Dr Ahmad abanamy hospital Dr Nuaman danawar general& gastrointestinal surgeon

Acute Pancreatitis

Etiology: Gallstones - 45% of cases. Ethanol - 35% cases. Trauma. Steroids. Mumps. AUI - SLE, panarteritis. Scorpion venom - native species to Trinidad. Hyperlipidaemia, hypercalcaemia (calcium activates trypsinogen). ERCP, abdominal surgery. Drugs -azathioprine, NSAID, furosemide, sulphonamides.

Presentation: Pain - severe acute epigastric, radiating to the back possibly relieved by leaning forward. SIRS - systemic inflammatory response syndrome. Vomiting. Loss of appetite. Eponymous signs: Grey-Turner's - flank bruising secondary to retroperitoneal haemorrhage tracking from anterior para-renal space to the lateral edge of quadratus lumborum. Cullen's - peri-umbilical oedema and bruising secondary to pancreatic enzyme tracking, via the gastrohepatic and falciform ligament to the anterior abdominal wall. Note: Both take hours to appear and are associated with a poorer prognosis.

Investigations: Bedside - ECG, urine dipstick, BM. Blood - FBC, LFTs, Electrolytes, Calcium, Urea, Albumin, Glucose. Amylase - above 3 times normal level (i.e. >300) supports diagnosis. Level is not an indicator of severity and can be normal on admission. In acute on chronic pancreatitis amylase increase is often absent. Lipase - can also be used and stays elevated longer. CRP - > 150 indicates severe pancreatitis. Arterial blood gas - pH, P02, Lactate. Imaging: USS - check for gallstones. CT/ MRI - can be used to judge severity/complications. ERCP - if gallstones present can be used to further delineate and provides intervention through sphincterotomy.

Prognostic score Modified Glasgow Criteria Used in both gallstone and alcohol related pancreatitis. Both on admission and after 48hrs. Mortality score 6 = almost 100% Scoring: P02 < 8kpa Age >55 Neutrophils (WCC) >15 Calcium <2 mmol/l Renal: Urea >16 mmol/l Enzymes: AST>200 IU/l, LDH > 600 IU/l Albumin <32 g/dl Sugar: Glucose >10mmol/l

Ranson 2 versions for alcohol and gallstone aetiology. Based on score at admission and 48 hours after. Similar mortality scoring to modified Glasgow criteria. Alcohol: At admission: Age > 55 years WCC > 16 Glucose > 10 mmol/L AST > 250 IU/L LDH > 350 IU/L At 48 hours: Calcium < 2.0 mmol/L Hematocrit fall > 10% PO2 < 6 Kpa BUN increased by 1.8 or more mmol/L after IV fluid hydration Base deficit > 4 mEq/L Sequestration of fluids > 6

Gallstones: At admission: Age > 70 years WCC> 18 Glucose > 12.2 mmol/L AST > 250 IU/L LDH > 400 IU/L At 48 hours: Calcium < 2.0 mmol/L Hematocrit fall > 10% Oxygen PO2 < 6 Kpa BUN increased by 1.8 or more mmol/L after IV fluid hydration Base deficit > 5 mEq/L Sequestration of fluids > 4 L

Management Mainly conservative/supportive: 1. Close monitoring. 2. Oxygen - maintain saturations above 95%. 3. IV fluid resuscitation: Manages distributive shock and therefore reduces complications/organ failure. Maintain urine output above 0.5ml/(kg/hr). Note: Some advocate the avoidance of lactate containing solutions. 1. Analgesia 2. PPI 3. Anti-thrombotic 4. Moderate to severe - HDU/ITU admission for continuous monitoring and organ support. 5. Nutrition - enteral or parenteral. 6. Treat cause e.g. ERCP and sphincterotomy for gallstones. 7. Role of antibiotics - rarely indicated unless infectious aetiology or concomitant infection.

Balthazar Uses CT appearance to grade severity: Grade A – normal CT Grade B – focal or diffuse enlargement of the pancreas Grade C – pancreatic gland abnormalities and peripancreatic inflammation Grade D – fluid collection in a single location Grade E – two or more collections and/or gas bubbles in or adjacent to pancreas APACHE-II - acute physiology and chronic health evaluation Severity of disease scoring system used on ITU admission. Score > 8 = severe.

Surgical: 1. Necrosectomy - resection of necrotic pancreas can be open or laparoscopic. +/- 1. Open - Laparoscopies for serial resections, drainage, abdominal decompression and lavage. 2. Closed - Large drains post resection for lavage, drainage particularly of less sac.

Complications: Local: Peri-pancreatic fluid collection. Pseudocyst - collection of sterile fluid within lesser sac. Abscess - either pancreatic or peri- pancreatic. Necrosis/gangrene. Splenic vein thrombosis (note also drains pancreas and in close contact posteriorly)

Systemic: Organ failure: Renal - hypovolaemia + direct damage from vasoactive peptides and inflammatory mediators. Respiratory - ARDS, pleural effusions (transudative - low albumin or exudative - inflammatory mediators). Cardiac - hypovolaemia, arrhythmias. Liver Haematological - DIC Metabolic: Hyperglycaemia Hypocalcaemia - saponification of calcium salts, reduced PTH, calcitonin release. Intestinal - haemorrhage, ileus. Death - 10%