Acute pancreatitis.
Dr. Maha Hafez. II year general surgery resident
Istiklal hospital
Amman- Jordan
December, 2020
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Acute Pancreatitis. Definition.
• Acute relapsing
pancreatitis.
• Chronic pancreatitis.
• Chronic relapsing
pancreatitis
Acute Pancreatitis. Classification.
Acute pancreatitis is divided into the following: ( Atlanta Criteria 2013)
▪ Mild acute pancreatitis, which is characterized by the absence of organ failure and local or systemic
complications
▪ Moderately severe acute pancreatitis, which is characterized by transient organ failure (resolves
within 48 hours) and/or local or systemic complications without persistent organ failure (>48 hours)
▪ Severe acute pancreatitis, which is characterized by persistent organ failure that may involve one or
multiple organs
Acute Pancreatitis. Classification.
Santhi Swaroop Vege, MD. Management of acute pancreatitis.Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com (Accessed on December 25, 2020
.)
Acute Pancreatitis. Etiology.
Santhi Swaroop Vege, MD. Management of acute pancreatitis.Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com (Accessed on December 25, 2020
.)
Acute Pancreatitis. Physiopathology.
Santhi Swaroop Vege, MD. Management of acute pancreatitis.Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com (Accessed on December 25, 2020
.)
Acute Pancreatitis. Symptoms and signs.
• Acute onset of persistent, severe abdominal pain:
In patients with gallstone pancreatitis, the pain is well localized and the onset of pain is
rapid, reaching maximum intensity in 10 to 20 minutes. In contrast, in patients with
pancreatitis due to hereditary or metabolic causes or alcohol, the onset of pain may be
less abrupt and the pain may be poorly localized. In approximately.
50% of patients, the pain radiates to the back .
The pain persists for several hours to days and may be partially relieved by sitting up or
bending forward.
• 90% of patients have associated nausea and vomiting
which may persist for several hours.
•
Severe acute pancreatitis: dyspnea due to diaphragmatic inflammation secondary to
pancreatitis, pleural effusions, or acute respiratory distress syndrome.
Santhi Swaroop Vege, MD. Management of acute pancreatitis.Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com (Accessed on December 25, 2020
.)
Acute Pancreatitis. Symptoms and signs.
• Good to bad general conditions.
• Vital signs changes according to severity of pancreatitis.
(fever, tachycardia, tachypnea, hypoxemia, and
hypotension).
• Dehydration.
• General pallor/jaundice/cachexia.
• Abdominal distention, tenderness and hypoactive bowel
sounds.
• 3% Cullen´s & Grey Turner signs.
• Findings suggestive of the underlying etiology:
hepatomegaly, xanthomas, parotid swelling, trauma, enter
point …
Santhi Swaroop Vege, MD. Management of acute pancreatitis.Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com (Accessed on December 25, 2020
.)
Acute Pancreatitis. Evaluation.
Serum amylase : rises within 6 to 12 hours of
the onset of acute pancreatitis, return to
normal within 3-5 days.
Sensitivity 67 - 83 % specificity of 85-88%.
Santhi Swaroop Vege, MD. Management of acute pancreatitis.Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com (Accessed on December 25, 2020
.)
Acute Pancreatitis. Evaluation.
Serum lipase: rises within 4-8 hours of the onset
of symptoms, peaks at 24 hours, and returns to
normal within 8 to 14 days.
Sensitivity 82 – 100%. Specificity up to 99%
Santhi Swaroop Vege, MD. Management of acute pancreatitis.Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com (Accessed on December 25, 2020
.)
Acute Pancreatitis. Evaluation.
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Leukocytosis.
CRP
Elevated Hcto.
Elevated BUN.
Metabolic acidosis.
Hypocalcemia.
ALT > 3x normal gallstone
pancreatitis (96% specific, but only
48% sensitive.
