejunal Feeding
22. Severe pancreatitis ENTERAL nutrition
whenever tolerable
Nasogastric Vs Nasojejunal
TPN only if not tolerated /fail to met the
metabolic demand of the patient
Meta analysis study (Enteral Vs TPN)
Reduced mortality
Reduced MOF
Reduced operations
Reduced local septic complications
23. Necrotizing Pancreatitis
Progression to necrosis- 20 -30% of patients
with SAP
International Symposium on Acute
Pancreatitis
Presence of one/more diffuse/focal areas of non
viable parenchyma, usually associated with
peripancreatic fat necrosis
Diffuse/focal area of non viable pancreatic
parenchyma >3cm / >30%
The Acute pancreatitis classification working
group
24. Can be Sterile or Infected
Sterile necrosis
Early operative intervention even with MOF
obsolete b/c of No mortality benefit rather
may increase morbidity
Rare indications
• Failure to improve after 4-6wks of non
operative mgt
• Worsening organ failure despite maximal
support
• Inability to tolerate enteral nutrition
• Worsening jaundice, fever
25. • Deterioration/fail to improve after 7-10dy of hospitalization
• CT guided FNAc for gram stain and culture
• Gas on CT-scan
• CT guided FNAc for gram stain and culture
• Empiric antibiotic Rx
Infected Necrosis
• Necrotic tissue will be well demarcated
• Necrosis will be walled off
• Less bleeding
Stable patients surgery should be delayed for >
4wks
Unstable patients urgent
intervention
26. Role Of Surgery
Designed to ameliorate the emergent problems
associated with ongoing inflammatory state
Designed to ameliorate chronic sequele
Designed to prevent a subsequent episode of acute
pancreatitis
27. necrosis
“Everything should be made as simple as
possible but not simpler.” Albert Einstein
Pancreatic debridement should be as
minimally invasive as possible but not more
so.
Step up approach
Percutaneous/endoscopic drainage
Minimally invasive retroperitoneal
necrostomy
Open Necrostomy
28. • Death/Major complication 69%
vs 40%
• New onset MOF 40% vs 12%
• Incisional hernia 24% vs 7%
• New onset diabetes 38% vs
16%
(RCT)
Open
Necrostomy
Vs
Step up
approach
29. Minimally invasive surgery
approach
Semi open technique /VIDEOSCOPIC
Gaining popularity
Minimize operative trauma
Avoidance of bacterial contamination
Decreased incidence of incisional hernia
Limitations
Poor surgical exposure
Difficulty of removing solid necrotic tissue
through small ports
Need for multiple procedures
Need for reliance on interventional radiology
30. Open Necrostomy
Necrostomy & closure
with surgical drains MR-
4-19%
Necrostomy with open
packing -- MR- 4-18%
with repeat
laparatomy q48hr
high risk of
pancreatic fistulas,
bleeding
Necrostomy & closure
with large bore drains &
Midline / Bilateral Kocher
Lesser sac/Transverse
Mesocolon
Blunt Necrostomy
31. Gallstone
pancreatitis
Problem:
Recurrence 29-63%
Index cholecystectomy
for mild pancreatitis
Interval cholecystectomy
for severe pancreatitis
If cholecystectomy is
contraindicated b/c of
comorbidities------ERCP
sphicterotomy
32. Pseudocysts
Pancreatic juice
contained in a fibrous
granulation tissue
Dx- contrast CT
Spontaneous
resolution-20%
Acute intervention
Symptomatic pts.
Signs of infection
Complications
Suspicion of cystic
Options of mgt
Endoscopic drainage
Percutaneous
drainage
Open internal drainage
o Cystogastrostomy
o Cystoduodenosto
my
o Roux-en-y
cystojej.
o Distal
pancreatectomy