Pancreatitis

Luis Gerardo Caballero Romero.EPG MCPA

PANCREATITIS.UNIVERSIDAD DE GUADALAJARA

CENTRO UNIVERSITARIO DE CIENCIAS DE LA SALUD

Dr. Benjamín Robles MariscalProfesor: Dr. Héctor Virgen Ayala

Surgical Clinics.

• Non-bacterial disease, caused by interstitial release and activation of pancreatic enzymes that perform the self digestion of the pancreas, the process is accompanied by morphological and functional changes.

CAUSES

• Biliar Lithiasis 40%choledocholithiasis 25%

• Alcoholic Pancreatitits in the USA causes more of the 40%

• Hypercalcemia

• Hyperlipidemia

• familiar pancreatitis

• protein deficiencies

• postoperative pancreatitis (iatrogenic)

• Drug pancreatitis corticosteroidssteroidal contraceptivesazathioprinethiazide diureticstetracyclines

• Obstructive pancreatitis

• idiopathic pancreatitis and for different reasons.

PATHOGENY

• Phospholipase A (Able to create necrotizing pancreatitis severe)

• Trypsin (not attack living tissue, but activates phospholipase A).

• Elastase (can digest blood vessels)

• Lipase

SYSTEMIC MANIFESTATIONS

• Acute respiratory distress syndrome (ARDS)

• Myocardial depression

• Renal insufficiency

• Gastric ulcerComplement C5

ACUTE PANCREATITIS

• Sudden epigastric pain

• Nausea, vomiting

• High concentrations of amylase

• Edematous condition

• Bleeding form Similar disease processes and treatment

• Edematous condition: interstitial fluid congestion, infiltrated by inflammatory cells surrounding small areas of parenchymal necrosis.

• Bleeding form: Effusion of blood into the parenchyma and extensive pancreatic necrosis

SIGNS AND SYMPTOMS

• Acute attacks after a hearty meal

• epigastric pain radiating to back

• Vomiting and retching.

• According to gravitydeep dehydrationtachycardiahipertencion posturalDecreased myocardial function

1 to 2% Grey Turner's sign (bluish discoloration flanc)Cullen's sign (bluish Periumbilical)

LABORATORY STUDIES• Hematocrit - Bleeding Pancreatitis

(by dehydration)

• Hematocrit - Bleeding Pancreatitis(For bleeding into the abdomen)

• Moderate leukocytosis

• Normal liver function tests

• In the first 6 hours up to twice amylase 1000 IU / dl

• Lipase - alcoholic pancreatitis

• Amylase - calculous pancreatitis

IMAGING STUDIES

• Abnormalities were observed up to 66% of cases More often an isolated dilated bowel segment (loop Sentinel).

• Sometimes it is remarkable glandular calcification.

• TC

• ERCP (Endoscopic Retrograde cholangiopancreatography)

RANSON CRITERIA IN TERMS OF SEVERITYCriterios Iniciales Criterios de

Evolución en 24 Hrs

EDAD > 55 DISMINUCION DEL HEMATOCRITO

> 10%

CUENTA DE LEUCOSITOS

> 16,000 AUMENTO DEL BUN >8 mg/dl

GLUCOSA 200 mg/dl Ca EN SUERO < 8mg/dl

LDH EN SUERO >350 IU/L Po2 ARTERIAL < 60 mmHg

AST (GOT) > 250 IU/dl DEFICIT BASALCALCULO DE LIQUIDOS

>4mg/L>600 mL

AST ---ASPARTATO TRASNAMINASA

•Chronic pancreatitis

• Persistent abdominal pain

• Pancreatic calcification observed in radiographs.

• Pancreatic insufficiency, malabsorption and diabetes mellitus

• Common cause alcohol

SIGNS AND SYMPTOMS

• Asymptomatic in many cases.

• Malabsorption.

• DM

• Epigastric abdominal pain (deep, radiating to back, increases and decreases from one day to another, episodic lasting days or weeks and then disappears for months)

LABORATORY STUDIES

• Amylase (in acute exacerbations)

• Exocrine function tests of the pancreas

• DM (75% of calcific pancreatitis px and px 30% of pancreatitis without calcification).

