This document provides an overview of acute pancreatitis including its anatomy, epidemiology, pathophysiology, etiology, clinical presentation, workup, severity scoring, treatment, prognosis, and complications. It begins with definitions of the pancreas' anatomy and functions. It then discusses the disease's worldwide incidence, risk factors, presentations, diagnostic criteria, hematological and radiological evaluations, and key findings on imaging studies like CT scans. The document provides a comprehensive review of acute pancreatitis.
Acute Pancreatitis (According to American College of Gastroenterology 2013 gu...Jibran Mohsin
This Presentation focuses on definition, new classification, different scoring systems for severity, rationale for radiological signs and new management recommendations as per 2013 American College of Gastroenterology guidelines
Approach to Management of Upper Gastrointestinal (GI) BleedingArun Vasireddy
Upper gastrointestinal bleeding is gastrointestinal bleeding in the upper gastrointestinal tract, commonly defined as bleeding arising from the esophagus, stomach, or duodenum. Blood may be observed in vomit (hematemesis) or in altered form in the stool (melena). Depending on the severity of the blood loss, there may be symptoms of insufficient circulating blood volume and shock. As a result, upper gastrointestinal bleeding is considered a medical emergency and typically requires hospital care for urgent diagnosis and treatment. Upper gastrointestinal bleeding can be caused by peptic ulcers, gastric erosions, esophageal varices, and some rarer causes such as gastric cancer.
The initial assessment includes measurement of the blood pressure and heart rate, as well as blood tests to determine hemoglobin concentration. In significant bleeding, fluid replacement is often required, as well as blood transfusion, before the source of bleeding can be determined by endoscopy of the upper digestive tract with an esophagogastroduodenoscopy. Depending on the source, endoscopic therapy can be applied to reduce rebleeding risk. Specific medical treatments (such as proton pump inhibitors for peptic ulcer disease) or procedures (such as TIPS for variceal hemorrhage) may be used. Recurrent or refractory bleeding may lead to need for surgery, although this has become uncommon as a result of improved endoscopic and medical treatment.
Acute Pancreatitis (According to American College of Gastroenterology 2013 gu...Jibran Mohsin
This Presentation focuses on definition, new classification, different scoring systems for severity, rationale for radiological signs and new management recommendations as per 2013 American College of Gastroenterology guidelines
Approach to Management of Upper Gastrointestinal (GI) BleedingArun Vasireddy
Upper gastrointestinal bleeding is gastrointestinal bleeding in the upper gastrointestinal tract, commonly defined as bleeding arising from the esophagus, stomach, or duodenum. Blood may be observed in vomit (hematemesis) or in altered form in the stool (melena). Depending on the severity of the blood loss, there may be symptoms of insufficient circulating blood volume and shock. As a result, upper gastrointestinal bleeding is considered a medical emergency and typically requires hospital care for urgent diagnosis and treatment. Upper gastrointestinal bleeding can be caused by peptic ulcers, gastric erosions, esophageal varices, and some rarer causes such as gastric cancer.
The initial assessment includes measurement of the blood pressure and heart rate, as well as blood tests to determine hemoglobin concentration. In significant bleeding, fluid replacement is often required, as well as blood transfusion, before the source of bleeding can be determined by endoscopy of the upper digestive tract with an esophagogastroduodenoscopy. Depending on the source, endoscopic therapy can be applied to reduce rebleeding risk. Specific medical treatments (such as proton pump inhibitors for peptic ulcer disease) or procedures (such as TIPS for variceal hemorrhage) may be used. Recurrent or refractory bleeding may lead to need for surgery, although this has become uncommon as a result of improved endoscopic and medical treatment.
Revised Atlanta classification of Acute PancreatitisDr M Venkatesh
The most important change in Atlanta classification is the categorization of the various pancreatic collections.
In acute IEP, collections that do not have an enhancing capsule are called APFCs; after development of a capsule, they are referred to as
pseudocysts
In necrotizing pancreatitis,a collection without an enhancing capsule is called an ANC (usually in the first 4 weeks) and thereafter a WON, which has an enhancing capsule.
The most important distinction between collections in necrotizing pancreatitis and those associated with acute IEP is the presence of nonliquefied material in collections due to necrotizing pancreatitis.