Markers of immune activation Acute pancreatitis
• Alteration in serum glucose is associated with elevations in C-reactive
protein (CRP), interleukin (IL)-6, IL-8, IL-10,
tumor necrosis factor (TNF), and PMN elastase
Santhi Swaroop Vege, MD. Management of acute pancreatitis.Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com (Accessed on December 25, 2020
.)
Acute Pancreatitis. Evaluation.
Ranson’s Prognostic Signs that
Correlate with the Risk of Major
Complications or Death
Acute Pancreatitis. Evaluation.
Acute Pancreatitis. Evaluation.
Acute Pancreatitis.
Colon cut-off sign
Sentinel loop
Abdominal
radiography
Pancreatic calcifications
Chronic pancreatitis
Acute Pancreatitis.
Elevation of a hemidiaphragm, pleural effusions, basal
atelectasis, pulmonary infiltrates, or acute respiratory
distress syndrome
Chest X ray
Abdominal US
The pancreas appears diffusely enlarged and hypoechoic
on abdominal ultrasound. Gallstones may be visualized in
the gallbladder
Santhi Swaroop Vege, MD. Management of acute pancreatitis.Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com (Accessed on December 25, 2020.)
Acute Pancreatitis.
Santhi Swaroop Vege, MD. Management of acute pancreatitis.Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com (Accessed on December 25, 2020
.)
Acute Pancreatitis. Evaluation. Baltazar severity index.
Santhi Swaroop Vege, MD. Management of acute pancreatitis.Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com (Accessed on December 25, 2020
.)
Acute Pancreatitis.
MRI is as effective as CT in
demonstrating the presence
and extent of pancreatic
necrosis and fluid collections,
and is probably superior for
indicating the suitability of
such collections for
nonsurgical drainage .
MRI can characterize the
"pancreatic necrosis" seen
on CT as necrotic pancreatic
parenchyma, peripancreatic
necrotic fluid collections, or
hemorrhagic foci
MRI showing acute edematous pancreatitis. pancreas showed swelling and there was homogeneous peripancreatic fluid
collection on the axial T1WI (A, arrow) and the T2WI (B, arrow). The pancreas was homogeneous enhanced after contrast
injection (C, asterisk). After 9 days of treatment, the peripancreatic collection was absorbed (D, arrow)
Santhi Swaroop Vege, MD. Management of acute pancreatitis.Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com (Accessed on December 25, 2020
.)
Acute Pancreatitis. Evaluation.
Acute Pancreatitis. Management.
Supportive care with the use of
IV fluid hydration is a mainstay of
treatment for AP in the first 12-24
hours
Medge gastroenteroly:New concepts in the management of acute pancreatitis. Publish date: February 1, 2019. Amar Mandalia, MD Matthew J. Dimagno, MD, AGAF
Acute Pancreatitis. Management.
• Gastric decompresion with
NG tube +-.
• Nutritional support.
• Antiemetics:
metroclopramide/ondasetron.
• PPI
• Respiratory support.
• DVT prophylaxis.
• Blood gas analysis if o2 sat
less than 90 % or if the
clinical situation demands.
• Urine output
Medge gastroenteroly:New concepts in the management of acute pancreatitis. Publish date: February 1, 2019. Amar Mandalia, MD Matthew J. Dimagno, MD, AGAF
Acute Pancreatitis. Management.
Acute Pancreatitis.
Course of disease.
Disease course . Approximately 85% of patients with acute
pancreatitis have acute interstitial edematous pancreatitis ; 15%
of patients have necrotizing pancreatitis with necrosis of the
pancreatic parenchyma, the peripancreatic tissue, or both.
4%
Acute Pancreatitis. Local Complications.
<4
weeks
Santhi Swaroop Vege, MD. Management of acute pancreatitis.Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com (Accessed on December 25, 2020
.)
Acute Pancreatitis. Local Complications.
>4
weeks
Santhi Swaroop Vege, MD. Management of acute pancreatitis.Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com (Accessed on December 25, 2020
.)
Acute Pancreatitis. Systemic Complications.
Thank you