ACUTE & CHRONIC
PANCREATITIS
ILA GIT
BY SA3
7TH JUNE
2016
INTRODUCTION
OF ACUTE
PANCREATITIS
PRESENTED BY:
SITI KHADIJAH BINTI MANSOR 10-6-89
PREPARED BY:
SITI ZULAIKHA BINTI SAIAN 10-6-90
SITI SUHAILA BINTI MOHAD SARIF 10-6-91
SITI AISYAH BINTI RUSMAN 10-6-92
SITI NAJWA BINTI KHAMSUL 10-6-84
Acute
pancreatitis (AP)
the
single most frequent gastrointestinal cause of
hospital admissions in the US.
The
risk and etiology of pancreatitis differ with age and
sex, and all pancreatic disorders affect Blacks more
than any other race.
Gallstones
are the most common cause of acute
pancreatitis, and early cholecystectomy eliminates the
risk of future attacks.
CAUSES OF ACUTE
PANCREATITIS
1.
2.
3.
4.
5.
Bile duct stones (50%)
Excess alcohol intake (35%)
Trauma
Rare : viral infections,
hyperparathyroidism, corticosteroid
Idiopathic (20%)
increasing incidence of obesity promotes
gallstone formationthe most common cause of AP.
Increased availability and use of tests to measure
serum levels of pancreatic enzymes detect milder
cases of AP but can also result in over diagnosis
The
Graph shows incidence from 19962005 in White and Black
residents of Allegheny County, PA, US, based on age-group, sex and
etiology.
INCIDENCE IN MALAYSIA
Etiology
Malay
Indian
Total
Alcohol
17
18
Biliary
disease
Viral
14
17
ERCP
Others
Unknown
13
13
Total
31
21
52
DIAGNOSIS OF
ACUTE
PANCREATITIS
PRESENTED BY:
SITI NUR JANNAH BT SHAARI 10-6-97
PREPARED BY:
SITI NUR AFIQAH BT JOHARI 10-6-95
SITI NUR BAIZURI BT HASAN 10-6-96
SYED ALWI BIN SYED HUSIN 10-6-98
SHARIFAH ANITH ATIQA BT SYED ROZHAN 10-6-99
HISTORY
Abdominal
Site:
pain
upper abdomen
Acute
onset
Gradually
intensifies in severity
Duration:
varies
Radiates
to the back
Worsening
Relieve
when drinking alcohol or eating heavy meal
sometimes by sitting upright or leaning
forward
Associated
with nausea, vomiting, anorexia, fever
Dont forget to ask..
History
of previous biliary colic
History
of alcohol consumption
Any
recent operative or other invasive procedures
(e.g. ERCP)
Any
intake of certain medications
Any
viral infection
Family
history of hypertriglyceridemia
EXAMINATION
General examination
Pale
Diaphoretic
Listless
Jaundice
(minority of patients)
Vital signs
Fever
Tachycardia
Hypotension
Tachypnea
Abdominal examination
Abdominal
tenderness
Muscular
guarding (guarding
tends to be more pronounced in
the upper abdomen) and
distention.
Bowel
sounds are often
diminished or absent because of
gastric and transverse colonic
ileus.
Uncommon physical findings
Cullens sign:
bluish discoloration
around the umbilicus resulting from
hemoperitoneum
Grey-Turners sign
: reddish-brown
discoloration along the flanks resulting
from retroperitoneal blood dissecting
along tissue planes.