Case Report : Integrating Review Inflammation and Commorbid diseasesSoroy Lardo
Diabetes is associated with atherosclerosis and COPD contributed to the chronic inflammation within the systemic vascular. Management of CVI with diabetes and COPD requires multi-disciplinary approach
Revised Atlanta classification of Acute PancreatitisDr M Venkatesh
The most important change in Atlanta classification is the categorization of the various pancreatic collections.
In acute IEP, collections that do not have an enhancing capsule are called APFCs; after development of a capsule, they are referred to as
pseudocysts
In necrotizing pancreatitis,a collection without an enhancing capsule is called an ANC (usually in the first 4 weeks) and thereafter a WON, which has an enhancing capsule.
The most important distinction between collections in necrotizing pancreatitis and those associated with acute IEP is the presence of nonliquefied material in collections due to necrotizing pancreatitis.
Case Report : Integrating Review Inflammation and Commorbid diseasesSoroy Lardo
Diabetes is associated with atherosclerosis and COPD contributed to the chronic inflammation within the systemic vascular. Management of CVI with diabetes and COPD requires multi-disciplinary approach
Nephritis is a inflammation of kidney .
It is classified into various types like lupus nephritis ,interstitial nephritis , glomerulonephritis ,pyelonephritis.
Lupus nephritis is an inflammation of kidney due to autoimmune disorder named as lupus .
It is inflammation of lower urinary tract .
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
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Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
3. Anatomy
• Pancrease is a complex lobulated structure.
• Its retroperitoneal organ that lies in an oblique
position, sloping upward from the C-loop of
duodenum to the splenic hilum.
• It has both exocrine and endocrine components.
• Endocrine components is less is less then 1 %
of whole panrease which secret many regulatory
harmones while exocrine portion secret many
digestive anatomy.
4.
5. Epidemiology
• World wide incidence ranges between 5 and 80 per 100,000
population.
• Generally Male > Female
• In males more often related to alcohol
• In females more often related to biliary tract disease.
» Geographical
• Highest incidence worldwide is recorded in the United States and
Finland ( 73.4 cases per 100,000)
• Mortality: 2-3% overall mortality from acute pancreatitis
• Physician Visits: 911,000 per year.
• Hospitalizations: Around 230,000 per year
• Deaths: 2500 per year.
6. • The median age of onset depends on the
etiology:
• AIDS related – 31 years
• Vasculitis related – 36 years
• Achohol related – 39 years
• Drug induced etiology – 42 years
• ERCP related – 58 years
• Trauma related – 66 years
• Biliary tract related – 69 years
9. Clinical Presentation
• Pain ( 95% )
• Acute onset
» Mid-abdominal or mid-epigastric
» Radiates to back (50%)
» Peak intensity in 30 mints
» Last for several hours,
» Severe in intensitiy
» Relieved with sitting or leaning forward
( Muhammedan Prayer Sign)
Aggrevated with food,alcohol, walking or lying supine
10. Other Menifestations
• Nausea, frequent and effortless vomiting,
anorexia,diarrhea
– Due to reflex pylorospasm
– More intense in necrotizing than in edematous
pancreatitis.
• Persistent retching
– despite empty stomach
• Hiccups
– Due to gastric distension/diaphragmatic irritation
• Fever
– Low grade
• Weakness, Anxiety, Sweating
– Indicates severe attack
• Polyarthritis
11. General Physical Examination
• Appearance: well gravely ill with profound shock, toxicity and
confusion.
• Vitals: Tachypnea(and dyspnea-10%), Tachycardia(65%), Hypotension,
temp high(76%)/normal/low (acute swinging pyrexia in cholangitis)
• Icterus(28%)
– gallstone pancreatitis or due to edema of pancreatic head.
