1. Acute Pancreatitis Diagnosis EtOH: history EtOH: history Gallstones: abnormal LFTs & sonographY Gallstones: abnormal LFTs & sonographY Hyperlipidemia: lipemic serum, Tri>1,000 Hyperlipidemia: lipemic serum, Tri>1,000 Hypercalcemia: elevated Ca Hypercalcemia: elevated Ca Trauma: history Trauma: history Medications: history Medications: history

2. Abdominal Exam - Abdominal tenderness and rigidity - Bowel sounds decreased - Palpable upper abdominal mass Acute fluid collections and pseudocysts Skin Exam Skin Exam - Erythematous skin Nodule (Subcutaneous Fat Necrosis) Subcutaneous Fat NecrosisSubcutaneous Fat Necrosis - Cullen's Sign (periumbilical discoloration) Cullen's Sign Cullen's Sign - Turner's Sign (flank discoloration) * due to exudation of blood-stained fluid into the subcutaneous tissue, usually 72 h into the illness. Turner's Sign Turner's Sign

4. Acute Pancreatitis Clinical Manifestations PANCREATICPERIPANCREATIC Adjacent viscera: SYSTEMIC Mild: edema, inflammation, fat necrosis Severe: phlegmon, necrosis, hemorrhage, infection, abscess, fluid collections Retroperitoneum, perirenal spaces, mesocolon, omentum, and mediastinum ileus, obstruction, perforation ileus, obstruction, perforation Cardiovascular: hypotension Pulmonary: pleural effusions, ARDS Renal: acute tubular necrosis Hematologic: disseminated intravascular coag. Metabolic: hypocalcemia, hyperglycemia

5. Diagnosis: Biochemical - Serum Amylase elevated Serum Amylase Serum Amylase Nonspecific Nonspecific Returns to normal in 48-72 hours Returns to normal in 48-72 hours Normal amylase does not exclude pancreatitis Normal amylase does not exclude pancreatitis Level of elevation does not predict disease severity Level of elevation does not predict disease severity - Serum Lipase elevated Lipase Specific for pancreatic disease Specific for pancreatic disease Returns to normal in 7-14 days Returns to normal in 7-14 days

6. Diagnosis: Biochemical White Blood Cells White Blood Cells White Blood Cells White Blood Cells increased to 15k-20k increased to 15k-20k Hypertriglyceridemia (15%) Hypertriglyceridemia (15%) Hypertriglyceridemia liver Function Tests liver Function Tests liver Function Tests liver Function Tests (ALP) (AST),elevated (ALP) (AST),elevated (LDH) elevated (Poor prognosis) (LDH) elevated (Poor prognosis) Hyperglycemia HyperglycemiaHyperglycemia Albumine Albumine (Poor prognosis) - Serum Electrolytes Hypocalcemia (25%) Hypocalcemia (25%) Hypocalcemia

7. Another criteria often used to assess the severity of pancreatitis is the (APACHE-II). Another criteria often used to assess the severity of pancreatitis is the (APACHE-II). A cute P hysiology A nd C hronic H ealth E valuation age and vital signs age and vital signs Specific laboratory parameters, Specific laboratory parameters, Chronic health status Chronic health status The main advantage is the immediate assessment of the severity of pancreatitis. A score of eight or more at admission is usually considered indicative of severe disease

9. Predictors of Severity Why are they needed? Why are they needed? - Appropriate triage & therapy - compare results of studies of the impact of therapy When are they needed? When are they needed? - optimally, within the first 24 hours Which is the best? Which is the best?

10. Ranson Criteria Alcoholic Pancreatitis AT ADMISSION 1. Age > 55 years 2. WBC > 16,000 3. Glucose > 200 4. AST > 250 IU/L 5. LDH > 350 IU/L WITHIN 48 HOURS 1. HCT drop > 10% 2. BUN > 5 3. Arterial PO2 < 60 mm Hg 4. Base deficit > 4 mEq/L 5. Serum Ca < 8 6. Fluid sequestration > 6L Number Mortality <21% 3-416%5-640%7-8100%

11. Glasgow Criteria Non-alcoholic Pancreatitis 1. WBC > 15,000 2. Glucose > 180 3. BUN > 16 4. Arterial PO2 < 60 mm Hg 5. Ca < 8 6. Albumin < 3.2 7. LDH > 600 U/L 8. AST or ALT > 200 U/L

12. CT Severity Index appearancenormalenlargedinflamed 1 fluid collection 2 or more collections gradeABCDE score01234 necrosisnone < 33% 33-50% > 50% score0246 scoremorbiditymortality1-24%0% 7-1092%17% Balthazar et al. Radiology 1990.

13. Useful markers of severe disease. Pleural effusion Pleural effusion BMI (High body mass index) BMI (High body mass index) Necrosis on contrast-enhanced CT-SCAN Necrosis on contrast-enhanced CT-SCAN CRP level greater than 150 mg/L at 48 h CRP level greater than 150 mg/L at 48 h Infection of the necrotic tissue after the first week of illness is the major determinant of later outcome. Infection of the necrotic tissue after the first week of illness is the major determinant of later outcome.

14. Pancreatic necrosis

15. CT-guided percutaneous fine-needle aspiration of the pancreatic tail

16. Pseudocyst

17. Pseudocyst

18. Pseudocyst

19. Pseudocyst

20. Pseudocyst

21. Pseudocyst

22. Pseudocyst

24. Acute pseudocyst

25. Pancreatic Cancer Pancreatic cancer is one of the most lethal malignancies. Pancreatic cancer is one of the most lethal malignancies. An estimated 32,300 patients will die of pancreatic cancer in year 2006. The tenth most common malignancy in the United State. Despite recent advances,in pathology, molecular basis and treatment, the overall survival rate remains 4% for all stages and races. Palliative care represents an important aspect of care in patient with pancreatic malignancy. Identifying and treating disease related symptomology are priorities. Common problems include pain, intestinal obstruction, biliary obstruction, pancreatic insufficiency, anorexia-cachexia and depression.