Erythematous
skin nodules : focal
subcutaneous fat necrosis(size not more
than 1 cm, and the site is on extensor
skin surfaces)
Polyarthritis
INVESTIGATIONS
LABORATORY
CBC
Anemia(hgic),
Liver
leukocytosis (inflammation, infection)
enzymes
ALT
if increases more that 150 U/L probably dto
gallstones
Serum
Low
Blood
electrolytes, BUN, creatinine
Ca2+
glucose, cholesterol, triglycerides
Blood
glucose high dto B-cell injury
ABG
respiratory
distress
Serum
amylas
e
Other
marker
s
LABORATO
RY
STUDIES
Creactiv
e
protein
Serum
lipase
Pancreatic
enzymes (serum amylase and lipase)
Serum
amylase sensitivity of 81-95% but not specific for
pancreatitis
Serum
lipase more preferred dto its improved sensitivity esp
in alcohol-induced pancreatitis, and its prolonged elevation
Rise
2-4 times the upper limit of normal is recommended for
dx
Neither
is useful in monitoring or predicting the severity the
episode of acute pancreatitis
Serum
C-Reactive Protein: best marker for severity
Trypsinogen
and elastase have no significant advantage
over amylase or lipase
IMAGING IN ACUTE
PANCREATITIS
Role:
To clarify
the diagnosis when the clinical picture is
confusing
Help
in determine the possible causes
Assess
severity (Balthazar score)
Determine
Detecting
prognosis
complications
1. Abdominal Ultrasound
Indicated early in acute pancreatitis
Pros
Inexpensive
Excellent for identifying gallbladder pathology
Technique of choice of detecting gallstones (Most common cause of pancreatitis!)
Evaluate bileduct dilation
May visualize masses and follow up of pseudocyst
Cons
Not optimal for pancreas; retroperitoneal location easily obscured by bowel gas
distension
Less sensitive for stones in distal CBD
Limited in early assessment of pancreatitis
2. Abdominal X-ray
Limited
role in acute pancreatitis
Poor
visualization of the pancreas and
retroperitoneum
Most
common radiologic signs associated with
acute pancreatitis include:
Free
The
air in the abdomen, indicating a perforated viscus
colon cut-off sign, and sentinel loop sign, both
indicating inflammatory process damaging
peripancreatic structures
COLON CUT-OFF SIGN
Markedly
distended transverse
colon with air
Absence
flexure
of gas distal to splenic
SENTINEL LOOP SIGN
Mildly dilated, gas-filled segment of small bowel
with or without air fluid level
3. Contrast-Enhanced CT
Standard
imaging of choice
Pros
Aid
in diagnosis and staging of pancreatitis
Evaluate
complications
Evaluate
common bile duct for stones or other obstructions
Assess
severity of acute pancreatitis (CT Severity Index)
Cons
limited
in patients who are allergic to intravenous (IV)
contrast or have renal insufficiency.
CTSI
3. MRI
Increasingly used in diagnosis and management of acute pancreatitis
Pros
alternative
in situations in which CECT is contraindicated
Noninvasive
and no use of IV contrast
Ability
to delineate pancreatic and bile ducts (detect
choledocholithiasis missed on U/S )
Greater
sensitivity than CT in detecting mild pancreatitis
Cons
Expensive
Less
readily available in nontertiary medical centers
SUMMARY
MANAGEMENT OF
ACUTE PANCREATITIS
PRESENTED BY:
SHAFIRA BT SHAHAMEN 10-6-104
PREPARED BY:
SHAHIZAN BT MOHD RASID 10-6-102
SHARIFAH NUR ATIQAH 10-6-103
AIDA NABILAH BT MOHD NASIR 10-6-109
ATIQAH ATHIRAH BT MUSTAFA 10-6-110
Management Algorithm from American College of Gastroenterology
INITIAL MANAGEMENT
Fluid
rehydration
Nutritional
support
Aggressive fluid
Early
AND Aggressive IV fluid hydration must be initiated.
rehydration
How aggressive?
What kind of IV
fluids?
How soon to
start?
Goal with IV fluid
hydration?
If severe hypovolemia present, bolus IV fluids initially
Then keep maintenance rate of 250 500 mL/hr IV
fluids.
Isotonic crystalloid
Lactated Ringers solution may be the preferred
isotonic crystalloid replacement
VERY VERY EARLY
Most beneficial in the first 12-24 h
Decrease BUN
Fluid requirements should be reassessed at frequent
intervals within 6 h of admission and for the next 2448 h.
