4. Physiology of Pancreas
• It is exocrine and endocrine gland.
• Produce digestive enzymes(trypsin, amylase,
lipase)
• Regulatory enzymes(insulin, glucagon)
• Water and bicarbonate.
• Digestive enzymes regulated by acetylcholine
and cholecystokinin.
• Bicarbonate and water regulated by secretin.
5. Definition:
• Acute pancreatitis is an inflammatory condition of
the pancreas characterized clinically by abdominal
pain and elevated levels of pancreatic enzymes in the
blood or urine.
• Because of premature activation of pancreatic
enzymes within the pancreas leads to organ injury
and pancreatitis(autodigestion).
6. Classification:
According to Atlanta classification:
1. Interstitial edematous acute pancreatitis w/o tissue
necrosis
2. Necrotizing acute pancreatitis
According to the severity:
1. Mild acute pancreatitis(absence of organ failure and local
or systemic complications)
2. Moderately acute pancreatitis(no organ failure or
transient organ failure (<48 hours) and/or local
complications)
3. Severe acute pancreatitis(persistent organ failure (>48
hours) that may involve one or multiple organs)
8. Pathogenesis:
• Pancreatic duct obstruction occurs due to biliary tract stones
(commonest), duodenal ulcer, duodenal Crohn’s, periampullary
diverticulum/tumour, trauma, pancreatic duct stricture,
ascariasis.
• OR alcohol causes direct toxicity, hypersecretion of gastric and
pancreatic juices.
• Trypsinogen gets activated forming trypsin which activates
other enzymes
• Proelastate elastate (Causes capillary rupture)
• Prolipase lipase ( metabolise TG to glycerol + fatty acid
and fatty acid combined with Ca to form saponified fat
9. • Extruded of toxins, saponified fat, blood across the
basolateral membrane into the interstitium, where they act
as chemoattractants for inflammatory cells.
• Activated neutrophils then exacerbate the problem by
releasing superoxide proteolytic enzymes. Finally,
macrophages release cytokines(TNF-α, IL-6,8) that further
mediate local (and, in severe cases, systemic) inflammatory
responses.
• Increase pancreatic vascular permeability hemorrhage,
edema and necrosis.
10. Clinical presentation:
• The cardinal symptom is abdominal pain.
• Characters of the pain:
1. Site: usually epigastrium but it may be in UQs or whole
abdomen
2. Onset: sudden and the pain has no upper limit
3. Character: dull, boring and steady
4. Radiation: to back in 50%
5. Associated with: nausea, vomiting, retching, anorexia &
hiccough.
6. Time duration: persist for hours to days
7. Exacerbate in the supine position, refractory to the usual
analgesics and may relived by sitting or leaning forward.
11. Cont.
• Age *
• Ask the pt about recent operative or invasive
investigations(ERCP)
• Hyperlipidemia
• Alcohol consumption
• Previous biliary colic
• Hematemesis and melena
12. Physical examination:
Vital signs:
Fever(76%), tachypnea (common), tachycardia(65%)
and hypotension may be present.
Inspection:
Varies from being well till gravely ill, pale, cyanotic,
jaundice(28%), diaphoretic and listless,
distention(65%), Grey Turner`s sign, Cullen`s sign
or Fox sign.
13.
14. Cont.
Superficial palpation:
Tenderness, rebound tenderness, rigidity and guarding(68%).
Deep palpation:
Epigastrium mass due to inflammation.
Percussion:
Ascites with shifting dullness, pleural effusion(15%)
Auscultation:
Absence of bowel sound due to illeus.
16. Diagnosis:
• Based on clinical presentation and elevated serum amylase
level (3-4 fold).
• Diagnostic imaging is unnecessary in most cases.
Labs:
• CBC (leuckocytosis > 12.000)*
17. Cont.
• Elevated serum amylase(commonly used)
• CRP
• Elevated serum lipase
• LFTs (AST)*
• Electrolytes (hypocalcaemia as a complication or
hypercalcaemia as a cause)
• Hyperglycemia
• Hyperlipidemia
• Amylase creatinine clearance.
• Pregnancy test
• LDH*
• Serum urea*
• PaO2*
19. Imaging:
Chest and abdominal X-ray in erect position are not
diagnostic but are useful in ddx:
Sentinel loop, colon cut-off sign, calcified gall stones, pleural
effusion, calcified pancreas…etc
Ultrasound should performed within 24hrs to detect gall
stones, rule out cholecystitis and dilated CBD
CT with contrast indicated in:
1. There is doubt in diagnosis
2. Sever acute pancreatitis to determine the extent of
necrosis
3. Pts with organ failure & sepsis
4. Suspicion in localized complication(fluid, pseudocyst)
20. Sentinel loop: a single dilated
jejunal loop in the upper
abdomen.
Colon cut-off sign: dilated colon
to the mid-transverse colon with
no air seen behind the splenic
flexure. This is due to extension
of inflammation along
mesocolon.
21.
22. Management:
It is on of acute abdomen treated conservatively.
Conservative (70-90%):
• Admission to ICU.
• NPO
• Rehydration(250-400ml/hr)
• Analgesia(don`t use morphine)
• In sever hemorrhage (FFP,PCV,Platlets)
• NG tube for aspiration and feeding.
• Urinary catheterization to maintain and monitor
urine output.
23. Cont.
• Antibiotics( ciprofloxacin + metronidazole)
• Calcium gluconate in hypocalcaemia
• If ultrasonograms show evidence of gallstones and
if the cause of pancreatitis is believed to be biliary, a
cholecystectomy should be performed during the
same hospital admission.
24. Cont.
Surgery (10-30%):
• If condition of patient deteriorates in spite of good
conservative treatment.
• If there is formation of pancreatic abscess, or
infected necrosis
• In severe necrotizing pancreatitis as a trial to save
the life of the patient which has got very high
mortality
• Open surgery is the gold standard for infected
pancreatic necrosis.
26. Acute fluid collection:
• In or near the pancreas
• ill-defined or lacking fibrin wall
• Sterile fluid
• Usually resolve spontaneously
• Usually no intervention
• An acute fluid collection that does not resolve can
evolve into a pseudocyst or an abscess if it becomes
infected.
27. Sterile and infected pancreatic necrosis:
• Focal or diffuse of non-viable parenchyma with
peripancreatic necrosis.
• Sterile and due to translocation of gut bacteria
become infected.
• Diagnosed by CT with contrast
• Mortality rate up to 50% in infected necrosis
• No need intervention in sterile necrosis
• Infected necrosis treated by needle aspiration
under CT or ultrasonography guidance
• Laprotomy necrosectomy
28. Pancreatic abscess:
• Demarcated intra-abdominal collection of pus
• It may be acute collection or infected pseudocyst
• Diagnosis and management as in infected
pancreatic necrosis.
29. Pseudocyst:
• Collection of amylase rich fluid enclosed in fibrous
tissue.
• Often single
• Diagnosed by CT or US
• Pseudocyst resolve spontaneously in most cases
• Intervention advised if the pseudocyst cause
symptoms or complications.
• Cystogastrostomy is the choice.
