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Acute Pancreatitis
Shiwani Kamath
Acute Pancreatitis
• Inflammation of the gland parenchyma of the
pancreas
• Acute condition presenting with abdominal
pain...
Pathogenesis
Defective
intracellular
transport and
secretion of
pancreatic zymogens
Pancreatic duct
obstruction
Hyperstimu...
Etiology
Common (90% of cases)
– Gallstones
– Alcohol
– Post-ERCP
– Idiopathic
Rare
– Post-surgical
– Trauma
– Drugs
– Met...
Clinical Features
Symptoms
• Severe, constant upper abdominal pain
– with increasing intensity over 15-20 minutes
– radiat...
Clinical Features
Signs
• Epigastric tenderness with guarding and rebound
(later)
• Decreased/absent bowel sounds
• Grey T...
Clinical Features
Cullen’s Sign
Clinical Features
Turner’s Sign
Complications
Pancreatic
• Acute Fluid Collection
• Pseudocyst
• Abscess
• Necrosis
• Pancreatic Ascites and Effusion
Complications
Systemic and Other Systems
Systemic
• Systemic inflammatory
response syndrome
• Hypoxia
• Hypergylcemia
• Hy...
Investigations
• Serum amylase (N: 23-85 IU/L)
• Serum lipase (N: 0 – 160 IU/L)
• Ultrasound
– Confirms diagnosis
– Shows ...
Acute Pancreatitis
Normal Pancreas
CT Findings
Tail Indistinct
Intraperitoneal fluid
PANC
PANC
LIVERLIVER
CT Findings
Severe Pancreatitis
Peripancreatic edema
and inflammation
Necrosis
(less
enhancement)PANC
PANCLIVERLIVER
GBGB
• CBC: leucocytosis
• Electrolyte abnormalities include hypokalemia,
hypocalcemia
• Elevated LDH in biliary disease
• Glyc...
To rule out other conditions
i.e. perforated ulcer disease.
Nonspecific findings
-cutoff colon sign gaseous distension see...
MANAGEMENT
• Establish the diagnosis
• Assess severity
• Early Treatment (Resuscitation)
• Detection and Treatment of Complications
•...
• RANSON’S CRITERIA
• MODIFIED GLASGOW CRITERIA
• Acute Physiology and Chronic Health
Evaluation (APACHE II)
MANAGEMENT
As...
• RANSON’S CRITERIA
• MODIFIED GLASGOW CRITERIA
• Acute Physiology and Chronic Health
Evaluation (APACHE II)
MANAGEMENT
As...
Non-gallstone pancreatitis, the parameters are:
At admission:
•Age in years > 55 years
•White blood cell count > 16000 cel...
Gallstone pancreatitis, the parameters are:
At admission:
•Age in years > 70 years
•White blood cell count > 18000 cells/m...
MANAGEMENT
Glasgow’s
alanine
MANAGEMENT
APACHE II
• Initial Assessment
– Clinical Impression
– BMI > 30
– Pleural Effusion (on CX-ray)
– APACHE II Score > 8
• 24 Hours Afte...
• Intravenous fluid administration
• Analgesics
• Anti-emetics
• Recommended brief period of fasting
• Frequent, non-invas...
• Admission to HDU or ICU
• Analgesia
• Aggressive fluid rehydration
• Oxygen
• Monitor Vitals, central venous pressure, u...
• Cholecystectomy within 2 weeks following
resolution of pancreatitis
• Necrotising pancreatitis/Pancreatic Abscess
– Endo...
Thank You
Acute Pancreatitis
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Acute Pancreatitis Slide 1 Acute Pancreatitis Slide 2 Acute Pancreatitis Slide 3 Acute Pancreatitis Slide 4 Acute Pancreatitis Slide 5 Acute Pancreatitis Slide 6 Acute Pancreatitis Slide 7 Acute Pancreatitis Slide 8 Acute Pancreatitis Slide 9 Acute Pancreatitis Slide 10 Acute Pancreatitis Slide 11 Acute Pancreatitis Slide 12 Acute Pancreatitis Slide 13 Acute Pancreatitis Slide 14 Acute Pancreatitis Slide 15 Acute Pancreatitis Slide 16 Acute Pancreatitis Slide 17 Acute Pancreatitis Slide 18 Acute Pancreatitis Slide 19 Acute Pancreatitis Slide 20 Acute Pancreatitis Slide 21 Acute Pancreatitis Slide 22 Acute Pancreatitis Slide 23 Acute Pancreatitis Slide 24 Acute Pancreatitis Slide 25 Acute Pancreatitis Slide 26 Acute Pancreatitis Slide 27 Acute Pancreatitis Slide 28 Acute Pancreatitis Slide 29 Acute Pancreatitis Slide 30
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Acute Pancreatitis (According to American College of Gastroenterology 2013 guidelines)
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Acute Pancreatitis