Nutritional support
Mild Acute Pancreatitis
Oral feedings can be started immediately if there is no nausea and
vomiting, and abdominal pain has resolved.
Initiation of feeding with a low-fat solid diet appears as safe as a
clear liquid diet
Severe Acute Pancreatitis
Enteral nutrition is recommended to prevent infectious
complications.
Parenteral nutrition should be avoided unless the enteral route is
not available, not tolerated, or not meeting caloric requirements.
Nasogastric delivery and nasojejunal delivery of enteral feeding appear
comparable in efficacy and safety
The Role of Antibiotics in AP
ACG Recommendations
1.
Antibiotics should be given for an extrapancreatic infection, such as cholangitis, catheteracquired infections, bacteremia, urinary tract infections, pneumonia
2.
Routine use of prophylactic antibiotics in patients with severe AP is not recommended
3.
The use of antibiotics in patients with sterile necrosis to prevent the development of infected
necrosis is not recommended
4.
Infected necrosis should be considered in patients with pancreatic or extrapancreatic necrosis
who deteriorate or fail to improve after 710 days of hospitalization. In these patients, either
(i) initial CT-guided fine-needle aspiration (FNA) for Gram stain and culture to guide use of
appropriate antibiotics or
(ii) empiric use of antibiotics after obtaining necessary cultures for infectious agents, without CT
FNA, should be given
The Role of Antibiotics in AP
ACG Recommendations
4. In patients with infected necrosis, antibiotics known to penetrate pancreatic
necrosis, such as carbapenems, quinolones, and metronidazole, may be useful in
delaying or sometimes totally avoiding intervention, thus decreasing morbidity and
mortality
5. Routine administration of antifungal agents along with prophylactic or therapeutic
antibiotics is not recommended
MANAGEMENT OF ACUTE
PANCREATITIS
PRESENTED BY:
IZZATI SHAHIRAH BT SHAHARUDIN
10-6-114
PREPARED BY:
FADZRIN BIN FADHIL 09-6-115
IZZA NADZMI BT OTHMAN 10-6-111
IZZAH ILYANI BT ISMAIL 10-6-112
AIZAT AMIR BIN MOHD ABDUL SALAM 10-6-113
INITIAL ASSESSMENT & RISK
STRATIFICATION SCORE FOR
ICU SETTINGS
(according to the American College of
Gastroenterology updated guidelines)
Recommendations
1- Assessment of hemodynamic status & resuscitative
measures
2- Risk Stratification for Intensive Care Setting
3- Patients with organ failure admission to an intensive
care unit
1- Hemodynamic status
should
be assessed immediately upon
presentation and resuscitative measures
begun as needed
(strong recommendation)
2- Risk assessment
should
be performed to stratify patients into
i-higher-risk categories
ii- lower-risk categories
to assist triage, such as admission to an
intensive care setting.
3- Patients with organ failure
should
be admitted to an intensive care unit
or intermediary care setting whenever
possible.
The
Revised Atlanta Criteria now define organ
failure as a score of 2 or more for one of
these organ systems using the modified
Marshall scoring system.
Management of
post ERCP
pancreatitis
ROLE OF ERCP IN AP
ACG Recommendations
1.
Patients with AP and concurrent acute cholangitis should undergo ERCP within
24 h of admission
2.
ERCP is not needed early in most patients with gallstone pancreatitis who lack
laboratory or clinical evidence of ongoing biliary obstruction
3.
In the absence of cholangitis and/or jaundice, MRCP or EUS rather than diagnostic
ERCP should be used to screen for choledocholithiasis if highly suspected
4.
Pancreatic duct stents and/or post procedure rectal nonsteroidal anti-inflammatory
drug (NSAID) suppositories should be utilized to lower the risk of severe postERCP pancreatitis in high-risk patients
Preventing post-ERCP pancreatitis
Interventions to decrease the risk are:
i.
Guidewire cannulation
ii.
Pancreatic duct stents
iii.
