Presented By: Ehsan Arefnia June 2012

Anatomy Retroperitoneal Organ Weighs 75 To 100 G 15 To 20 Cm Long Head Neck Body Tail 2

Physiology Three General Functions: Neutralizing the acid chyme entering the duodenum from the stomach Synthesis and secretion of digestive enzymes after a meal Systemic release of hormones that modulate metabolism of carbohydrates, proteins, and lipids 3

Acute Pancreatitis 4

Definition and Incidence Inflammatory disease with little or no fibrosis Initiated by several factors Develop additional complications 300,000 cases occur in the united states each year leading to over 3000 deaths 5

Etiology Biliary tract disease Alcohol Drugs 30 meds identified AIDS therapy: didanosine, pentamidine Anti-inflammatory: sulindac, salicylates Antimicrobials: metronidazole, sulfonamides, tetracycline, nitrofurantoin Diuretics: furosemide, thiazides IBD: sulfasalazine, mesalamine Immunosuppressives: azathioprine, 6- mercaptopurine Neuropsychiatric: valproic acid Other: calcium, estrogen, tamoxifen, ACE-I Hypertryglycerides Greater than 1000 mg/dL Trauma External pancreatic duct injury Surgical CABG, Organ transplant, ERCP, Billroth II, Splenectomy Pancreatic duct obstruction Neoplasms Pancreas divisum Ischemia Hypoperfusion Atheroembolic Vasculitis Ampullary and duodenal lesions Infections Mumps, CMV, EBV, Coxaci, ECOV,HBV, Herpes HIV 35 to 800 times greater risk of AP c/w general pop. Hypercalcemia Most often secondary to hyperparathyroidism Hereditary Venom Scorpion, spider, Gila Monster, lizard bites Pregnancy Third trimester until 6 weeks post partum Chinese liver fluke Cystic fibrosis 6

Etiology: (GET SMASHED) G: Gallstone E: Ethanol T: Trauma S: Steroid M: Mump A: Alcoholism or Autoimmune S: Scorpion bits H: Hyperlipidemia E: ERCP D: Drugs 7

Differential Diagnosis Pancreatitis Acute Cholecystitis Cholangitis Perforated Viscous Intestinal Obstruction Ruptured Aaa Diverticulitis Bowel Ischemia MI Severe Pneumonia Appendicitis Caecal Perforation Ruptured Ectopic 8

Clinical Presentation Abdominal pain Epigastric Radiates to the back Worse in supine position Nausea and vomiting Tachycardia, Tachypnea, Hypotension, Hyperthermia Elevated Hematocrit Cullen's sign Grey Turner's sign 9

Grey Turner sign Cullen’s sign 10

Diagnosis: Biochemical serum amylase Nonspecific Returns to normal in 3-5 days Normal amylase does not exclude pancreatitis Level of elevation does not predict disease severity Urinary amylase P-amylase Serum Lipase Serum Electrolytes Hypocalcaemia (Poor prognosis) Hyperglycemia (Poor prognosis) Hypoalbuminemia CBC Increased Hb Thrombocytosis Leukocytosis Liver Function Test Serum Bilirubin elevated Alkaline Phosphatase elevated Aspartate Aminotransferase elevated 11

Assessment of Severity Ranson Criteria Biochemical Markers Computed Tomography Scan 12

Ranson Criteria Criteria for acute gallstone pancreatitis Admission Age > 70 WBC > 18,000 Glucose > 220 LDH > 400 AST > 250 During first 48 hours Hematocrit drop > 10 points Serum calcium < 8 Base deficit > 5.0 Increase in BUN > 2 Fluid sequestration > 4L 13 <2 pos sign: mortality rate is pos sign: mortality rate is 10 to 20% >7 pos sign: mortality rate is >50%

50 year-old woman CT scans of normal kidneys and pancreas Spleen L Kidney R Kidney A Stomach Liver V Pancreas 14

Large, edematous, homogeneously attenuating pancreas (1). Peripancreatic inflammatory changes (white arrows). There is no pancreatic necrosis. Calcified gallstones are seen in gallbladder (black arrow) Gallstone-induced pancreatitis in 27 year-old woman 15

