A 42-year-old woman presents with acute onset of epigastric pain radiating to the back along with nausea and vomiting. Physical exam reveals mid-epigastric tenderness and mild ileus on abdominal radiography. Ultrasonography of the abdomen is the most appropriate next step, as it can detect gallstones, the most common cause of acute pancreatitis in the United States. Serum lipase and amylase are also elevated in most cases of pancreatitis and help make the diagnosis.

1. PANCREATITIS (ACUTE & CHRONIC)
90

2. 1-Manage severe acute pancreatitis
► A 34-year-old woman
► is evaluated for continued severe mid-epigastric pain that radiates to the
back-nausea-vomiting………5 days after being hospitalized for acute
alcohol-related pancreatitis
► She has not been able eat or drink and has not had a bowel movement
since being admitted
► On physical examination the temperature is 38.2 °C -blood pressure is
132/84 mm Hg-pulse rate is 101/min-respiration rate is 20/min-no scleral
icterus or jaundice-abdomen is distended and diffusely tender with
hypoactive bowel sounds

3. ► CT scan of the abdomen shows a diffusely
edematous pancreas with multiple
peripancreatic fluid collections, and no
evidence of pancreatic necrosis
Which of the following is the most appropriate
next step in the management of this patient?
A- Enteral nutrition by nasojejunal feeding
tube
B-Intravenous imipenem
C-Pancreatic débridement
D-Parenteral nutrition

4. ► Enteral feeding is the preferred route of providing nutrition in patients with
severe acute pancreatitis
► This patient has moderate to severe acute pancreatitis and after 5 days
remains febrile, continues to be in pain, and cannot take in any oral nutrition
► The patient will likely have an extended period before being able to take in
oral nutrition
► Two routes are available for providing nutrition in patients with severe acute
pancreatitis enteral nutrition-parenteral nutrition
► Enteral nutrition is provided through a feeding tube ideally placed past the
ligament of Treitz so as not to stimulate the pancreas
► Parenteral nutrition is provided through large peripheral or central
intravenous line
► Enteral nutrition is preferred over parenteral nutrition because of its lower
complication rate……..especially a lower infection rate
► Enteral nutrition is associated with a significantly lower incidence of
infections-reduced surgical interventions to control complications of
pancreatitis-reduced length of hospital stay-faster attenuation of
inflammation-fewer septic complications

5. ► Imipenem therapy is only helpful in acute pancreatitis when there is
evidence of pancreatic necrosis
► Pancreatic necrosis is diagnosed by contrast-enhanced CT scan……….that
shows nonenhancing pancreatic tissue
► In patients with noninfected pancreatic necrosis, prophylactic antibiotics
may↓incidence of sepsis-↓systemic complications (for example, respiratory
failure)-↓local complications (for example, infected pancreatic necrosis or
pancreatic abscess)
► antibiotic use in acute pancreatitis of mild to moderate severity shown no
benefit from-but may lead to development of nosocomial infections with
resistant pathogens
► Similarly pancreatic débridement is recommended only in infected
pancreatic necrosis

6. 2-Diagnose pancreatic necrosis
► A 44-year-old man with a long history of alcohol abuse is evaluated on the sixth
day of hospitalization for acute pancreatitis
► On admission to the hospital he was afebrile-blood pressure was 150/88 mm Hg-
pulse rate was 90/min-respiration rate was 16/min
► Abnormal findings were limited to the abdomen, which was flat and tender to
palpation -without peritoneal signs-Bowel sounds were normal
► Plain abdominal and chest radiographs were normal
► Abdominal ultrasonography revealed a diffusely enlarged, hypoechoic pancreas
-without evidence of gallstones or dilated common bile duct
► He was treated with aggressive intravenous hydration and opioid analgesia
► For the past 2 days, the patient has had repeated febrile episodes-persistent
severe abdominal pain-increasing shortness of breath