Rectal NSAIDs
Treatment of post ERCP pancreatitis
Role of endoscopist:
Volume of fluid
resuscitation
Frequency and type of
narcotic analgesia
SURGICAL
INTERVENTIONS
IN ACUTE PANCREATITIS
PRESENTED BY:
AINI HAFIZAH BT SALLEH 10-6-121
PREPARED BY:
AIZURA BT ABD AZIZ 10-6-115
AFIFUL FIDAIY BIN HASLAN 10-6-116
AISYAH BT JAAFAR 10-6-119
FAIZUL ADLAN BIN ANUAR 10-6-122
1.
ROLE OF SURGERY IN ACUTE
PANCREATITIS (ACG
In patients with mild AP, found to have gallstones in the GB, a cholecystectomy should be performed
Recommendations
2013)
before discharge to prevent a recurrence of AP.
2.
In a pt with necrotizing biliary AP, in order to prevent infection, cholecystectomy is to be deferred until
active inflammation subsides & fluid collections resolve / stabilize.
3.
The presence of asymptomatic pseudocysts & pancreatic and/or extrapancreatic necrosis do not
warrant intervention, regardless of size, location and/or extension.
4.
In stable pts with infected necrosis, surgical, radiologic and/or endoscopic drainage should be delayed
preferably for more than 4 weeks to allow liquefaction of the contents & the development of a fibrous
wall around the necrosis (walled-off necrosis).
5.
In symptomatic patients w infected necrosis, minimally invasive methods of necrosectomy are preferred
to open necrosectomy.
PANCREATIC PSEUDOCYST
Def: a localized fluid collection that is rich in amylase
& other pancreatic enzymes & is surrounded by a wall
of fibrous tissue that is not lined by epithelium.
Should be suspected when a pt with AP fails
to resolve pain / recover after a week of Rx or
symptoms recur after improving!!
20-50% regress spontaneously w/in 6-7 weeks.
Acute complications:
Chronic complications:
1. Bleeding (usually from
splenic artery
pseudoaneurysm)
2. Infection
3. Rupture
1. Gastric outlet obstruction,
2. Biliary obstruction,
3. Thrombosis of the splenic
or portal vein with
development of gastric
varices
Mx of Pancreatic Pseudocyst
Imaging:
Transabdominal US hypoechoic / anechoic collections w low
level echoes are often seen dependent representing debris
CT scan well-circumscribed usually round or oval
peripancreatic fluid collections of homogenously low
attenuation, usually surrounded by well defined enhancing
wall.
Rx options:
1.
Observation: IV fluids, analgesics, antibiotics wait for ~ 6
weeks for spontaneous resolution & to allow maturation of the
wall so to be fit for surgical interventions.
2.
Drainage procedure:
Indications: size > 5cm, symptomatic, presence of complications
CT or US-guided external/percutaneous drainage
Surgical drainage: (take biopsy of cyst wall to exclude
cystadenocarcinoma)
Cystogastrostomy
Cystojejunostomy
Cystoduodenostomy
3. Endoscopic drainage:
less invasive, avoids the need for external drain, high long term
success rate
Transpapillary approach with ERCP
Transgastric / transduodenal approach
4. Other interventions:
Pseudocyst in tail of pancreas resection
Infected pseudocyst percutaneous external drainage with IV
antibiotics
Pseudocyst with bleeding into the cyst angiogram &
embolization
MANAGEMENT OF BILIARY
PANCREATITIS DUE TO GALL
BLADDER STONE
Overview of Biliary
Pancreatitis
Definition:
Gallstones obstructing pancreatic duct
causing the juice to attack its own tissues.
Signs
and Symptoms:
severe upper abdominal pain.
jaundice
nausea
vomiting
fatty stool production.
weight loss.
How do we approach such
case?
Investigation:
MRCP/CT
(gold)
ALP
AST
Pancreatic
US
Guided
Amylase
Algorithm
HAEMORRHAGIC
PANCREATITIS
Debridement
of necrotic tissues (necrosectomy)
o Endoscopic
approach
o Transgastric,
o Laparoscopic
transduodenal, transpapillary
debridement
o Retroperitoneal
approach
Retroperitoneal debridement
Endoscopic transgastric
necrosectomy
SURGERY OF
PANCREATIC
ABSCESS
What is pancreatic abscess?
