surgical importance of acute pancreatitis

1. PRESENTED BY:
Dr Pratyush Kumar

2. • Inflammation of pancreatic parenchyma.
• Broadly of 2 types:
1. Acute: Presents as an emergency
2. Chronic: Prolonged and frequently lifelong disorder resulting from
development of fibrosis within the pancreas.
• Acute pancreatitis is defined as an acute condition presenting with:
• Abdominal pain
• Threefold or greater rise in serum levels of pancreatic enzymes
amylase or lipase.
• And/or characteristic findings of pancreatic inflammation on CECT.
• Acute pancreatitis may be categorized as mild (interstitial edematous
pancreatitis) or severe (necrotizing pancreatitis).

3. • Acute pancreatitis has an early phase that usually lasts a week and is
characterized by a Systemic Inflammatory Response Syndrome(SIRS)
• The late phase is characterized by persistent systemic signs of
inflammation and/or local complications, particularly fluid collection and
peripancreatic sepsis.

4. RISK FACTORS
• Biliary or Gallstone Pancreatitis
• Most common cause
• Seen more frequently in women between 50& 70 years of age
• Triggered by passage of gall stone down the CBD and getting
impacted at Ampulla of Vater which allows reflux of bile or activated
pancreatic enzyme into pancreas
• Alcohol induced injury
• 2nd most common cause
• More prominent in young male than women

5. • Anatomic Obstruction
• Abnormal flow of pancreatic juice into duodenum can result in
pancreatic injury.
• May be due to pancreatic tumours, parasites (Ascaris lumbricoides)
and congenital defects.
• ERCP induced pancreatitis
• Acute pancreatitis is the most common complication after ERCP
probably as a consequence of duct disruption and enzyme
extravasation.
• Patient with Sphincter of Oddi dysfunction or a history of recurrent
pancreatitis and those who undergo sphincterotomy or balloon
dilatation of sphincter carry higher risk.

6. • Drug induced Pancreatitis
• Most common agents include Sulfonamides, Furosemide,
Metronidazole, erythromycin, Thiazides
• Metabolic Factors
• Hypertriglyceridemia
• Hypercalcemia (Through activation of trypsinogen to trypsin and
intraductal precipitation of calcium leading to ductal obstruction )

7. • Miscellaneous conditions
• Blunt and penetrating abdominal trauma
• Prolonged intraoperative hypotension
• Excessive pancreatic manipulation
• Scorpion venom stings

8. PATHOPHYSIOLOGY

10. CLINICAL FEATURES
• The cardinal symptom is epigastric or periumbilical pain that radiates to
back.
• Dehydration
• Poor skin turgor
• Tachycardia
• Hypotension
• Tachypnoea
• Bleeding into fascial planes can produce bluish discolouration of flanks
(Grey Turner sign) or Umbilicus (Cullen sign)
• Muscle guarding in upper abdomen although marked rigidity is unusual

11. CULLEN’S SIGN GREY TURNER’S
SIGN
FOX’S SIGN

12. DIAGNOSIS
• Requires two of the following 3 features:
1. Abdominal Pain
2. Threefold or higher elevation of serum amylase or lipase levels
above normal.
3. Characteristic finding of pancreatitis by imaging

13. ASSESSMENT OF SEVERITY
• Atlanta Classification of acute pancreatitis (revised in 2013)
1. Mild pancreatitis
 No organ failure
 No local or systemic complications
2. Moderate Pancreatitis
 Organ failure that resolves within 48hrs
 Local or systemic complication without persistent organ failure
3. Severe Acute Pancreatitis
 Persistent organ failure
 Single organ failure
 Multiple organ failure

17. Severity of
pancreatitis
Ranson’s criteria APACHE II CT SEVERITY INDEX
MILD PANCREATITIS ≤ 3 < 8 < 7
SEVERE
PANCREATITIS
> 3 ≥ 8 > 7
• Other scoring systems used are SAPS, SOFA, Modified Marshal
scoring System

18. IMAGING STUDIES
• These are not required for diagnosis but may be helpful in determining
need for intervention in severe cases or to rule out other diseases.
• Non specific findings in pancreatitis includes a generalized or local ileus,
Colon cut off sign and Renal halo sign
• Occasionally calcified gallstone or pancreatic calcification may be seen.
• Chest radiograph may show pleural effusion.

19. • COLON CUTOFF SIGN
Abrupt cutoff of colonic gas at the
splenic flexure.
Infiltration of the phrenicocolic
ligament results in functional spasm
and/or mechanical narrowing of the
splenic flexure at the level colon
returns to the retroperitoneum.

20. • B/L RENAL HALO SIGN
The halo appears as ground glass
attenuation on imaging, due to
enhancement of the peri-renal fat from
the retroperitoneal collection of
pancreatic exudates.

21. • USG doesn’t establish a diagnosis but it should be performed within
24hrs in all patients:
 To detect gallstones as a potential cause
 Rule out acute cholecystitis as a differential diagnosis
Determine whether the CBD is dilated
• Indication for CT:
Diagnostic uncertainty
Confirmation of severity based on clinical predictors
Failure to respond to conservative treatment or clinical deterioration.

22. • Abdominal MRI is also useful to
evaluate the extent of necrosis,
inflammation and presence of
free fluid.
• ERCP allows the identification
and removal of stones in the
CBD in gallstone pancreatitis.