Pancreatic Necrosis 16

Treatment of Mild Pancreatitis Pancreatic rest Supportive care fluid resuscitation – watch BP and urine output Pain Control NG tubes and H 2 blockers or PPIs are usually not helpful Refeeding (usually 3 to 7 days) If: Bowel Sounds Present Patient Is Hungry Nearly Pain-free (Off IV Narcotics) Amylase & Lipase Not Very Useful 17

Treatment of Severe Pancreatitis Pancreatic Rest & Supportive Care Fluid Resuscitation – may require 5-10 liters/day Careful Pulmonary & Renal Monitoring – ICU Maintain Hematocrit Of 26-30% Pain Control – PCA pump Correct Electrolyte Derangements (K +, Ca ++, Mg ++ ) R/O necrosis Contrasted CT scan at hours Prophylactic antibiotics if present Surgical debridement if infected Nutritional support May be NPO for weeks TPN vs. enteral support (TEN) 18

Complications Local Phlegmon, Abscess, Pseudocyst, Ascites Involvement of adjacent organs, with hemorrhage, thrombosis, bowel infarction, obstructive jaundice, fistula formation, or mechanical obstruction Systemic A. Pulmonary: Pneumonia, atelectasis, ARDS, Pleural Effusion B. Cardiovascular: Hypotension, Hypovolemia, Sudden Death, Nonspecific ST-T wave changes, Pericardial effusion C. Hematologic :Hemoconcentration, DIC D. GI: Hemorrhage, Peptic ulcer, Erosive gastritis, Portal vein or splenic vein thrombosis with varices E. Renal: Oliguria, Azotemia, Renal artery/vein thrombosis F. Metabolic :Hyperglycemia, Hypocalcemia, Hypertriglyceridemia, Encephalopathy, Sudden Blindness (Purtscher's retinopathy) G. CNS: Psychosis, Fat Emboli, Alcohol withdrawal syndrome H. Fat necrosis: Intra-abdominal saponification, Subcutaneous tissue necrosis 19

Acute Pseudocyst 20

Management 21

Chronic Pancreatitis 22

Definition and Prevalence Incurable, Chronic Inflammatory Condition 5 To 27 Persons Per 100,000 Fibrosis Alcohol 23

Etiology Alcohol, 70% Idiopathic (including tropical), 20% Other, 10% Hereditary Hyperparathyroidism Hypertriglyceridemia Autoimmune pancreatitis Obstruction Trauma Pancreas divisum 24

Signs and Symptoms Steady And Boring Pain Not Colicky Nausea Or Vomiting Anorexia Is The Most Common Malabsorption And Weight Loss Apancreatic Diabetes 25

Laboratory Studies Tests for Chronic Pancreatitis I. Measurement of pancreatic products in blood A. Enzymes B. Pancreatic polypeptide II. Measurement of pancreatic exocrine secretion A. Direct measurements 1. Enzymes 2. Bicarbonate B. Indirect measurement 1. Bentiromide test 2. Schilling test 3. Fecal fat, chymotrypsin, or elastase concentration 4. [ 14 C]-olein absorption III. Imaging techniques A. Plain film radiography of abdomen B. Ultrasonography C. Computed tomography D. Endoscopic retrograde cholangiopancreatography E. Magnetic resonance cholangiopancreatography F. Endoscopic ultrasonography 26

27 Pancreatic calcifications. CT scan showing multiple, calcified, intraductal stones in a patient with hereditary chronic pancreatitis Endoscopic retrograde cholangiopancreatography in chronic pancreatitis. The pancreatic duct and its side branches are irregularly dilated

Treatment Analgesia Enzyme Therapy Antisecretory Therapy Neurolytic Therapy Endoscopic Management Surgical Therapy 28

Complications Pseudocyst Pancreatic Ascites Pancreatic-Enteric Fistula Head-of-Pancreas Mass Splenic and Portal Vein Thrombosis 29

Management 30

References Schwartz's Principles of Surgery, Ninth Edition Sabiston Textbook of Surgery, 18th Edition

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