• Cyanosis
– Improper lung perfusion
• Pallor, cold clammy skin,diaphoretic
12. Abdominal Examination
• Tenderness + Rebound tenderness:
– epigastrium/upper abdomen
• Distension:
– Ileus(BS decreased or absent)
– ascites with shifting dullness
• Mass in epigastrium(usually absent)
– due to inflammation
• Guarding(also called “defense musculaire” )-upper abdomen
– tensing of the abdominal wall muscles to guard inflamed organs within
the abdomen from the pain of pressure upon them(i.e. during palpation)
• Rigidity(involuntary stiffness)-unusual
– Tensing of the abdominal wall muscles to guard inflamed organs even if
patient not touched
13. Cutaneous Ecchymosis (1% cases)*
Acute Hemorrhagic Necrotizing/fulminant
Pancreatitis Periperitoneal/retroperitoneal
Hemorrhage
Methemalbumin formed from digested blood
tracks around
Fascial planes
hemorrhagic
spots and
ecchymosis in
flanks
(GREY
TURNER’S
SIGN)**
FALCIFORM
LIGAMENT
Bluish
Discoloration
around
umbilicus(CULLEN’S SIGN)
(umbllical black
eye)
Below inguinal
ligament
(FOX SIGN)
*Neither sign is pathognomonic of acute
**More commonly, ruddy
erythema in flanks due to
extravasated pancreatic
exudate
14. Differential Diagnosis
GREY TURNER/CULLEN/FOX SIGNs
Acute Pancreatitis
Pancreatic Hemorrhage
Ruptured AAA
Blunt Abdominal Trauma
Ruptured Ectopic Pregnancy
Retroperitoneal Hemorrhage
Coagulopathy
: George Grey Turner Thomas Stephen Cullen
16. Respiratory Examination
• Left sided Pleural Effusion (10-20%)
• Pulmonary edema
• Pneumonitis
– These all can result in
» Reduced Chest movements
» Decreased vocal fremitus/resonance
» Stony dull percussion notes
» Decreased air entry basally bilaterally
» Basal fine mid/end inspiratory crepitation’s that don’t
can with cough.
18. Other Manifestations
• Subcutaneous fat necrosis
– Small(<1 cm), red, tender nodules on
extensor skin of legs
• Purtscher retinopathy(on fundoscopy)
– Activation of complement and agglutination
of blood cells within retinal vessels causing
Ischemic injury of retina
– May cause temporary or permanent
blindness
19. Manifestation of Complications
• Hypocalcaemia
– circumoral numbness or paresthesia (1st symtpom to develop) /tingling
of
distal extremities
– carpopedal spasm (=main d'accoucheur- French "hand of the
obstetrician”)
• Flexion of wrist and MCP joints with extension of IP joints
– laryngospasm
– generalized seizures
– Chvostek*(-Weiss) sign
• Depending on calcium level, graded response occur: twitching first at angle of
mouth, then by nose, the eye and the facial muscles
• Positive in 10 % population in absence of hypocalcaemia
– Trousseau** sign of latent tetany
• BP cuff around arm and inflating to 20 mmHg above SBP for 3-5 minutes
• Carpal spasm observed
• More specific and sensitive than chvostek sign(postive even before
tetany/hyperreflxia)
21. • A 44-year-old woman comes to the emergency department with severe epigastric pain
• that radiates to her back. The pain was sudden in onset and has remained steady for
• the past several hours. She has associated nausea and vomiting. Past medical history
• is notable for a surgically repaired femoral hernia and appendectomy as a child. The
• patient takes no medications and does not use tobacco, alcohol. or recreational drugs.
• Temperature is 37.2 C (98.9 F). blood pressure is 112170 mm Hg. pulse is 98/min. and
• respirations are 18/mln. BMIIs 35 kg/m'. Examination shows an agitated woman who
• sits leaning forward on the bed. Her skin has no evidence of icterus or excoriations.
• Lungs are clear to auscultation and heart sounds are normal. There is moderate
• tenderness in the epigastrium but no guarding, rebound tenderness, or
• hepatosplenomegaly. Bowel sounds are normal. Laboratory results are as follows:
• Serum chemistries
• Albumin 4.8 g/dl
• Total bilirubin 1.0mg/dl
• Alkaline phosphatase 291 U/L
• Aspartate aminotransferase 133 U/L
• Alanine aminotransferase 172 U/L
• Amylase 2610 U/L
• Lipase 3680 U/L
• Triglycerides 110mg/dl
• Calcium 8.9 mg/dl
• Hemoglobin 12.6 g/L
• Platelets 340,000/mm3
• Leukocytes 14,100/mm3.
•
• Which of the following is the best next step in evaluating the underlying etiology of the patient’s acute conditon
• 1) CT scan of the abdomen
• 2) HIDA scan
• 3) Radiograph of the abdomen
• 4) Abdominal Ultrasound
5) Serologic testing for viral titers.
