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Pancreatitis

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acute pancreatitis, pseudocyst of pancreas

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Pancreatitis

  1. 1. Dr.S.Easwaramoorthy MS FRCS (Eng) FRCS (Glas) FRCS (Edin) FIAGES, FMAS, FALS, FAES Chairman, ASITN & P Chapter Vice President, IAGES South Zone Examiner, RCS of Edinburgh Consultant Surgeon, Lotus hospital, Erode
  2. 2. Pancreatitis  Learning Objectives  Acute Pancreatitis Pathophysiology Management of acute pancreatitis Complications of pancreatitis  Pseudocyst of pancreas  Chronic Pancreatitis
  3. 3. Acute Pancreatitis  Introduction/ Definition  Etiology  Pathophysiology  Clinical features  Symptoms  Signs  General examination  Examination of Abdomen  Inspection/palpation/percussion/Auscultation/PR  Investigation  Hematological/biochemical/radiology/Special  Management  Outcome  Summary
  4. 4. Acute Pancreatitis: Definition  Acute inflammatory process of pancreas  With variable degree of involvement of  Regional tissues  Remote organ systems
  5. 5. Acute Pancreatitis:Acute Pancreatitis: EtiologyEtiology  Gall stone  Alcohol  Metabolic- hypertriglyceridaemia, hypercalcemia  ERCP, Cardiac surgery, post-operative  Trauma  Infection- mumps,coxackie  Drugs- thiazides,6-MP,estrogen etc  Tumours
  6. 6. Acute Pancreatitis: Pathophysiology Release of Mediators Trigger Mechanism Acinar Cell Injury Cell Activation Consequences IL1 IL6 IL8 IL10 TNF NO PAF E.g.: Alcohol, Gall stones E.g.: Neutrophil, Monocyte
  7. 7. Types of Pancreatitis Acute edematous pancreatitis Acute nectrotizing pancreatitis Mild acute pancreatitis Good Prognosis Severe acute pancreatitis Poor Prognosis
  8. 8. Pancreatitis: Clinical Features  Typical History  Severe Upper abdominal pain radiating to back  Clinical Findings  Hypovolumic shock  Inspection  Distended  Grey Turner’s Sign  Cullen’s Sign  Palpation  Tender  Mild guarding  No rigidity  Percussion  Dull to percuss due to ascites  Asucultation  Bowel sounds: often absent Grey Turner’s Sign Cullen’s Sign
  9. 9. Acute Pancreatitis:Acute Pancreatitis: Investigations:  Haemotological:  FBC  Leucocytosis  Biochemical:  Serum Amylase/Lipase  Normal values  Amylase: Up to 80 u/l  Lipase: Up to 160 u/l  Blood urea and Sugar  Liver Function tests  Calcium  Radiological:  Non Invasive  X ray chest and abdomen  US abdomen  CT abdomen  Invasive  CT guided biopsy  ERCP
  10. 10. Acute Pancreatitis is aAcute Pancreatitis is a biochemical diagnosis!biochemical diagnosis! Serum amylaseSerum amylase - >- >1000 units is diagnostic1000 units is diagnostic -starts to rise after 2-12 hrs and normal again by 3-5-starts to rise after 2-12 hrs and normal again by 3-5 daysdays -Normal in 30% of cases(alcoholics)-Normal in 30% of cases(alcoholics) Serum amylase level is helpful For making the diagnosis But not for assessing the prognosis
  11. 11. Acute PancreatitisAcute Pancreatitis Non-pancreatic causes of hyperamylasaemia  AAA(leaking)  Bowel pathology  Perf DU/Ischemic bowel  Chronic renal failure  Diabetic ketoacidosis  Ectopic gestation  Salivary gland disease
  12. 12. US Scan in Acute Pancreatitis Edematous Pancreas Gall Stones
  13. 13. CT Scan Abdomen Pancreas Renal vein SMA Splenic v Aorta Kidney Stomach
  14. 14. Severity Scoring  Glasgow Severity scoring  Ranson’s criteria  Apache II Criteria  Balthazar CT criteria APACHE: Acute physiology and chronic health evaluation