Pancreatic abscess is a late complication
of acute necrotizing pancreatitis, occurring
more than 4 weeks after the initial attack.
A pancreatic abscess is a collection of pus
resulting from tissue necrosis, liquefaction,
and infection.
Surgical Treatment
EUS-guided necrosectomy is the standard
treatment for pancreatic necrosis and
abscess.
CT-guided drainage is the next best strategy
when a good transluminal window is not
available for EUS-guided transgastric
drainage.
CHRONIC
PANCREATITIS
PRESENTED BY:
FATIN KHAIRANNI BT AHMAD KHAIRUDDIN 10 6 - 128
PREPARED BY:
FATHIN AZIZAH BT MOHAMAD BASRI 10 6 123
FATIMAH AMIRA BT ZUHAIRI 10 6 125
FATIMATUL SYAHIRAH BT MOHD BADLI SHAH 10 6 126
FATIMAH NADHIRAH BT ABDULLAH ALWI 10 6 127
DEFINITION
A continuing, chronic, inflammatory process
of the pancreas, characterized by irreversible
morphologic changes
ETIOLOGY
Autoimmune pancreatitis
Increased circulating levels of gamma globulin, the presence
of autoantibodies, and a possible association with other
autoimmune diseases
Alcoholic chronic pancreatitis
The most common cause of pancreatitis (60%). A theory
suggests that the persistent demands of metabolizing
alcohol cause oxidative stress within the pancreas and may
lead to cellular injury and organ damage
Hereditary pancreatitis
An autosomal dominant disorder accounting for
about 1% of cases.
Cystic fibrosis in pancreatitis
The most common genetic abnormalities, is an
autosomal recessive disorder accounting for a small
percent of patients with chronic pancreatitis
Idiopathic
CLINICAL PICTURE
Abdominal
pain :
character : dull aching
worsens after eating
site : epigastric
radiation : to the back
Type B : prolonged, severe pain
Steatorrhea
(oily,
smelly stool)
Weight
loss
Gastroparesis
diarrhea
Type A : short relapsing episodes
lasting days to weeks, separated by
pain-free intervals
&
(type B is associated with worse quality of
life, greater healthcare need and
disability)
May be caused by :
Maldigestion
Fear of eating
multifactorial
Anorexia
Nausea
Vomiting
*severe / rapid weight loss is a red
flag for pancreatic cancer
INVESTIGATIONS
LABORATORY
Blood test
RADIOLOGY
Liver function test
Ultrasound
Renal function test
CT scan
Serum amylase and
lipase
ERCP
MRCP
Abdomen ultrasound
Serum trypsinogen
Fecal test
ESR
Serum amylase and lipase
not that relevant in chronic
pancreatitis as theyre only
high in acute pancreatitis
Low concentrations of serum
trypsin - relatively specific for
advanced chronic pancreatitis,
but not sensitive enough
Steatorrhea is seen in patients
with advanced chronic
pancreatitis
Ultrasound is the best initial
test and has sensitivity of
70%-80%
CT scan is good for assessing
complications
ERCP and MRCP can be used to
detect duct obstruction
MRCP is safer and safer than
ERCP, but less sensitive
TREATMENT
GOALS :
The goals of medical treatment are as follows:
Modify behaviors that may exacerbate the natural history of the
disease
Enable the pancreas to heal itself
Determine the cause of abdominal pain and alleviate it
Detect pancreatic exocrine insufficiency and restore digestion and
absorption to normal
Diagnose and treat endocrine insufficiency
Lifestyle
modification
Cessation of
tobacco
smoking,
Cessation of
alcohol intake
Endoscopic
treatment
Diet
Low fat diet,
High in protein
and carbohydrate
Surgical
treatment
pancreatic duct
drainage,
pancreatic
resection
Hospitalization
depends on the
severity of the
patient.