22. 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 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
23. Famous People who hadFamous People who had APAP
• Alexander the Great
• Ludwig von Beethoven
• Dizzie Gillespie
• Maximilian Schell
• Matthew Perry
• John Ashcroft
Acute
25. Hematological
• BASELINES
– CBC:
• Low Hb: prolonged hemetemesis/melena, internal hemorrhage
• Leucocytosis (10,000-30,000/mcL)-infection, non infectious
inflammation
• Low platelets-DIC
• Hct –raised in hemoconcentration
– LFT’s:
• raised bilirubin, AST/ALT/LDH, ALP, GGTP- gall stone
pancreatitis
– RFT’s:
• raised BUN/cretainine- ATN ARF
– Coagulation profile:
• increased INR-DIC
– BSR: > 180 mg/dl-diabetes as a sequelae or cause
– Serum electrolytes:
• Low sodium/potassium: persistent
vomiting
• Hypocalcemia- saponification/fat
necrosis
– Serum Protein: Low protein/albumin
26. Hematological
• ABG’s
• Acid-Base Disturbance Etiology
• Metabolic (lactic) acidosis with high anion gap Hypovolumic shock
• Chloride responsive Hypokalemic Hypochloremic Persistant Vomiting
metabolic alkalosis.
Respiratory Acidosis ARDS/Resp Failure
• Etiology specific investigations
– Serum fasting lipid profile
– Viral titers
– Serum Calcium (HypercalcemiaAPHypocalcemia)
– Autoimmune markers
• increased serum levels of IgG4
• serum autoantibodies such as anti-nuclear antibody (ANA), anti-
lactoferrin
antibody, anti-carbonic anhydrase II antibody, and rheumatoid factor (RF),
27. Hematological
• Pancreatic Enzyme’s Assay
– Serum Amylase:
• ONSET: almost immediately
• PEAK: within several hours
– Serum Lipase:
• more sensitive/specific than amylase
• Remains elevated longer than amylase(12
days)
• Useful if late presentation
– 3-4 times upper limit of normal within 24 hrs (90%)
•RETURN to normal depends on severity(3-5 days)
•normal at time of admission in 20% cases
•Compared with lipase, returns more quickly to values
below the upper limit of normal.
SERUM INDICATOR OF HIGHEST
28. • Pancreatic Enzymes’ Assays
– Urine Amylase
• More sensitive than serum levels
• Remain elevated for several days after serum levels
returned to normal
– Pancreatic-specific amylase(p-amylase)
• Measuring p-amylase instead to total amylase(also
includes salivary amylase) makes diagnosis more
specific(88-93%)
29. Plain X-ray abdomen erect AP view
• Xray erect abdomen is non-diagnostic and non-specific but there
are some signs which may be found in acute pancreatitis.
• Sentinel loop sign
• Localized isolated distended gut loop ( ileus) seen near th site of inflammed
organ
• Colon cutoff sign
• Gas filled ( distended) segment of proximal ( mainly transverse) colon
associated with narrowing of the splenic flexure.
• Renal Halo sign
• Peripancreatic inflammatory reaction with extension into pararenal space.
33. Abdominal U/S
• Not diagnostic
• Should be performed within 24 hours in all
patients to
– detect gall stones as a potential cause
– Rule out acute cholecystits as differential diagnosis
– Detect dilated CBD
– sensitivity-(70-80%)
– DEMERIT: overlying gas shadows 2ndary to bowel
distension
• THERAPEUTIC:
– USG-guided aspiration for gram staining and culture
– USG-guided pig tail catheter insertion
34. Contrast enhanced CT scan
• Provides over 90 % sensitivity and specificity for the diagnosis of AP….. BUT
• Routine use in patients with AP is unwarranted, as the diagnosis is apparent in
many patients and most have a mild, uncomplicated course.
• When do I Order a CT scan ???
• If the patient has
• Signs of severe acute pancreatitis
• No signs of clinical improvement after several days.
• Diagnostic dilemma
• Infection suspected
• Temp > 101 F
• Positive blood cultures
What Kind of CT??
Dynamic with rapid bolus of IV contrast ( CT with pancreatic
protocols )
What are you looking for on CT??
Necrosis: Lack of enhancment with contrast
Fluid collections
Alternate diagnosis.
