MODERATOR – Dr.BasavarajCHAIR PERSON – Dr.Rajanna

Presented by Dr.Anuraj

LAB tests

Diagnosis of AP- clinical findings+ elevation of pancreatic enzyme levels in the plasma

threefold or higher elevation of amylase and lipase levels confirms the diagnosis.

SERUM AMYLASE

Normal value 23-85U/L

IF >4 times normal levels (>450 U/L)

Normal levels do not exclude AP esp. if patient present 48 hrs later

Less sensitivity and specificity

SERUM LIPASE

Normal value 0-160 U/L

If elevated (>400 U/L) likely indicate pancreatic damage or pancreatitis

rises 4 to 8 hours from the onset of symptoms and normalizes within 7 to 14 days after treatment

CBC: neutrophil leucocytosis

Electrolyte abnormalities include hypokaemia, hypocalcemia

Elevated LDH in biliary disease

Glycosuria ( 10% of cases) Blood sugar: hyperglycaemia in severe cases

Serum phosphate

LFTs

RFTs

CRP

To RULE OUT other conditions, such

as perforated ulcer disease.

Nonspecific findings

-cutoff colon sign gaseous distension seen in proximal colon associated with withnarrowing of the splenic flexure

-Widening of the duodenal C loop caused by severe pancreatic head edema

- complications of lung such as pleural effusion, pulmonary

edema and interstitial inflammation.

to find an enlarged pancreas, a pseudocyst, ascites, biliary

stone, dilated common bile duct and other pancreatic mass

The usefulness of ultrasound to diagnose pancreatitis is limited by intra-abdominal fat and increased intestinal gas as a result of the ileus.

However USG should be ordered because of high sensitivity in diagnosing gallstones

Contrast enhanced CT If the patient has…..◦ Signs of severe acute pancreatitis◦ No signs of clinical improvement after several days◦ Diagnostic dilemma◦ Infection suspected

T > 101o F Positive blood cultures

What are you looking for?◦ Necrosis: Lack of enhancement with contrast◦ Fluid Collections◦ Alternate diagnosis

Acute Pancreatitis

Pancreas◦ Pancreatic enlargement

◦ Decreased density due to edema

◦ Intrapancreatic fluid collections

◦ Blurring of gland margins due to inflammation

Peripancreatic◦ Fluid collections and stranding densities

◦ Thickening of retroperitoneal fat

Acute Pancreatitis

* It may take up to 72h for inflammatory changes to become apparent on CT *

Acute Pancreatitis

Tail Indistinct

Intraperitoneal fluid

Acute Pancreatitis

Peripancreatic edemaand inflammation

UnenhancingNecrosis

Acute Pancreatitis

Normal Pancreas

useful to evaluate the extent of necrosis, inflammation, and presence

of free fluid.

Cost and availability limits its applicability

Not indicated in the acute setting of AP

unexplained or recurrent pancreatitis - the biliaryand pancreatic duct anatomy.To rule out pancreas divisum, intraductal

papillary mucinous neoplasm (IPMN),

small tumor in the pancreatic duct.

Assessment of severity of disease

RANSON’S CRITERIA

MODIFIED GLASGOW CRITERIA

ATLANTA classification

Acute Physiology and Chronic Health Evaluation (APACHE II)

For non-gallstone pancreatitis, the parameters are: At admission: Age in years > 55 years White blood cell count > 16000 cells/mm3

Blood glucose> 10 mmol/L (> 200 mg/dL) Serum AST > 250 IU/L Serum LDH > 350 IU/L Within 48 hours: Serum calcium < 2.0 mmol/L (< 8.0 mg/dL) Hematocrit fall > 10% Oxygen (hypoxemia PaO2 < 60 mmHg) BUN increased by 1.8 or more mmol/L (5 or more mg/dL) after IV

fluid hydration Base deficit (negative base excess) > 4 mEq/L Sequestration of fluids > 6 L

For gallstone pancreatitis, the parameters are: At admission: Age in years > 70 years White blood cell count > 18000 cells/mm3

