1. Ministry of Health of the Republic of Moldova   State University of Medicine and Pharmacy "Nicolae Testemiţanu" ACUTE PANCREATITIS Severity Classification, Complications and Outcome
Mahamied Manar
Gr.1638

3. Physiology
In response to a meal, the pancreas secretes digestive enzymes in an alkaline (pH 8.4) bicarbonate-rich fluid.
The proteolytic enzymes are secreated in an inactive form, the maintenance of this is important in preventing pancreatitis.
Spontaneous secretion is minimal; the hormone secretin, which is released from the duodenal mucosa, evokes a bicarbonate-rich fluid. Cholecystokinin (CCK) (synonym: pancreozymin) is released from the duodenal mucosa in response to food. CCK is responsible for enzyme release. Vagal stimulation increases the volume of secretion.

4. Pathophysiology
Due to many causes, pancreatic pro-enzymes will be activated, and not released to the duodenum, so they will return back to the pancreas in the active form and cause autodigestion of the pancreas, which in turn will lead to an acute inflammatory reaction.

5. Incidence
Acute pancreatitis accounts for 3% of all cases of abdominal pain.
The disease may occur at any age, with a peak in young men and older women.

6. Etiological Factors 1 Biliary tract disease 7 Scorpion venom 2 Alcohol8
Drugs 3
Ischemia (hypotension, cardio-pulmonary by-pass, atheroembolism, vasculitis) 9
Pancreatic duct obstruction (tumor, pancreatic divisum, ampullary stenosis, ascaris infestiopn) 4
Duodenal obstruction 10
Metabolic (hypercalcemia, hyperthyroidism, Hyperlipidemia) 5
Trauma (external, operative, ERCP) 11
Viral infection (mumps, coxsaki B4) 6
Familial 12
Idiopathic

7. Clinical features (Symptoms)
Pain (sudden,intense,continuous, upper abdomen back, bizarre position)
Nausea and Vomiting

8. Clinical features (Signs)
General
Local
Shock
Peritonitis
Fever
Paralytic ileus
Jaundice
Abdominal mass
Left pleural effusion
Cullen’s sign. Grey Turner sign
Acute pulmonary failure
Subcutaneous necrosis
Cerebral abnormalities

9. Severity Classification
Pancreatitis severity ranges from mild to MOF with sepsis and necrotizing or hemorrhagic forms
Overall mortality: %
Biphasic time to death

10. Prognostic scoring systems
Atlanta classification
Ranson Score
Glasgow Score
Modified Glascow

11. Atlanta Classification
ACUTE PANCREATITIS Acute pancreatitis is an acute inflammatory process of the pancreas, with variable involvement of other regional tissues or remote organ systems.
SEVERE ACUTE PANCREATITIS Severe acute pancreatitis is associated with organ failure and/or local complications such as necrosis (with infection), pseudocyst or abscess. Most often this is an expression of the development of pancreatic necrosis, although patients with oedematous pancreatitis may manifest clinical features of a severe attack.
MILD ACUTE PANCREATITIS Mild acute pancreatitis is associated with minimal organ dysfunction and an uneventful recovery. The predominant pathological feature is interstitial oedema of the gland.
ACUTE FLUID COLLECTIONS Acute fluid collections occur early in the course of acute pancreatitis, are located in or near the pancreas, and always lack a wall of granulation of fibrous tissue.
PANCREATIC NECROSIS AND INFECTED NECROSIS Pancreatic necrosis is a diffuse or focal area(s) of non-viable pancreatic parenchyma, which is typically associated with peripancreatic fat necrosis. The onset of infection results in infected necrosis, which is associated with a trebling of the mortality risk.
ACUTE PSEUDOCYST An acute pseudocyst is a collection of pancreatic juice enclosed in a wall of fibrous or granulation tissue that arises following an attack of acute pancreatitis. Formation of a pseudocyst requires four or more weeks from the onset of acute pancreatitis.
PANCREATIC ABSCESS A pancreatic abscess is a circumscribed intra-abdominal collection of pus, usually in proximity to the pancreas, containing little or no pancreatic necrosis, which arises as a consequence of acute pancreatitis.
SPECIALIST UNIT A specialist unit is one in which multidisciplinary expertise is available on-site. Full intensive care facilities are mandatory, together with recourse to ERCP at any stage on an emergency basis. Expert radiological input for dynamic scanning, percutaneous procedures and angiography is essential. A surgeon with pancreatico-biliary expertise should supervise management.