7. ► On physical examination T 38.6 °C -BP 98/60 mm Hg - pulse rate is 112/min- RR
22/min-oxygen saturation is 92% with the patient breathing oxygen 3 L/min-Breath
sounds are decreased at the base of both lungs-The abdomen is distended and
diffusely tender with hypoactive bowel sounds
► Laboratory studies reveal leukocyte count of 19,800/µL-creatinine 1.4 mg/dL
-amylase 388 U/L-lipase 842 U/L.
► Which of the following is the most appropriate next step in the evaluation of this
patient?
A- CT scan of the abdomen with intravenous contrast
B-Endoscopic retrograde cholangiopancreatography
C-Endoscopic ultrasonography
D-Stool chymotrypsin

8. ► CT scan of the abdomen with intravenous contrast is the most sensitive test
to diagnose pancreatic necrosis
► Pancreatic necrosis should be suspected in a patient with severe acute
pancreatitis ………..whose condition is not improving or is worsening after 5
days or more of treatment
► Pancreatic necrosis on CT scan can be identified as unenhanced areas of
the pancreas
► pancreatic necrosis in the setting of acute pancreatitis cannot detect by
endoscopic retrograde cholangiopancreatography or endoscopic
ultrasonography

9. ► Stool chymotrypsin can be measured when
chronic pancreatitis is suspected………..to help
evaluate for decreased pancreatic function
► Pancreatic necrosis is the most important
predictor of poor outcome in acute pancreatitis
► Patients who develop pancreatic necrosis
should be given antibiotic prophylaxis, usually
with imipenem
► The necrosis should be sampled for the
presence of infection………….and if infection is
present, surgical débridement is recommended

10. 3-Manage gallstone pancreatitis
► A 55-year-old woman
► is evaluated in the hospital for a 2-day history of epigastric abdominal pain -
nausea and vomiting - anorexia
► The patient has no significant medical history
► takes no medications
► On physical examination temperature is 38.0 °C - blood pressure is 124/76
mm Hg - pulse rate is 99/min - respiration rate is 16/min - There is scleral
icterus and a slight yellowing of the skin - mid-epigastric and right upper
quadrant tenderness - no palmar erythema, spider angiomata, or other
evidence of chronic liver disease

11. ► Abdominal ultrasonography shows a biliary tree with a dilated
common bile duct of 12 mm and cholelithiasis but no
choledocholithiasis
► Which of the following is the most appropriate next step in the
management of this patient?
A-CT scan of the abdomen and pelvis with pancreatic protocol
B- Endoscopic retrograde cholangiopancreatography
C-Hepatobiliary iminodiacetic acid (HIDA) scan
D-Magnetic resonance cholangiopancreatography

12. ► In patients with gallstone pancreatitis and evidence of biliary obstruction,
endoscopic retrograde cholangiopancreatography and stone removal will
reduces morbidity and mortality…………..by reducing the risk of biliary sepsis
► This patient has a classic presentation of acute pancreatitis with the acute onset
of epigastric abdominal pain, nausea, and vomiting - associated with markedly
elevated pancreatic enzymes
► The presence of stones in the gallbladder- dilated bile duct - elevated
aminotransferase levels…………….highly suggest gallstones as the cause of
pancreatitis
► The presence of scleral icterus – jaundice - elevated bilirubin level…….suggest
continuing bile duct obstruction
► Abdominal ultrasonography has a sensitivity of only 50% to 75% for
choledocholithiasis
► a common duct stone should be suspected in the correct clinical situation even
when ultrasonography does not show a stone
► Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy
and stone removal…..is the most appropriate procedure in patients with acute
gallstone pancreatitis and with imaging and biochemical evidence of biliary
obstruction from a common duct stone

13. ► The procedure can document the diagnosis of
choledocholithiasis and remove the gallstones………..which
lessens the morbidity and mortality due to biliary sepsis.
► CT scan acute pancreatitis and the presence of a common duct
stone=sensitivities ranging from 80% to 100%
► magnetic resonance cholangiopancreatography (MRCP) will
show acute pancreatitis and the presence of a common duct
stone=sensitivities ranging from 80% to 100%
► ERCP = diagnosis of choledocholithiasis
► Biliary scintigraphy may show obstruction of the cystic or
common bile duct…..but will not determine the cause
► However CT - biliary scintigraphy and MRCP………are not be
therapeutic for bile duct stones

