ACUTE PANCREATITIS

ANATOMY

ACUTE PANCREATITIS -Acute pancreatitis (AP) are characterized by edematous lesions, eventually necrosis and bleeding inside and in peripancreatic area.

Pathology: - 2 types of AP 1. Edematous AP congestion and edema of the pancreas. swelling normal/mild inflammation of the retroperitoneum

2. Necrotic pancreatitis Severe +++. Important swelling of the pancreas, bleeding multiples areas and hematomas till the complete distruction of the gland. Involvement of all retroperitoneum, fatty necrosis- white spots Plasmal escape – peripancreatic and retroperitoneal spaces + ascites

ETIOLOGY: 2 MAIN CAUSES GALLSTONES ALCOHOL 1. GALLSTONES

2. ALCOHOL

3. Rare etiology Postoperative and postraumatic AP Less than 10% Postoperative and postraumatic AP Billiary ,pancreatic, gastric surgery Kidney transplantation Post- ERCP Pancreatic tumors Infections Leptospirosis Ascaridiosis Metabolical factors Hypercalcemia Hypertriglyceridemia Drug induced Corticotherapy Chlorothiazide, Isothiazide Immunosupressors Oral Contraceptives Auto-immune AP Idiopathic factors

3 mechanisms STOP the autodigestion of the pancreas C. PATHOPHYSIOLOGY 3 mechanisms STOP the autodigestion of the pancreas 1.enzymes - preserved as zymogenes separates from other proteins 2.enzymes sont secreted – inactive forms 3.inhibitors of proteolitic enzymes in the pancreatic tissu and pancreatic juice AP= enzimatic autodigestion of the pancreas--- trypsinogen activation in trypsine in the pancreatic cells . Trypsine --- cascade activation of proenzymes from zymogens granules – pancreatic acinar cell distruction SIRS --- proinflammatory cytokines(Il-1, TNF) in the pancreatic tissu and other organs (kidney, liver, lung) SEVERE SYSTEMIC EVENTS

PATHOPHYSIOLOGY

D. CLINICAL SIGNS ABDOMINAL PAIN Describe it!!! Nausea and vomiting Abdominal distension- paralitic ileus +/ tachycardia, low/ high temperature, hypotension, tachypnea- severe forms Oliguria Jaundice Ascites !! Pain intensity vs poverty of clinical signs

50 %- symptoms are not specific Differential dg: Acute cholecystitis Mesenteric infarction Bowel obstruction Ruptured abdominal aortic aneurism Respiratory distress Oligo-anuria Peritonitis

E. DIAGNOSTIC 1. Blood tests HIGH levels of amylase and lipase (≥ 3 N) ESSENTIAL BUT NOT SPECIFIC!! CRP > 15 mg/100 ml – SEVERE AP.

2. IMAGING DG Plain abdominal X- Ray- localised ileus- sentinel loop, free air, calcifications Abdominal US- swelling , diffuse hypoechogenity - Eventually the cause - gallstones

CT SCAN SEVERITY EVALUATION criteria Balthasar score- severity and extent of necrosis, peripancreatic fluid collection Correlation with morbidity and mortality

MRCP Non-invasive Safer Faster THAN ERCP but less sensitive WHEN Suspicion of bile duct obstruction

MRI - severity of AP - no iodine contrast - bile obstruction

F. COMPLICATIONS PANCREATIC NECROSIS PSEUDOCYST PANCREATIC ABCESS

PSEUDOCYST- necrosis organising - Wirsung disruption - after aprox 4 w evolution of AP

PANCREATIC ABCESS- pseudocyst infection/ infection of necrotic areas

Venous thrombosis ( splenic, portal, SMV ) Pleural effusion Ascites OTHER COMPLICATIONS Venous thrombosis ( splenic, portal, SMV ) Pleural effusion Ascites Fatty necrosis- cutaneus

Good – Edematous AP – mortality< 2% G. PROGNOSIS Good – Edematous AP – mortality< 2% Bad – Necrotic forms of AP- high mortality Severity prediction RANSON scale- if > 3 crt- AP severe if > 7- 100% mortality AP induced by alcohol RANSON scale Admission After 48 H Age > 55 years Leucocytes/mm³ > 16.000 Glycemia > 200 mg% LDH > 1.5 N SGOT > 6 N Hematocrit reduced with 10% Urea raised with 5 mg % Calcemia < 8 mg% PaO2 < 60 mm Hg Base deficit > 4 mEq/l Liquid sechestration > 6 l

!!! Admission: High levels of CPR – bad prognosis Other severity scales- Glasgow, Apache III

TREATMENT MEDICAL NPO - NGT ? IVF PPI PAIN CONTROL - ANTIBIOTICS- ???? SURGICAL Indications !!! WHEN WE HAVE THE PROOF OF INFECTION Choosing of the moment!!

ERCP with sphyncterotomy INDICATIONS- gallstones in bile duct

SURGICAL TREATMENT Surgical infected necrose debridement Drainage +/- Laparostomy

SURGICAL TREATMENT- PSEUDOCYSTS INDICATIONS: IF > 7 cm Rapidly growing Bleeding Compression Disruption Pain Infection

PSEUDOCYST TREATMENT- TRANSPAPILLARY DRAINAGE; IF COMMUNICATING- STENT

PSEUD0CYST TREATMENT-EXTERNAL DRAINAGE

SURGICAL TREATMENT – if proximal duct disrupted- WHIPPLE