Pancreatitis - Doctor 2015 - JU Medicine › ... › sites › 5 › 2018 › 09 › UJ-Pan… · Recurrent Pancreatitis Pancreatic Divisum 5 - 10% Population Most common congenital

PancreatitisOMAR ALQUDAH M.D

FACULTY OF MEDICINEUNIVERSITY OF JORDAN

Pancreatitis

PancreasOverview

l Three major types of cellsn Ductal 10%n Acinar 80%n Islet 10%

l Four major types of Islet cellsn Insulinn Glucagonn Somatostatinn Pancreatic polypeptides

PancreasOverview

PancreasOverview

Acute PancreatitisCauses

Alcohol

Gallstones

OthersOther

IdiopathicDrugs

HyperlipidemiaInfectious agentsHypercalcemia

Ductal obstructionTrauma

HypotensionPost op

Acute PancreatitisIdiopathic

Acute PancreatitisDrug-induced

Azathioprine/ 6-MP IdiosyncraticSulfonamide IdiosyncraticPentamidine IdiosyncraticValproic acid IdiosyncraticThiazide High doseEstrogens Associated with high TG

Cimitidine Idiosyncratic

Hypotension/ ischemia

Acute PancreatitisPathogenesis

Ductal obstruction, reflux,Increase permeability of

The ducts

Alcohol, drugs, infectionsCausing disruption of cell

membranes

Interstitial Necrotizing

Acute PancreatitisPathology

Acute PancreatitisClinical features

Symptoms & Signs

Abdominal painNausea/ Vomiting

FeverTachycardia

Grey- Turner signCullen

Labs

LeukocytosisHigh AmylaseHigh Lipase

Differential Diagnosis

CholedocholithiasisPerforated Ulcer

Mesentric IschemiaSalpingitis

Ectopic pregnancyIntestinal obstruction

Acute PancreatitisGrey - Turner sign

Acute PancreatitisCullens sign

Acute PancreatitisCauses of Hyperamylasemia

Amylase LipasePancreatitis Increase Increase

Parotitis Increase NormalBiliary stones Increase Increase

Intestinal injury Increase IncreaseTubo-overian Increase NormalRenal failure Increase Increase

Macroamylasemia Increase Normal

Acute PancreatitisThe course of enzymes

0

20

40

60

80

100

1 to 2 3 4 to 5

GallstonesAlcohol

•Age > 50•Female•Amylase > 4000 IU/L•AST > 100 U/L•Alkaline phosphatase> 300 IU/L

Acute PancreatitisFactors predictive of Gallstone pancreatitis

Acute PancreatitisRanson’s criteria of severity

At admission

Age 55WBC 16 KGlucose 200 mg/dlLDH >350 IU/LAST > 250 U/L

During the first 48 hours

Hct decrease of 10BUN increase of >5 mg/dlCa <8 mg/dlPaO2 < 60 mm HgBase deficit >4 mEq/LFluid sequestration > 6L

Acute PancreatitisMortality related to Ranson’s

0102030405060708090

0 to 2 3 to 5 6 to 8 9 to 11

Acute PancreatitisDiagnosis: Ultrasound

Normal Pancreatitis

CAT Scan

Acute PancreatitisIndications for CT scan

l Ranson’s score >3l Refractory Hypoxemial Refractory Hypotensionl Persistant leukocytosis or feverl Tender abdominal massl Hemodynamic deteriorationl Cullen or Grey-Turner signs

Acute PancreatitisCT Criteria of severity

A Normal

B Enlargement

C Peri-pancreatic Inflammation

D Single fluid collection

E Multiple fluid collection


Grade C Grade D


PhlegmonIll defined mass

Sterile or infectedStage E

Acute PancreatitisInterstitial

Acute PancreatitisNecrotizing

Acute PancreatitisPrognosis based on CT findings

Interstitial

NecrotizingInfection <1%Mortality <1%

Infection 30-50%Mortality

Sterile 10%Infected 30%

Acute PancreatitisTreatment Goals

l Supportive care

l Reduce inflammation

l Assess and treat complications

Acute PancreatitisSupportive care

EssentialClose clinical survillanceNPOIV fluid replacementNutritional supportPain control