14. 4-Evaluate acute pancreatitis
► A 42-year-old woman
► is evaluated in the emergency department for the acute onset of epigastric
pain …that radiates to the back …and is associated with nausea and
vomiting
► The patient had previously been healthy
► no history of alcohol or tobacco use
► Her only medication is an oral contraceptive pill
► On physical examination=temperature is 37.2 °C - blood pressure is 158/90
mm Hg - pulse rate is 101/min - respiration rate is 20/min - no scleral icterus
or jaundice
► The abdomen is distended with mid-epigastric tenderness - no rebound or
guarding - hypoactive bowel sounds

15. ► Radiography of the abdomen shows mild ileus
► Which of the following is the most appropriate
next step in the evaluation of this patient?
A-CT scan of the abdomen and pelvis
B-Endoscopic retrograde
cholangiopancreatography
C-Esophagogastroduodenoscopy
D- Ultrasonography of the abdomen

16. ► Gallstones=most common cause of acute pancreatitis in the United States -
diagnosed with abdominal ultrasonography
► The diagnosis of pancreatitis relies heavily on the serum amylase and
lipase…….which are elevated in 75% to 90% of patients
► Serum lipase is more specific and stays elevated longer than amylase
► The two most common causes of acute pancreatitis in the United States are
alcohol and gallstones
► this patient who does not consume alcohol , so gallstones are the most likely
cause of acute pancreatitis as shown by the pattern of liver enzymes
► Abdominal ultrasonography is the most sensitive test for detecting the
presence of gallstones and ductal dilation - can provide indirect evidence for
the presence of a retained common duct stone - Ultrasonography = has no
risk + widely available + inexpensive

17. ► CT scan is less sensitive than ultrasonography for the detection of
cholelithiasis
► CT with contrast is indicated in patients with moderate or severe pancreatitis
= to confirm the diagnosis - to grade the severity of pancreatitis - to
diagnose local complications such as pancreatic necrosis , pseudocyst &
abscess
► Magnetic resonance cholangiopancreatography is used if there is a
contraindication to intravenous radiocontrast
► Endoscopic retrograde cholangiopancreatography (ERCP) is the most
sensitive test for choledocholithiasis - can provide direct treatment by
removing common duct stones
► ERCP is indicated in patients with - persisting pancreatitis - persistent
elevation of aminotransferase levels - dilated bile ducts suggesting the
presence of retained bile duct stones - can do stone extraction with biliary
sphincterotomy so improves the outcome, prevents further attacks of acute
biliary pancreatitis, and reduces pancreatitis
► But in this patient there is not enough evidence yet that a common duct
stone is still present to perform this more invasive test before
ultrasonography
► Upper endoscopy = no role in determining the cause of acute pancreatitis

18. 5-Diagnose chronic pancreatitis
► A 51-year-old man
► is evaluated for an 8-month history of mid-epigastric pain that is worse after
eating - six to eight bowel movements a day usually occurring after a meal -
loss of 6.8 kg over the past 6 months
► The patient drinks six to eight cans of beer a day
► He takes no medications
► On physical examination BMI 21 - normal bowel sounds - mid-epigastric
tenderness - no hepatosplenomegaly or masses
► Rectal examination reveals brown stool - negative occult blood
► The remainder of the examination is normal
► Plain radiograph of the abdomen shows a normal bowel gas pattern and is
otherwise normal

19. Which of the following tests is most likely to
establish the diagnosis in this patient?
A-Colonoscopy
B- CT scan of the abdomen
C-Measurement of serum antiendomysial
antibodies
D-Stool for leukocytes, culture, ova, and parasite

