Acute pancreatitis Kamal Bani-Hani FRCS (Glasgow), M.D. (Leeds) King Abdullah University Hospital Department of Surgery – Faculty of Medicine Jordan University of Science & Technology

Acute pancreatitis Autodigestion of the pancreas by its escaped enzymes

Etiological Factors 1 Biliary tract disease 7 Scorpion venom 2 Alcohol 8 Drugs 3 Ischemia (hypotension, cardio-pulmonary by-pass, atheroembolism, vasculitis) 9 Pancreatic duct obstruction (tumor, pancreatic divisum, ampullary stenosis, ascaris infestiopn) 4 Duodenal obstruction 10 Metabolic (hypercalcemia, hyperthyroidism, Hyperlipidemia) 5 Trauma (external, operative, ERCP) 11 Viral infection (mumps, coxsaki B4) 6 Familial 12 Idiopathic

Drug Induced pancreatitis Azathioprine* L-asparaginase Estrogenes* Phenformin Corticosteroids Procainamide Thiazide diuretics Valproic acid Furosemide Clonidine Ethacrynic acid Pentamidine Sulfonamides Dideoxyinosine Tetracycline H2 antagonist

Surgical Pathology Edema Exudation Hemorrhage Suppuration Necrosis Fat necrosis (combination of liberated fatty acids from hydrolized fat with calcium) Fluid loss  Hypovolemia Pseudocyst

Clinical features (Symptoms) Pain (sudden,intense,continuous, upper abdomen back, bizarre position) Nausea and Vomiting

Clinical features (Signs) General Local Shock Peritonitis Fever Paralytic ileus Jaundice Abdominal mass Left pleural effusion Cullen’s sign. Grey Turner sign Acute pulmonary failure Subcutaneous necrosis Cerebral abnormalities

Investigation General Laboratory Tests Radiology CBC S. amylase Chest X-ray S. electrolytes S. amylase isoenzymes (P+S types) Abdominal X-ray Lft Urinary amylase Ba. Meal S. Ca+2 Amylase-creatinine clearance ratio US Blood glucose S. lipase CT scan S. methemalbumin MRI Peritoneal fluid analysis

Intra-abdominal Disorders associated with Hyperamylasemia Pancreatic disorders Non pancreatic disorders Acute pancreatitis Ruptured aortic aneurysm Chronic pancreatitis Ruptured ectopic pregnancy Trauma Intestinal obstruction Carcinoma Acute appendicitis Pseudocyst pancreatic ascites Perforated peptic ulcer Abscess Biliary tract disease Mesenteric infarction Afferent loop syndrome

Extra-abdominal Disorders associated with Hyperamylasemia Salivary gland disorders + Impaired amylase excretion +Miscellaneous Mumps Pneumonia Parotitis Pancreatic pleural effusion Trauma Mediastinal pseudocyst Calculi Cerebral trauma Irradiation sialadenitis Severe burns Renal failure Diabetic ketoacidosis Macroamylasemia Pregnancy Drugs bisalbuminemia

D Dx MI Perforated peptic ulcer Acute cholecystitis

Mortality and Prognosis Mortality rate is 6-20% Causes of death: Hypovolaemic shock Electrolyte disturbances Toxaemia Renal failure Respiratory failure (collapse, consolidation, effusion)

Ranson’s Criteria At admission During initial 48 hours Age >55 Hematocrite fall > 10% WBC > 16000/cu.mm BUN rise 5mg/dl Glucose > 200mg/dl Ca+2 < 8 mg/dl LDH > 350 IU/L PO2 < 60 mm.Hg SGOT > 250 U/dl Base deficit > 4 meq/L Fluid sequestration > 6 L

Mortality and Prognosis (3) ¨      <2  no mortality ¨      3-4  15% mortality ¨      5-6  50% mortality ¨       7  test the limits of modern medicine

Treatment (When diagnosis certain Rest the patient (Relief pain) Pethidine 100mg/4hr + antispasmodic Rest the pancreas NPO, IV fluid, electrolytes replacement Rest the bowel NG tube Resuscitation Replacement therapy Resist enzymatic activity Protease inhibitors, Trasylol , H2 antagonist, glucacon ? Resist infection Antibiotics ? Repeated examination General features, abd signs, fluid balance Repeated serum estimations Daily Ca+2 , WBC ( fibrinogen, methaemalbumin, Mg+2 ) Respiratory support O2 , assisted respiration

Treatment (When diagnosis uncertain) Peritoneal lavage Laparotomy

Treatment (When complications become apparent ) Toxic patient Abdominal mass Persistently high gastric aspiration

Complications MOF Abscess formation Cyst formation Recurrent acute attacks Chronic pancreatitis