Pancreatitis
o
Acute
o
Chronic – due to fibrosis within the gland
o
Acute on chronic
o
Injury to acinar cells / impairment of secretion
of zymogen granules of Premature activation of pancreatic enzymes à auto-digestion à Local effects (oedema,
hemorrhage, necrosis), systemic effects (hemodynamic instability, bactaraemia,
ARDS, Pleural effusion, GI hemorrhage, renal failure, DIC)
Acute Pancreatitis
·
Mortality – 10 -15 %
·
Mild – oedema, minimal organ dysfunction ,
Mortality rate – 1%
·
Severe – Pancreatic necrosis, SIR, multi organ
failure, Mortality rate – 20-50%
·
3% of all abdominal pain
·
Peak – young men, older women
·
Causes
o
I – Idiopathic, iatrogenic, inborn (mutation of
cationic trypsinogen gene à
acute pancreatitis in teen ages à chronic pancreatitis in next two decades à pancreatic cancer in
70 Years of age)
o
G – Gall stones ( commonest cause in west)
o
E – Ethanol ( commonest cause in east)
o
T – Trauma ( commonest cause in children)
o
S – Steroids
o
M – Malnutrition, Mumps, CMV, EBV, Coxsackie B
o
A – Autoimmune (SLE,PAN)
o
S – Scorpion bite
o
H – Hyperlipidaemia, Hypercalcaemia, Hypothermia
o
E – ERCP – 1-3 %
o
D – Drugs
§
S – Steroids
§
A – Azathioprim
§
N – NSAIDS
§
D – Diuretics
Diagnosis/
investigations
·
Clinical
·
Biochemical
o
Serum amylase
§
Rises within 12 hours and remains elevated for
2-3 days
§
High up to 14 days
§
Three to four times above normal
§
Normal levels does not exclude the disease
o
Urine amylase
o
Serum lipase
§
Slightly more specific and sensitive than
amylase
·
Radiological
o
Contrast enhanced CT
·
To find out complications
·
To find the etiology
·
To assess the fitness for surgery
Local Complications
·
Phlegmon – abscess or an inflammatory mass in
the pancreas
·
Acute fluid collection
o
Sterile
o
Most resolves
o
Intervene only when large collections cause
pressure effects – percutaneous aspiration under US or CT guidance
o
Transgastric drainage under EUS guidance
o
Can become a pseudocyst or a abscess if become
infected
·
Sterile and infected pancreatic necrosis
o
Sterile – should not interfere
o
Infected necrosis – 50% mortality
o
If the patient is septic – CT or US guided
aspiration of the fluid à
if aspirate is purulent – percutaneous drainage à
send for microbiology à
start antibiotics
o
If sepsis worsens à
pancreatic necrosectomy
·
If head is involves à Midline laparotomy
·
If body and tail are involved à retroperitoneal
approach through a left flank incision
·
Feeding jejunostomy
·
Cholecystectomy if gall stone pancreatitis
·
Also laparoscopic surgery is performed
o
Closed continuous lavage
o
Closed drainage
o
Open packing
o
Closure and relaparotomy
o
Nutritional support
·
Pancreatic abscess
o
Acute fluid collection or an infected pseudocyst
o
Percutaneous drainage
·
Pancreatic ascites
o
Turbid fluid
o
High amylase level
o
Drainage via wide bore draine
o
Suppress pancreatic secretion by parenteral and
Nasojejunal feeding and ocreotide
o
ERCP – identify the duct disruption and
placement of a stent
·
Pancreatic Effusion
o
Encapsulated collection of fluid in the pleural
cavity
o
Percutaneous drainage under image guidance
·
Haemorrhage
o
Diagnosis by CT angiography and MR angiography
o
Treatment – embolisation or surgery
·
Portal or splenic vein thrombosis
·
Pseudocyst
o
Collection of amylase rich fluid enclosed in a
wall of fibrous or granulation tissue
o
Forms after 4 or more weeks after an attack of
acute pancreatitis, in chronic pancreatitis or after trauma
o
More than half have communication with
pancreatic duct
o
DD –
·
acute fluid collection
·
abscess
·
cystic neoplasm
o
EUS and aspiration of fluid
o
Fluid is tested for carcinoembryonic antigen
level, amylase level and cytology
o
Can resolve spontaneously
o
Intervene only if symptoms, complications
develops or have to distinguish from tumor
o
Complications
·
Infection
·
Rupture in to the gut or peritoneum
·
Enlargement causing pressure effect and pain
·
Erosion into a vessel
o
Drainage
·
Percutaneous transgastric cystgastrostomy
·
Endoscopic
·
Surgical
Systemic
Complications
·
CVS – shock, arrhythmias
·
ARDS
·
Renal failure
·
DIC
·
Hypocalcaemia, hyperglycaemia, hyperlipidaemia
·
Ileus
·
Visual disturbances, confusion, irritability, encephalopathy
·
Subcutaneous fat necrosis, arthralgia
