1. ACUTE PANCREATITIS

2. ANATOMY

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

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

5. 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

6. ETIOLOGY: MAIN CAUSES
GALLSTONES
ALCOHOL
1. GALLSTONES

7. 2. ALCOHOL

8. 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

9. 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

10. PATHOPHYSIOLOGY

11. 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

12. 50 %- symptoms are not specific
Differential dg:
Acute cholecystitis
Mesenteric infarction
Bowel obstruction
Ruptured abdominal aortic aneurism
Respiratory distress
Oligo-anuria
Peritonitis

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

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

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

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

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

18. F. COMPLICATIONS
PANCREATIC NECROSIS
PSEUDOCYST
PANCREATIC ABCESS

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

20. PANCREATIC ABCESS- pseudocyst infection/ infection of necrotic areas

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

22. 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 > % mortality
AP induced by alcohol
RANSON scale
Admission
After 48 H
Age > 55 years
Leucocytes/mm³ >
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

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

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

25. ERCP with sphyncterotomy
INDICATIONS- gallstones in bile duct

26. SURGICAL TREATMENT Surgical infected necrose debridement Drainage
+/- Laparostomy

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

28. PSEUDOCYST TREATMENT- TRANSPAPILLARY DRAINAGE; IF COMMUNICATING- STENT

30. PSEUD0CYST TREATMENT-EXTERNAL DRAINAGE

32. SURGICAL TREATMENT – if proximal duct disrupted- WHIPPLE