Blood glucose > 12.2 mmol/L (> 220 mg/dL) Serum AST > 250 IU/L Serum LDH > 400 IU/L Within 48 hours: Serum calcium < 2.0 mmol/L (< 8.0 mg/dL) Hematocrit fall > 10% Oxygen (hypoxemia PaO2 < 60 mmHg) BUN increased by 1.8 or more mmol/L (5 or more mg/dL) after IV

fluid hydration Base deficit (negative base excess) > 5 mEq/L Sequestration of fluids > 4 L

Acute Pancreatitis

MORTALITY †

MORBIDITY *

† Sn 73%, Sp

77%

* > 7 d in ICU

Management depends on SEVERITY

MILD ACUTE PANCREATITISAcute pancreatitis

No dysfunction of organ or local complications

Ranson’s score <3

or CT grading: A, B, C or CTSI <2

SEVERE ACUTE PANCREATITIS

Acute pancreatitis

Local complications

or organ failure

or Ranson’s score >3

or CT grading: D, E or CTSI >3.

Supportive care,fluid resuscitation and electrolyte balance

NPO with i.v. fluids and electrolytes

Analgesia

Morphine

Nutrition

If unable to meet adequate protein and calorie needs within 5 days ->nasoenteric feeding

Antibiotics

Routine antibiotics not recommendedGeneral recommendations for use:◦ Biliary pancreatitis with signs of cholangitis◦ > 30% necrosis on CT scanOPERATIVE MANAGEMENT◦ Early cholecystectomy once symptoms have

subsided and cholestatic liver enzymes have returned to normal in GALLSTONE PANCREATITIS

◦ If cholestatic enzymes not returned to normal then suspect choledocholithiasis and do ERCP

Mainstay of management is

Early diagnosis

Aggressive resuscitation

Staging by clinical scoring systems

Radiologic imaging

Admission to ICU Aggressive fluid resuscitation Analgesia Invasive monitoring of vitals,CVP,urine

output,blood gases Nasogastric aspiration Frequent monitoring of lab investigations Antibiotics - imipenem Supportive therapy for organ failure ERCP if cholangitis

Timing of cholecystectomy

Should be delayed until patient is stabilised,pseudocyst resolves or if it persists beyond 6 weeks then drained concomitantly at time of cholecystectomy

Infected necrosis◦ Organisms on gram

stain after aspirate

◦ Surgical drainage

◦ Trans-gastric drainage

◦ Try to delay necrosectomy 2-3wk for demarcation of necrosis

Pancreatic abscess◦ CT or EUS guided

drainage Walled collection of

pus

Similar to management of pseudocyst

Acute Pancreatitis

Open

Endoscopic transluminal

Once necrosectomy is completed,furthernecrotic tissue may form

-Closed continuous lavage(Beger)

-Closed drainage

-Open packing

-Closure and relaporotomy

Collection of pancreatic fluid enclosed by wall of granulation tissue

Complicates 5-10% cases of AP

Usually 4 weeks after attack The diagnosis is corroborated with by CT

25-50% resolve spontaneously

Acute Pancreatitis

Infection - 14%

Rupture - 6.8%

Hemorrhage - 6.5%

Common bile duct obstruction - 6.3%

GI obstruction - 2.6%

Acute Pancreatitis

Observation for asymptomatic patients

spontaneous regression has been documented in up to 70% of cases

Invasive therapies are indicated for

symptomatic patients or when the differentiation between a cystic neoplasm and pseudocyst is not possible.

Percutaneous

endoscopic drainage

Surgical drainage is indicated for patients with pancreatic pseudocysts that cannot be treated with endoscopic techniques and patients who fail endoscopic treatment

-cystogastrostomy

-cystoduodenostomy

Acute Pancreatitis

Acute Pancreatitis

Open Cystgastrostomy

Acute Pancreatitis

Bailey and love’s

Sabiston textbook of surgery

Shackelford’s surgery of alimentary tract