Not provenAntibioticsReduction of pancreatic secreations:

(H2 Blockers, NG suction, glucagon, somatostatin)

Acute PancreatitisAntibiotics Therapy

l Antibiotics with effective penetrationCiprofloxacinOfloxacinImipenemMetronidazole

l Antibiotics with poorer penetrationAminoglycosidesBroad spectrum penicillinsThird generation cephalosporins

Acute PancreatitisDecrease Inflammation

l Remove impacted stonesn ERCP and Papillotomy

l Remove Ascitesn Peritoneal lavage

Acute PancreatitisAssess and treat complications

l Hypocalcemial ARDSl Infectionl Pseudocyst

Acute PancreatitisComplications: Hypocalcemia

Loss of non-ionized Calcium

CommonAsymptomatic

No treatment needed

Loss of ionized calcium

RareNeuromascular irritability

Treatment needed

Delay onsetMore associated with hyper-

LipidemiaPotentially reversible

Acute PancreatitisComplications: ARDS

1. Acute, severe, progressiverespiratory distress

2. Hypoxemia not responding to oxygen

3. Increase stiffness of the Lungs

4. Diffuse radiological opacity

Acute PancreatitisComplications: Pseudocyst

l Severe painl Obstruction(CBD, Duodenum)l Dissectionl Bleedingl Infectionl Leakagel Rupture



Rupture


Indications:Size > 5 cmDuration >4-6 weeksSevere painRapid expansioncomplications

Techniques:SurgicalPercutanousEndoscopic

Acute PancreatitisComplications: Infection



Recurrent PancreatitisPancreatic Divisum

5 - 10% Population

Most common congenitalabnormality of the pancreas

Failure of fusion of major andminor pancreatic ducts during

embryonic life

Treatment by minor ductsphinctorotomy

Recurrent PancreatitisHereditary Pancreatitis

l Autosomal dominantl Childhood onsetl Starts initially as acute attacks then they

develop calcifications by the second decade.

l High risk of carcinomas

Recurrent PancreatitisWork up for unexplained and recurrent Pancreatitis

No further tests Consider biliary manometry

Normal

Ampullary stenosisAnnular PancreasCholedochal cyst

GallstonesMicrolithiasis

Pancreatic DivisumPanc. duct stricture

Abnormal

ERCP

Negative History, Labs and Work up

Chronic PancreatitisEtiology

Alcohol

Idiopathic

Tropical PancreatitisHereditary

HyperparathyrodismCystic Fibrosis

Pancreatic divisumOthers

Chronic PancreatitisClinical Presentation

0

10

20

30

40

50

60

70

80

90

Pain Calcification Steatorrhea Diabetes

IdiopathicAlcohol

Chronic PancreatitisClinical Presentation

Chronic PancreatitisDiabetes

l Brittlel Loss of Insulin and

Glucagonl Only in severe diseasel Insulin requirment lowl Ketoacidosis rare

Chronic PancreatitisDiagnostic test

Sensitivity Structure Function

Most Endoscopic USERCP

Secretin test

Less CT ScanUS

Bentiromide(PABA)Serum TrypsinogenFecal Chemotrypsin

Least Abdomina X-Ray Fecal Fat

Chronic PancreatitisDiagnosis: ERCP

Chronic PancreatitisDiagnosis: ERCP

Chronic PancreatitisDiagnosis: X-Ray

Chronic PancreatitisTreatment

l Discontinue Alcoholl Suppress secretion

n (Pancreatic Enzymes)l Modify neurotransmission

n (nerve block)l Relieve Obstruction

n (Surgery, Stenting)

Chronic PancreatitisComplications

l Common Bile duct stenosisl Duodenal Obstructionl Splenic vien thrombosisl Pleural effusionl Pseudocystl Pancreatic ascites

Natural history of Alcohol Pancreatitis

Chronic PancreatitisNatural History

Pancreatitis - Doctor 2015 - JU Medicine › ... › sites › 5 › 2018 › 09 › UJ-Pan… · Recurrent Pancreatitis Pancreatic Divisum 5 - 10% Population Most common congenital

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