20. ► Patients with chronic pancreatitis=the three classic findings in chronic
pancreatitis are abdominal pain that is usually mid-epigastric - postprandial
diarrhea - and diabetes mellitus secondary to pancreatic endocrine
insufficiency
► This patient has chronic pancreatitis secondary to alcohol abuse…………
SO has resulted in malabsorption
► Malabsorption occurs in patients with chronic pancreatitis when
approximately 80% of the pancreas is destroyed
► because the damaged pancreatic gland is no longer producing the
pancreatic exocrine enzymes to absorb food so malabsorption occurs that
presents with diarrhea and steatorrhea - weight loss - deficiencies of fat-
soluble vitamins
► Patients with a typical presentation may not need additional testing
► However, most patients with chronic pancreatitis have only nonspecific
abdominal pain ………….so require diagnostic radiographic imaging studies

21. ► The presence of pancreatic calcifications on radiographs confirms the
diagnosis
► Plain films of the abdomen will show pancreatic calcifications in
approximately 30% of patients…………so confirms the diagnosis
► But most patients require abdominal CT scans, which are able to detect
pancreatic calcification in up to 90% of patients
► CT scanning can also exclude other causes of pain
► Radiographic evidence of pancreatic ductal dilation – pseudocysts - or mass
lesions ………….may also help identify the cause of pain and determine the
type of therapy
► Antiendomysial antibodies are a marker for celiac disease ……….. but
celiac disease is unlikely in this patient with an evident history of pancreatic
malabsorption

22. ► colonoscopy is indicated as a screening tool for
asymptomatic patients beginning at the age of 50
years - and for patients with a change in bowel
habits and weight loss
► But this patient’s history suggests pancreatic
malabsorption so colonoscopy is less likely than
abdominal CT scan to confirm the diagnosis
► Stool studies are appropriate fordetermining the
cause of an acute infectious diarrhea……but this
patient has had diarrhea for 8 months
…………..so infectious diarrhea is not usually
associated with such a degree of weight loss

23. 6-Diagnose chronic pancreatitis
► A 42-year-old man
► is evaluated in the hospital for a 1-year history of postprandial abdominal pain that
radiates to the back -worse after eating - and is associated with nausea
► He has no (vomiting -weight loss -change in bowel habits)
► The patient has had at least five alcohol-containing drinks a day for 20 years
► he has reduced his intake in the past year because of continued abdominal pain
► On physical examination vital signs are normal - BMI is 24 - mild epigastric tenderness
- no guarding or rebound - normal bowel sounds
► Laboratory studies reveal normal complete blood count - normal fasting glucose -
normal liver chemistry tests - amylase is 221 U/L and lipase 472 U/L.
► esophagogastroduodenoscopy , AXR, ultrasonography, and CT scan of the abdomen
are normal
► Which of the following is the most appropriate next step in the evaluation of this patient?
A-Biliary scintigraphy
B-Colonoscopy
C- Endoscopic retrograde cholangiopancreatography
D-easurement of stool elastase

24. ► Endoscopic retrograde cholangiopancreatography is the most sensitive
imaging test for chronic pancreatitis
► diagnosis of chronic pancreatitis in a patient with early disease can be
difficult
► No blood or stool tests are currently available for the accurate diagnosis of
early chronic pancreatitis
► This patient’s pain is most likely secondary to chronic pancreatitis with
minimally elevated pancreatic enzymes and a history of harmful drinking
► The patient has no evidence of exocrine or endocrine insufficiency and thus
likely has early chronic pancreatitis
► Normal liver enzymes, normal upper endoscopy, and a normal abdominal
ultrasonography and CT scan of the abdomen make biliary causes and
peptic ulcer disease………less likely the cause of pain
► Endoscopic retrograde cholangiopancreatography (ERCP) has a sensitivity
of nearly 95% for chronic pancreatitis - can show ductal dilation,strictures
and irregularity in both the main duct and its side branches