12. Glasgow Scoring system for the initial prediction of severity in acute pancreatitis
Age >55 years
White blood cell count >15 × 109/L
Glucose >10 mmol/l
Urea >16 mmol/l
PaO <60 mm Hg
Calcium <2 mmol/l
Albumin <3.2 g/l
Lactate dehydrogenase >600 units/L
Asparate/alanine aminotransferase >100 units/L

13. Modified Glasgow Score
Age >55 years
PaO2 <60mmHg
WCC >15x109/litre
Ca <2.0 mmol/L
LDH >600 IU
glucose >10 mmol/L
urea >16 mmol/L
albumin <3.2g/L
Minimum score: 0
Maximum score: 8
If score<3: severe pancreatitis unlikely
If score>=3:severe pancreatitis likely

14. Ranson’s Criteria Ranson's Criteria on Admission :
age greater than 55 years
a white blood cell count of > 16,000/µL
blood glucose > 11 mmol/L (>200 mg/dL)
serum LDH > 350 IU/L
serum AST >250 IU/L
Ranson's Criteria after 48 hours of admission :
fall in hematocrit by more than 10 percent
fluid sequestration of > 6 L
hypocalcemia (serum calcium < 2.0 mmol/L (<8.0 mg/dL))
hypoxemia (PO2 < 60 mmHg)
increase in BUN to >1.98 mmol/L (>5 mg/dL) after IV fluid hydration
base deficit of >4 mmol/L
Score 0-2: 2% mortality
Score 3-4: 15% mortality
Score 5-6: 40% mortality
Score 7-8: 100% mortality

15. Differential diagnosis
Acute cholecystitis.
Perforated peptic ulcer.
Inferior wall MI.
Intestinal obstruction.
Mesenteric ischemia.
Ruptured abdominal aortic aneurysm.

16. Management of severe acute pancreatitis
Rest the patient (Relief pain): Pethidine 1mg/kg + antispasmodic.
Rest the pancreas: NPO(nil per os).
Rest the bowel: nothing by the mouth.
Resuscitation: IV fluid, electrolytes replacement.
Resist enzymatic activity: Protease inhibitors.
Resist infection: Antibiotics.
Repeated examination.
Repeated serum estimations:Ca+2, Mg+2.
Respiratory support.

17. Management
Urgent ERCP and biliary sphincterotomy within 72 hours improves outcome of severe gallstone pancreatitis.
Surgery in case of:
Uncertain diagnosis.
Infected pancreatic necrosis.
Complicated pancreatitis.

18. Causes of death: Hypovolemic shock. Electrolyte disturbances. Sepsis.
Renal failure.
Respiratory failure.

19. Complications Systemic Local (More common in the first week)
(Usually develop after the first week)
Cardiovascular
Shock
Arrhythmias
Pulmonary
ARDS
Renal failure
Haematological
DIC
Metabolic
Hypocalcaemia
Hyperglycaemia
Hyperlipidaemia
Gastrointestinal
Ileus
Neurological
Visual disturbances
Confusion, irritability
Encephalopathy
Miscellaneous
Subcutaneous fat necrosis
Arthralgia
Acute fluid collection
Hemorrhagic pancreatitis
Sterile pancreatic necrosis
Infected pancreatic necrosis
Pancreatic abscess
Pseudocyst
Pancreatic ascites
Pleural effusion
Portal/splenic vein thrombosis
Pseudoaneurysm
Chronic pancreatitis

20. Hemorrhagic pancreatitis
Definition:
Bleeding into the parenchyma and retroperitoneal structures with extensive pancreatic necrosis.
Signs:
Abdominal pain
Shock
Cullen’s sign, Grey turner’s sign & Fox’s sign

21. Grey Turner’s sign
Cullen’s sign
Cullen’s sign
Fox’s sign

22. Acute fluid collection
Located in or near the pancreas
The fluid is sterile, and most such collections resolve.
No intervention is necessary unless a large collection causes symptoms or pressure effects.

23. Sterile and infected pancreatic necrosis
Refers to a diffuse or focal area of non-viable parenchyma that is typically associated with peripancreatic fat necrosis.
Necrotic areas can be identified by an absence of contrast enhancement on CT.
These are sterile to begin with, but can become subsequently infected, probably due to translocation of gut bacteria.
Necrotizing pancreatitis accounts for 10% of all pancreatitis but is lethal disease.
Sterile necrotic material should not be drained or interfered with.