  1. 1. Acute Pancreatitis Shiwani Kamath
  2. 2. Acute Pancreatitis • Inflammation of the gland parenchyma of the pancreas • Acute condition presenting with abdominal pain and is usually associated with raised pancreatic enzyme levels in the blood or urine as a result of pancreatic inflammation
  3. 3. Pathogenesis Defective intracellular transport and secretion of pancreatic zymogens Pancreatic duct obstruction Hyperstimulation of pancreas Reflux of infected bile or duodenal contents into pancreatic duct Proenzymes Activated proteolytic enzymes Acute Pancreatitis (-) Pancreatic secretory trypsin inhibitors
  4. 4. Etiology Common (90% of cases) – Gallstones – Alcohol – Post-ERCP – Idiopathic Rare – Post-surgical – Trauma – Drugs – Metabolic – Pancreas divisum – Sphincter of Oddi dysfunction – Infection – Hereditary – Renal failure – Organ Transplantation – Severe hypothermia – Petrochemical exposure
  5. 5. Clinical Features Symptoms • Severe, constant upper abdominal pain – with increasing intensity over 15-20 minutes – radiating to back • Nausea and vomiting • Abdominal distension
  6. 6. Clinical Features Signs • Epigastric tenderness with guarding and rebound (later) • Decreased/absent bowel sounds • Grey Turner’s Sign: Discoloration of the flanks • Cullen’s Sign: Discoloration of the periumbilical region • Small, red, tender nodules on the skin of the legs • Abdominal distension – shifting dullness • Signs of pleural effusion
  7. 7. Clinical Features Cullen’s Sign
  8. 8. Clinical Features Turner’s Sign
  9. 9. Complications Pancreatic • Acute Fluid Collection • Pseudocyst • Abscess • Necrosis • Pancreatic Ascites and Effusion
  10. 10. Complications Systemic and Other Systems Systemic • Systemic inflammatory response syndrome • Hypoxia • Hypergylcemia • Hypocalcemia • Reduced serum albumin concentration • DIC Gastrointestinal • Hemorrhage • Portal/Splenic Vein Thrombosis • Erosion into colon • Duodenal Obstruction • Obstructive jaundice • Paralytic Ileus
  11. 11. Investigations • Serum amylase (N: 23-85 IU/L) • Serum lipase (N: 0 – 160 IU/L) • Ultrasound – Confirms diagnosis – Shows gallstones, biliary obstruction, pseudocyst • Contrast enhanced CT – 6-10 days after admission – Decreased pancreatic enhancement – necrotizing – Gas within necrotic material – infection, abscess – Other organ involvement
  12. 12. Acute Pancreatitis Normal Pancreas
  13. 13. CT Findings Tail Indistinct Intraperitoneal fluid PANC PANC LIVERLIVER
  14. 14. CT Findings Severe Pancreatitis Peripancreatic edema and inflammation Necrosis (less enhancement)PANC PANCLIVERLIVER GBGB
  15. 15. • CBC: leucocytosis • Electrolyte abnormalities include hypokalemia, hypocalcemia • Elevated LDH in biliary disease • Glycosuria ( 10% of cases) • Hyperglycaemia in severe cases • Serum phosphate • LFTs • RFTs • C – Reactive Protein - elevated Routine
  16. 16. To rule out other conditions i.e. perforated ulcer disease. Nonspecific findings -cutoff colon sign gaseous distension seen in proximal colon associated with narrowing of the splenic flexure -Widening of the duodenal C loop caused by severe pancreatic head edema Complications of lung such as pleural effusion, pulmonary edema and interstitial inflammation. X ray