35. CT scan Findings
• Pancreas
• Pancreatic enlargement
• Decreased density due to edema
• Intrapancreatic fluid collections
• Blurring of gland margins due to inflammation
• Peripancreatic
• Fluid collections and stranding densities
• Thickening of retroperitoneal fat
* It may take up to 72h for inflammatory changes to become apparent on
CT *
Acute
36. CT Scan FindingsCT Scan Findings
Tail
Indistinct
Intraperitoneal
fluid
PANC
Acute
LIVE
R
39. Therapeutic Indications of CT
– CT-guided aspiration of fluid
collection/necrotic tissue for gram staining
and culture(sterile vs infected necrosis)
– specimen should be delivered to the
laboratory within an hour and interpreted
promptly
– CT-guided pig tail catheter insertion
40. MRI
Suitable alternative to CT in patients with
a contrast allergy and renal insufficiency
where T2-weighted images without
gadolinium contrast can diagnose
pancreatic necrosis
41. MRCP
• INDICATION:
– diagnosis of suspected biliary and pancreatic duct
obstruction in the setting of pancreatitis.
– Repeated attacks of idiopathic acute pancreatitis
• Merit
– used if choledocholithiasis is suspected but there is
concern that
pancreatitis might worsen is ERCP is performed
– Provide non-invasive/fast/safe high-quality (Heavily T2–
weighted) imaging for diagnostic and/or severity purposes
42. Endoscopic US
• INDICATIONS
– Repeated idiopathic acute pancreatitis*
• occult biliary disease- small stones/sludge
• secretin-stimulated EUS study may reveal resistance to ductal outflow
at the level of the papilla,
– as evidenced by dilatation of the pancreatic duct to a greater extent and longer duration
than in a healthy population
– Age >40 to exclude malignancy
• especially those with prolong or recurrent course
• RATIONALE: 5 % CA pancreas present as AP
*Endoscopic investigation in patients with acute idiopathic pancreatitis should be
limited, as the risks and benefits of investigation in these patients are unclear and
should be referred to centers of expertise.
43. ERCP
INDICATION
•Severe gallstone AP or AP with concurrent acute cholangitis/biliary
obstruction/ biliary sepsis/jaundice (due to persistent stone)
• ERCP within 24(-72) h of admission
•Sphincterotomy/stent and bile duct clearance reduces infective
complications/mortality
NOT INDICATED
•Not needed early in most patients with gallstone pancreatitis who lack
laboratory or clinical evidence of ongoing biliary obstruction
– As most of gallstones causing AP readily pass to
duodenum and are lost in stool
– MRCP or EUS recommended if CBD stone still
suspected
• as risk of post-ERCP pancreatitis is greater with normal calibre bile duct and
normal bilirubin
• MRCP /EUS as accurate as diagnostic ERCP
44. Clinical Severity Scoring
Systems
ACUTE PANCREATITIS SPECIFIC SCORING
SYSTEMS
–Ranson score
– Atlanta Score
–POP score ( Panreatic outcome Prediction Score )
–Bedside Index for Severity in Acute Pancreatitis(BISAP) score
–Harmless Acute Pancreatitis Score(HAPS)
–Hong Kong Criteria
ACUTE PANCREATITIS NON-SPECIFIC SCORING
SYSTEMS (ICU SCORING SYSTEMS)
–Acute Physiology And Chronic Health Evaluation(APACHE) II
score
–Sequential Organ Failure Assessment(SOFA) score
51. Management Questions
Acute
• When should patients admitted with AP be monitored
in an ICU or step-down unit?
• Should patients with SAP receive prophylactic abx?
• What is the optimal mode and timing of nutritional
support for the patient with SAP?
• What are the indications for surgery in AP; optimal timing for
intervention, and roles for less invasive approaches including
percutaneous drainage and laparoscopy?
52. When do I transfer to unit?
Acute
• Severe pancreatitis
• Multi-organ failure
• Pulmonary
• Renal
• Consider it if you are placing the
patient on antibiotics and/or
ordering a CT to evaluate non-
improvement
53. Management
Acute
Mild-Moderate
•NPO with IVF (crystalloid)
• Colloid (blood if Hct <25, albumin if serum alb <2)
•Closely follow
•Generous narcotic
•NGT decompression
• if frequent emesis or evidence of ileus on plain films
•Start clear liquids when pain/anorexia resolve
•DO NOT follow amylase and lipase levels
54. • A 44-year-old woman comes to the emergency department with severe epigastric pain
• that radiates to her back. The pain was sudden in onset and has remained steady for
• the past several hours. She has associated nausea and vomiting. The
• patient takes no medications and does not use tobacco, alcohol. or recreational drugs.