  15. 15. Acute PancreatitisAcute Pancreatitis Glasgow Scoring SystemGlasgow Scoring System  Age >55  WBC  AST (SGOT)  LDH  Blood sugar  Urea  Calcium  Albumin  Po2 (3 or more in 48 hrs)
  16. 16. Acute Pancreatitis Mild Acute Pancreatitis  Minimal Organ Dysfunction  Uneventful Recovery Severe Acute Pancreatitis  Organ Failure  Local Complications  Necrosis: Sterile/infected  Pseudocyst  Abscess Atlanta 1992
  17. 17. Summary of Management in Acute Severe Pancreatitis Severity Stratification To ICU For CT Scan Predicted Severe DiseasePredicted Mild Disease To Ward Tackle the Complications Diagnosis
  18. 18. Multi organ Failure Organs Affected:  Pulmonary  Renal  Cardio Vascular  Central Nervous  GI Tract  Coagulation System ARDS
  19. 19. Acute PancreatitisAcute Pancreatitis ‘ Management of acute pancreatitis is essentially medical’
  20. 20. Acute PancreatitisAcute Pancreatitis Medicalmanagement:  Fluid replacement to correct the hypovolumia  Crystalloids/Colloids  Treatment of hypoxia  02  Minimize pancreatic secretion  Octreotide: doubtful value  Nutritional support  Enteral / Parenteral feeding  Antibiotics  Imipenum, Pipracillin, Cefuroxime, quinolones  Treatment of hyperglycemia,hypocalcemia  Short acting insulin/IV Ca gluconate
  21. 21. Acute PancreatitisAcute Pancreatitis Role of Surgery:  To remove necrotic pancreas  Intervention to remove gallstones  Surgery for late complications:  Pseudocyst  Abscess
  22. 22. Principles of Surgical Management of Acute Pancreatitis Atlanta Classification Treatment •Edematous pancreatitis(mild AP) Non-surgical •Necrotizing pancreatitis(severeAP) a) Sterile necrosis Non-surgical b) Infected necrosis Debridement c) Pancreatic abscess Drainage d) Pseudocyst Drainage
  23. 23. Pseudo Cyst of Pancreas Fluid collection in and around pancreas and not lined by epithelium
  24. 24. Pseudocyst Investigations:  Ultrasound/CT  Size and location of cyst  ERCP/MRCP  Define ductal disruption
  25. 25. Management of Pancreatic Pseudocysts Consider:  Size  >6cm  Duration of cyst  > 6 weeks  Symptomatic or not
  26. 26. Management of Pseudocyst  Asymptomatic cyst : Observe  Symptomatic cyst : Drainage  Cystogastrostomy Open surgery Laparoscopic surgery Endoscopic drainage
  27. 27. Laparotomy/Cystogastrostomy
  28. 28. Complications of Pseudocyst  Infection  Hemorrhage  Rupture
  29. 29. Acute Pancreatitis Key Messages  Consider pancreatitis in patients with acute onset of severe abdominal pain  Often caused by Alcohol and Gall stones  Serum amylase for diagnosis  CT abdomen for severity assessment  Early aggressive fluid resuscitation
  30. 30. Chronic Pancreatitis ‘Irreversible Progressive destruction of pancreatic tissue’ -Loss of Exocrine function : Steatorrhea -Loss of Endocrine Function : DM -Pancreatic ductal hypertension: Pain Causes: •Alcohol •Tropical
  31. 31. Chronic Pancreatitis Pathology  Fibrosis  Calcification  Dilatation and stricture of pancreatic duct Clinical Features:  Pain  Steatorrhea  DM
  32. 32. Plain x ray abdomen CT abdomen
  33. 33. ERCP/MRCP Stones & Strictures
  34. 34. Dilated PD with calculi
  35. 35. Chronic Pancreatitis Investigation  Imaging  X-ray abdomen  US abdomen  Endoscopic US  CT abdomen  MRCP  ERCP  Function tests  Stool Fat Treatment:  Low fat diet  No alcohol  Pain killers  Pancreatic Enzyme Preparation  Surgery  Resection of Pancreas  Pancreaticojejunostomy
  36. 36. Pancreatico Jejunostomy: Puestow’s Operation

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