25. ► CT scan of the abdomen =has a sensitivity of up to 90% for diagnosing
chronic pancreatitis and should be ordered with thin cuts of the pancreas to
improve sensitivity
► Endoscopic ultrasonography=may also be used to diagnose chronic
pancreatitis - sensitivities is equal to ERCP for moderate and advanced
chronic pancreatitis - but with lower sensitivity and specificity for mild and
early chronic pancreatitis
► Magnetic resonance cholangiopancreatography does not have sensitivities
or specificities that match ERCP in the diagnosis of mild and early chronic
pancreatitis and cannot be routinely recommended
► Biliary scintigraphy is used to diagnose acute cholecystitis - but does not
have a role in diagnosing chronic pancreatitis
► Stool elastase can be abnormal in patients with more advanced chronic
pancreatitis=particularly those who have malabsorption - but stool elastase
has poor sensitivity in patients with early chronic pancreatitis
► Colonoscopy has a low yield in patients with upper abdominal pain

26. 7-Treat chronic pancreatitis with pancreatic duct stones
► A 38-year-old man is evaluated for a 2-month history of progressive mid-epigastric
pain that is worse after eating - postprandial nausea - 4.6-kg weight loss
► The patient has a 5-year history of chronic pancreatitis
► has six alcohol-containing drinks a day
► His medications are Amitriptyline - oral morphine - and pancreatic enzyme
supplements
► On physical examination BMI 20 - appears to be in mild distress - There is epigastric
tenderness without rebound or guarding - The liver is slightly enlarged, but there are
no palpable masses
► Laboratory studies reveal normal complete blood count - serum amylase of 175 U/L
- lipase of 333 U/L
► CT scan of the abdomen and pelvis shows - multiple pancreatic calcifications - a
calcified stone in the head of the pancreas within the main pancreatic duct - dilation
of the duct in the body and tail of the gland
► In addition to alcohol cessation, which of the following is the most appropriate
management for this patient?
A-Celiac nerve block
B- Endoscopic retrograde cholangiopancreatography with removal of stones
C-Increasing the dose of pancreatic enzymes
D-Pancreatoduodenectomy

27. ► Endoscopic treatment of pain in chronic pancreatitis is performed by
removing pancreatic duct stones and placing stents in pancreatic duct
strictures ….to decrease pancreatic duct pressure
► Patients with chronic pancreatitis must avoid alcohol
► Patients who continue to drink alcohol have an increase in painful attacks
and mortality
► Pain in chronic pancreatitis results from chronic inflammation - chronic
noxious stimulation of the nerves to the pancreas - and increased pancreatic
intraductal pressure secondary to pancreatic duct stones, calcifications, or
strictures
► Large stones in the pancreatic duct can be - crushed with extracorporeal
shock wave lithotripsy - Then endoscopic retrograde
cholangiopancreatography can remove the stones and place stents in
pancreatic duct strictures to decrease pancreatic duct pressure…….so
symptom improvement in 11% to 75% of patients and resolution of stricture
in 10% to 50%

28. ► A surgical pancreatoduodenectomy (Whipple procedure) can be performed
to relieve pain - but is effective only in patients who have disease limited to
the head of the pancreas and who have failed to respond to medical and
endoscopic therapy
► A surgical procedure to divert the pancreatic duct into the small intestine
=The procedure involves removing pancreatic tissue that overlies the ductal
system in the head of the pancreas - has been used widely in the treatment
of patients with a chronic pancreatitis and is effective in many patients…..but
a less invasive procedure is preferred to surgical intervention as the next
management step
► Celiac nerve block =has been used to treat chronic pancreatitis pain - but is
considered by many experts to be an unproved therapy and even in patients
who respond, pain returns in 2 to 6 months and significant procedural
complications have been reported - Furthermore, it would not be the first
procedure of choice in a patient with a pancreatic ductal stone and evidence
of obstruction
► Pancreatic enzyme supplements are not effective for pain control in chronic
pancreatitis

29. THANK YOU
DR: WAEL AHMED EL-SADANY
ER resident