24. Pancreatic necrosictomy Peritoneal lavage
Management
Laparostomy
Pancreatic necrosictomy
Peritoneal lavage
If the sepsis worsens despite this, then a pancreatic necrosectomy
should be considered. This is a challenging operation that
carries a high morbidity and mortality, and is best carried out in a
specialist unit. The overwhelming majority of patients with peripancreatic
sepsis can be successfully treated by conservative
means, and necrosectomy should be necessary in a very small proportion
of patients. The surgical approach may be through a midline
laparotomy, especially if the area involved is around the head
of the gland. The duodenocolic and gastrocolic ligaments should
be divided and the lesser sac opened. Thorough debridement of
the dead tissue around the pancreas should be carried out. If the
body and tail of the gland are primarily involved (Fig ), a
retroperitoneal approach though a left flank incision may be more
appropriate. The tissues are inevitably friable, and one should be
careful not to precipitate excessive bleeding or inadvertently
breach the bowel wall. Blunt dissection is preferable to sharp dissection.
A feeding jejunostomy may be a useful adjunct to the
procedure. If gallstones are the precipitating factor of the pancreatitis,
a cholecystectomy should be included. Some prefer a minimally
invasive approach to a formal laparotomy. A rigid
laparoscope is inserted into the peripancreatic area through a
retroperitoneal approach, and vigorous irrigation and suction is
combined with a gradual nibbling away of the necrotic debris.
Once a necrosectomy has been completed, further necrotic
tissue may form. There are several possible ways of dealing with
this (listed below), none of which has been proved to be more
effective than the others. The last two approaches make greater
logistic demands as one is committed to a re-exploration every
48–72 hours.
• Closed continuous lavage: Tube drains are left in and the raw
area flushed (Beger) (Fig ).
• Closed drainage: The incision is closed, but the cavity is packed
with gauze-filled Penrose drains and closed suction drains.
The Penrose drains are brought out through the flank and
slowly pulled out and removed after 7 days
Open packing: The incision is left open, and the cavity is
packed with the intention of returning to the operating room
at regular intervals and repacking until there is a clean granulating
cavity.
• Closure and relaparotomy: The incision is closed with drains
with the intention of performing a series of planned relaparotomies
every 48–72 hours until the raw area granulates
(Bradley).

25. Pancreatic abscess Definition:
is a circumscribed collection of pus intra-abdominal resulting from tissue necrosis, liquefaction, and infection.
It may be an acute fluid collection or a pseudocyst that has become infected
Presentation:
Fever
Unresolving pancreatitis
Epigastric mass

26. is a late complication of acute necrotizing pancreatitis.
It is estimated that approximately 3% of the patients suffering from acute pancreatitis will develop an abscess.
Abdominal CT scans with needle aspiration to send for culture & Gram stain should be performed.
Organisms found Gram –ve (most common)
E.coli, pseudomonas, klebsiella
Gram +ve
Staphylococcus aureas, candida

27. Tx: Antibiotics and percutanous drain placement OR Operative debridement and drain placement.
An unremoved infected abscess may lead to sepsis, fistula formation and recurrent pancreatitis.

28. Pseudo cyst Definition:
Encapsulated collection of pancreatic fluid by inflammatory fibrosis NOT epithelial cell lining, that's why called “pseudo"cyst.
Its incidince is approximately 1 in 10 after alcoholic pancreatitis.
Presentation:
Epigastric pain
Vomiting
Mild fever
Weight loss
Signs
Palpable epigastric mass, Tender epigastrium, Ileus

29. Investigations: CBC >> leuckocytosis Amylase >> high
Bilirubin>> high if there is obstruction
US >> fluid filled mass
CT >> fluid filled mass, Multiple cysts
ERCP : radiopaque contrast material fills the cyst if there is a communicating pseudocyst

30. Cystadenocarcinoma,cystadenoma Complications :
DDx :
Cystadenocarcinoma,cystadenoma
Complications :
Infection
Bleeding into the cyst
Fistula
Pancreatic ascitis
Gastric outlet obstruction
Biliary obstruction
SOB

31. Treatment : drainage of the cyst or observation
50% will resolve spontaneously within 6 weeks
infection: Percutaneous external drainage & IV antibiotics
bleeding: angiogram and embolization

32. Cysts larger than 5cm have a small chance of resolving & a higher chance of complications(bleeding, Infection, rupture).
Treatment options are percutanous CT guided aspiration or operative drainage (cystogastrostomy, cystoduodenostomy).
A biopsy should be taken during surgical drainage to rule out cystic carcinoma.

33. Case history
A 53-year-old man presents to the emergency department complaining of severe mid- epigastric abdominal pain that radiates to the back. The pain improves when the patient leans forwards or assumes the fetal position and worsens with deep inspiration and movement. He also complains of nausea, vomiting, and anorexia, and gives a history of heavy alcoholic intake this past week. He is tachycardic, tachypnoeic, and febrile with hypotension. He is slightly agitated and confused. He is diaphoretic with decreased breath sounds over the base of the left lung.

34. Thank you