• Temperature is 37.2 C (98.9 F). blood pressure is 112170 mm Hg. pulse is 98/min. and
• respirations are 18/mln. BMIIs 35 kg/m'. Examination shows an agitated woman who
• sits leaning forward on the bed. Her skin has no evidence of icterus or excoriations.There is moderate
• tenderness in the epigastrium but no guarding, rebound tenderness, or
• hepatosplenomegaly. Bowel sounds are normal. Laboratory results are as follows:
• Serum chemistries
• Albumin 4.8 g/dl
• Total bilirubin 1.0mg/dl
• Alkaline phosphatase 271 U/L
• Aspartate aminotransferase 133 U/L
• Alanine aminotransferase 172 U/L
• Amylase 2610 U/L
• Lipase 3680 U/L
• Triglycerides 110mg/dl
• Calcium 8.9 mg/dl
• Hemoglobin 12.6 g/L
• Platelets 340,000/mm3
• Leukocytes 14,100/mm3.
• Diagnosis of Acute pancreatits was made. He was started on IV fluid and analagesic. His condition didn’t
improved. CT scan was done which showed 35% necrosis. What is the next best step in the management of this
patient.
• A) Necrosectomy
• B) IV antibiotics
• C) Percutaneous aspiration
• D) IV steroids
55. When Do I start Antibiotics?
Acute
• Acute pancreatitis with infection ~ 10%
• 30-50% of those with necrosis get infection
• Prophylactic antibiotics
• Controversial
• No benefit in mild acoholic pancreatitis
• Imipenem or meropenem in necrotizing pancreatitis
• Selective gut decontamination may be beneficial
• Abx do not appear to promote fungal infection
• General recommendations for use:
• Biliary pancreatitis with signs of cholangitis
• > 30% necrosis on CT scan
56. When can Patient Eat?
Nutritional issues in AP
• It is no longer acceptable to rest the pancrease by avoiding nutrition.
• TNP vs Enteral feeding ?
– No TPN per meta-analysis unless the calculated nutritional
requirements cannot be achieved by enteral route only.
– Enteral feeding should be commenced after initial fluid resuscitation and
within first 24 hours of admission.
– NJ feeding better then NG feeding but first start with NG feeding.
– If there is feeding intolerance with NG then the tube can be advanced to
the jejunum by endoscopy or floroscopy.
• Early initiation of enteral nutriton in severe AP
– Tube feed if anticipate NPO > 1week
– Reduce microbial translocation
– Enhance gut mucosal blood flow
– Promote gut mucosal surface immunity
– These all reduce incidence of infected necrosis
57.
58. Role of Surgery in AP
• In case of mild gallstone AP, cholecystectomy should be performed
before
discharge to prevent a recurrence of AP
– Within 48-72 hour od admission or briefly delay intervention(after 72 hrs
but during same admission
– Along with intraoperative cholangiography and any remaining CBD
stones can be dealt with intra/post operative ERCP or
– Along with preoperative EUS or MRCP
• In case of necrotizing biliary AP, in order to prevent infection,
cholecystectomy is to be deferred until active inflammation subsides
and fluid collections resolve or stabilize
• Cholecysectomy done for recurrent AP (IAP) with no stones/sludge
on USG and no significant elevation of LFTs is associated with >50
% recurrence of AP
If patient unfit for surgery(comorbid/elderly), biliary sphincherotomy
alone
may be effective to reduce further attacks of AP
61. Management of Pancreatic Complications
• Infected necrosis
• Organisms on gram
stain after aspirate
• Surgical drainage
• Trans-gastric drainage
• Try to delay
necrosectomy 2-3wk
for demarcation of
necrosis
• Pancreatic
abscess
• CT or EUS guided
drainage
• Walled collection of
pus
• Similar to
management of
pseudocyst
62. Pseudocyst
Acute
• Collection of pancreatic fluid
enclosed by non-epithelialized wall
of granulation tissue
• Complicates 5-10% cases of AP
• ~ 4 weeks after insult
• 25-50% resolve spontaneously
63. Complications of Pseudocyst
Acute
• Infection - 14%
• Rupture - 6.8%
• Hemorrhage - 6.5%
• Common bile duct obstruction - 6.3%
• GI obstruction - 2.6%
67. When to discharge Pateint?
• Pain is well controlled with oral analgesia
• Able to tolerate an oral diet that maintains
their caloric needs.
• All complications have been addressed
adequately.