  17. 17. MANAGEMENT
  18. 18. • Establish the diagnosis • Assess severity • Early Treatment (Resuscitation) • Detection and Treatment of Complications • Treating Underlying Cause MANAGEMENT Steps
  19. 19. • RANSON’S CRITERIA • MODIFIED GLASGOW CRITERIA • Acute Physiology and Chronic Health Evaluation (APACHE II) MANAGEMENT Assessment of Severity of Disease
  20. 20. • RANSON’S CRITERIA • MODIFIED GLASGOW CRITERIA • Acute Physiology and Chronic Health Evaluation (APACHE II) MANAGEMENT Assessment of Severity of Disease
  21. 21. Non-gallstone pancreatitis, the parameters are: At admission: •Age in years > 55 years •White blood cell count > 16000 cells/mm3 •Blood glucose> 10 mmol/L (> 200 mg/dL) •Serum AST > 250 U/L •Serum LDH > 700 U/L Within 48 hours: •Serum calcium < 2.0 mmol/L (< 8.0 mg/dL) •Oxygen (hypoxemia PaO2 < 60 mmHg) •BUN increased by 1.8 or more mmol/L (5 or more mg/dL) after IV fluid hydration •Base deficit (negative base excess) > 4 mEq/L •Sequestration of fluids > 6 L MANAGEMENT Ranson’s Criteria
  22. 22. Gallstone pancreatitis, the parameters are: At admission: •Age in years > 70 years •White blood cell count > 18000 cells/mm3 •Blood glucose > 12.2 mmol/L (> 220 mg/dL) •Serum AST > 250 IU/L •Serum LDH > 400 IU/L Within 48 hours: •Serum calcium < 2.0 mmol/L (< 8.0 mg/dL) •Oxygen (hypoxemia PaO2 < 60 mmHg) •BUN increased by 1.8 or more mmol/L (5 or more mg/dL) after IV fluid hydration •Base deficit (negative base excess) > 5 mEq/L •Sequestration of fluids > 4 L MANAGEMENT Ranson’s Criteria
  23. 23. MANAGEMENT Glasgow’s alanine
  24. 24. MANAGEMENT APACHE II
  25. 25. • Initial Assessment – Clinical Impression – BMI > 30 – Pleural Effusion (on CX-ray) – APACHE II Score > 8 • 24 Hours After Admission – Clinical Impression – APACHE II Score > 8 – Glasgow > 3 – Persisting Organ Failure – CRP > 150 mg/L • 48 Hours After Admission – Clinical Impression – Glasgow > 3 – Persisting, Multiple, and Progressive Organ Failure – CRP > 150 mg/L MANAGEMENT Factors Predicting Severity within 48 hours of admission
  26. 26. • Intravenous fluid administration • Analgesics • Anti-emetics • Recommended brief period of fasting • Frequent, non-invasive observation MANAGEMENT Conservative Measures
  27. 27. • Admission to HDU or ICU • Analgesia • Aggressive fluid rehydration • Oxygen • Monitor Vitals, central venous pressure, urine output, blood gases • Monitor hematological and biochemical parameters • Nasogastric drainage • Antibiotic prophylaxis (imipem, cefuroxime) • CT scan • ERCP • Supportive therapy for organ failure • Nasogastric feeding for nutritional support MANAGEMENT Severe Acute Pancreatitis
  28. 28. • Cholecystectomy within 2 weeks following resolution of pancreatitis • Necrotising pancreatitis/Pancreatic Abscess – Endoscopic/surgical necresectomy • Pseudocyst – Drainage into stomach, duodenum or jejunum – Endoscopic/Surgical – After 6 weeks MANAGEMENT Surgical Management of Severe Pancreatitis
  29. 29. Thank You
  • TheaLee11

    Aug. 18, 2021
  • sandeepgupta1610

    May. 15, 2021
  • salmaalmansour

    Feb. 24, 2021
  • PriyataPatel1

    Dec. 18, 2020
  • KyawZayYa18

    Oct. 5, 2016

Acute Pancreatitis

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