• Biliary obstruction

• Phlebothrombosis.

COMPLICATIONS

• Pancreatic pseudocyst.

• Biliary obstruction

• Duodenal obstruction.

• Malnutrition

• DM

TREATMENT

• Medical treatment:

Malabsorption and steatorrhea are treated with supportive measures.

You must leave the consumer to insist on Alcohol

Psychiatric treatment is beneficial.

• Surgical Treatment:It consists of a treatment that facilitates pancreatic duct drainage, or resection of the affected portion of pancreas.

SURGICAL TREATMENT:

• Drainage Procedure:

Dilatation of the ductal systemis used for alcoholic calcific pancreatitis.

Dilated duct (1 to 2 cm)with sites of stenosis ("Chain of Lakes")

Tx: pancreaticojejunostomy (Pastow Procedure)

PANCREATECTOMY:

• Pancreaticoduodenectomy (Whipple procedure)

Pain Relief in 80% of patients.

• Total pancreatectomy

Contraindicated in patients who do not leave alcohol.

CELIAC PLEXUS BLOCK:

• Thoracoscopic splanchnicectomy:

Splanchnic resection of major and minor nerve.

•Pancreatic pseudocyst.

• Mass and epigastric pain

• Grade fever and leukocytosis

• High concentration of amylase

• Cyst demonstrated by ultrasound.

• Accumulation of fluid in capsules containing large amounts of enzymes.

• Pseudocyst indicates that there is no epithelial lining.

• Two mechanisms of pathogenesis:

Complication of pancreatitis. 2% (one cyst, 85%)

Alcoholics and trauma victims.

SIGNS AND SYMPTOMS

When a person is suspected draw, no signs of recovery after a week, or after a temporary improvement, the symptoms reappear.

And tender palpable mass in the epigastrium, due to the swelling of the pancreas and adjacent viscera (cellulitis).

Common sign: Pain.

50% of the px:feverWeight Loss.hypersensitivity

COMPLICATIONS

Infections:Are rare, high fever, chills, and leukocytosis.It is possible percutaneous drain through a tube.

breakage:occurs in less than 5% of cases.Perforation into the peritoneal cavity, chemical peritonitis (abdominal rigidity board, severe pain).

hemorrhage:into the cavity of the cyst (false aneurysm)anemiaHemorrhagic shock.

Tx open cyst.Flirt glass.Drain cyst.

TREATMENT

• Symptomatic improvement and prevention of complications.Treatment expectation (40% spontaneous resolution)

• Cysts larger than 5 cm active treatment. (Percutaneous drainage or to the stomach).

• Resection:definitive treatment for traumatic cysts in the tail of the pancreas.

• External drainage:best treatment for patients in critical condition, although the incidence of recurrent pseudocyst is four times higher after external drainage into the intestine.

• Drainage Internal:Preferred method.Roux Anasotmosis And at one end of the jejunum (cistoyeyunostomia)the rear wall of the stomach (cystogastrostomy)or the duodenum (cistoduodenostomia).

• Nonsurgical drainage:Percutaneous external drainage tube was permanently eradicated 66% of infected cysts.

FORECAST:

• 10% recurrence

• More frequent relapse after tx with external drainage.

• Pancreatic abscess

PANCREATIC ABSCESS

• Complication of 5% of postoperative pancreatitis.

• Lethal without treatment.

• Secondary to bacterial contamination and exudate hemorrhagic necrotic debris.

CLINICAL MANIFESTATIONS

• Acute pancreatitis does not yield, fever or recurrence of symptoms after a period of recovery.

• Serum albumin concentration is less than 2.5 g / dl

• Alkaline phosphatase

TREATMENT AND PROGNOSIS• Drain the accumulated pus.

Surgical debridement for necrotic debris in the retroperitoneal space that do not pass by the probe.Antibiotics (Escherichia coli, Staphylococcus, Klebsiella, Proteus).

• 20% mortality rate for incomplete drainage and inability to establish Dx.

BIBLIOGRAPHY:

Diagnosis and surgical treatment, Gerard M. Doherty

13th edition, McGrawHill Lange.

P. 495-507