23. MANAGEMENT
Cornerstones of treating acute pancreatitis:
1. Aggressive fluid resuscitation
2. Pain control
3. Early nutrition
Frequent measurement of vital signs, urine output, central venous
pressure.
Supplemental oxygen should be administered and serial ABG analysis
performed.
The Haematocrit, Clotting profile, Blood glucose and serum levels of
Calcium & Magnesium should be closely monitored.
Adequate analgesia should be administered. Narcotics are usually
preferred, especially morphine.

24. Nutritional support is vital in treatment of acute pancreatitis. The main
options to provide this are enteral feeding and total parenteral nutrition.
As per current recommendations, antibiotics are to be administered if a
pre-existing infection is present or radiographic imaging suggests infected
peripancreatic fluid collection.
ERCP can be done in case of gallstone pancreatitis.

25. COMPLICATIONS AND THEIR
MANAGEMENT

26. 1. Acute Peripancreatic Fluid collection
Occurs early in the course of mild pancreatitis without necrosis and is
located adjacent to the pancreas.
Has no encapsulating walls and is confined within normal fascial
planes.
Fluid is sterile and no intervention is necessary unless a large
collection causes symptoms or pressure effects.
Percutaneous aspiration under USG or CT guidance.
Transgastric drainage under Endoscopic USG guidance is another
option.

27. 2. Sterile and infected pancreatic necrosis
Pancreatic necrosis refers to a diffuse or local area of non- viable
parenchyma.
Typically associated with lysis of peripancreatic fat.
< 4weeks: Acute Necrotic Collection
>4 weeks: Walled off necrosis (due to development of well defined
inflammatory capsule)
Collections are sterile to begin with but often become infected due to
translocation of gut bacteria.
Internal drainage into the stomach under endoscopic USG guidance should
be considered first.
If not possible then percutaneous drainage should be considered. The tube
drain inserted should have widest bore possible.
Pancreatic Necrosectomy should be considered if sepsis worsens despite
conservative measures.

29. Pancreatic Necrosectomy
• Midline laparotomy approach.
• Duodenocolic and Gastrocolic ligaments
divided and lesser sac opened
• Thorough debridement of dead tissue
• Retroperitoneal approach through left flank
incision if body and tail are involved.
• Blunt dissection preferred over sharp
dissection
• Feeding Jejunostomy may be a useful
adjunct.
• Cholecystectomy if gallstones are
precipitating factors

30. Methods to deal with further necrotic tissue formation:
a. Closed continuous lavarge using tube drains.
b. Closed drainage using gauge filled penrose drains (removed after 7 days)
c. Open packing
d. Closed and relaparotomy every 48-72 hrs until raw area granulates

31. 3. Psuedocyst
It is a collection of amylase-rich fluid enclosed in a well defined wall of
fibrous or granulation tissue.
Pseudocysts are often single but are occasionally multiple.
More than half have communication with main pancreatic duct.
Pseudocysts that are thick walled or large, have lasted for a long time
or have arisen in context of chronic pancreatitis are less likely to
resolve spontaneously.
3 approaches to drain a pseudocyst:
a. Percutaneous
b. Endoscopic
c. Surgical

32. Percutaneous approach:
 Should be avoided
 Carries high risk of recurrence
 Not advisable until it is confirmed that cyst is not neoplastic and it has no
communication with pancreatic duct.
Endoscopic approach:
 Usually involves puncture of cyst through the stomach or duodenal wall under
endoscopic guidance and placement of a tube drain with one end in cyst cavity and
the other end in gastric lumen.
 ERCP and placement of a pancreatic stent across the ampulla to drain a pseudocyst
having communication with duct.

33. Surgical approach:
 Involves internally draining cyst into gastric or jejunal lumen.
 The approach is conventionally through open incision but laparoscopic
cystgastrostomy is also feasible.
 Pseudocyst that have developed complications are best managed surgically.

34. 4. Pancreatic abscess
Circumscribed intra-abdominal collection of pus usually in proximity of
pancreas.
Endoscopic internal drainage or percutaneous drainage with widest
possible drains is the treatment along with appropriate antibiotics and
supportive care.
Repeated scans may be required depending on the progress of
patient and drains may need to be flushed, repositioned or reinserted.
5. Pancreatic ascites
Chronic, generalized, peritoneal, enzyme rich effusion usually
associated with pancreatic duct disruption.
Adequate drainage with wide bore drains placed under imaging
guidance is essential.

35. 6. Pancreatic effusion
Encapsulated collection of fluid in peritoneal cavity, arising as a
consequence of acute pancreatitis.
Concomitant pancreatic ascites may be present or there may be a
communication with an intra abdominal collection.

36. DIFFERENTIAL DIAGNOSIS
• Peptic Ulcer disease
• Cholangitis
• Cholecystitis
• Bowel Obstruction
• Bowel Perforation
• Mesenteric Ischemia
• Acute Hepatitis
• Basilar Pneumonia
• Aortic Dissection
• Renal Colic

37. TAKE HOME MESSAGE
• Pancreatitis is a multi system pro-inflammatory disease
associated with many complications.
• The majority of presentations with pancreas are self-limiting.
• Gallstone & alcohol are the leading causes of acute
pancreatitis.
• Severe acute pancreatitis mortality is approximately 40%
• Early enteral feeding is preferred.
• Routine antibiotics are not required unless there is evidence of
an infective complication.