ACUTE

PANCREATITIS
M. IQBAL RIVAI
ANATOMY
 INCIDENCE
• 3% of all cases of abdominal pain (in UK)

• Worldwide: 5 to 50 per 100.000

• Occur at any age

• Peak in young men and older women

 PATOPHYSIOLOGY
Pancreatic Ducts
become obstructed

Hypersecretion of the exocrine

enzymes of pancreas

These enzymes enter the bile duct,

where they are activated and with
bile back up into the pancreatic duct

Pancreatitis
 AETIOLOGY
POSSIBLE CAUSES OF ACUTE PANCREATITIS
• Gallstones
• Alcoholism
• Post ERCP
• Abdominal trauma
• Following billiary, upper GI or cardiothoracic surgery
• Ampullary tumor
• Hyperparathyroidism
• Hypercalcemia
• Pancreas divisum
• Autoimmune pancreatitis
• idiopathic
 AETIOLOGY
• It is essential to establish the aetiology
• Investigate thoroughly before labelling it as
‘idiopathic’
• After acute episode resolves, remember further
management of underlying aetiology
• If aetiology is gallstones, cholecystectomy is
desirable during the same admission
CLINICAL PRESENTATION
ANAMNESIS
• Abdominal pain (develops very quickly)
• Pain is severe, constant and refractory to analgesics
• Pain experienced first in the epigastrium, upper
quadrant, or diffuse
• Pain radiates to the back, or to the chest
• Nausea
• Repeated vomiting
CLINICAL PRESENTATION
PHYSICAL EXAMINATION
• General appearance: severely ill
• Tachypnoe
• Tachycardia
• Hypotension
• Mild icterus
• Grey Turner’s sign
• Cullen’s sign
• Muscle guarding in upper abdomen
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Cullen’s sign

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Grey Turner’s sign

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 INVESTIGATIONS
• Anamnesis
• Physical examination
• Elevated serum amylase level three to four times
above normal
• Serum lipase (more sensitive and spesific than
amylase)
• Contrast-enhanced Abdominal CT Scan
ASSESMENT OF SEVERITY
ASSESMENT OF SEVERITY
 IMAGING
• Abdominal radiographs  for differential diagnosis
• Ultrasonography  to detect gallstones, rule out
acute cholecystitis, or common bile duct is dilated

• Contrast-enhanced CT, if:

o If there is diagnostic uncertainty
o Severe acute pancreatitis
o In patients with organ failure, signs of sepsis or progressive
clinical deterioration
o When a localised complication is suspected: fluid
collection, pseudocyst or a pseudoaneurysm

• MRCP
• ERCP
 RADIOLOGY
• CE-CT
o Enlargement of the pancreas
• (focal/diffuse)
o Irregular enhancement
o Shaggy Pancreatic contour
o Thickening of fascial planes
o fluid collections.
• Intraperitoneal / retroperitoneal
o Retroperitoneal air

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 RADIOLOGY
• U/S
o Diagnosis of gallstones
o F/U of pseudocysts.
o Dx pseudoaneurysms
o EAUS vs. EUS

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MRCP
 MANAGEMENT
• Admission to ICU
• Analgesia
• Aggressive fluid rehydration
• Oxygenation
• Invasive monitoring of vital signs, CVP, urine output,
blood gases
• Frequent monitoring of haematological and
biochemical parameters
• Nasogastric drainage
 MANAGEMENT
• Antibiotic prophylaxis
• CT scan essential if organ failure, clinical
deterioration or signs of sepsis develop
• ERCP within 72 hours for severe gallstone
pancreatitis or signs of cholangitis
• Supportive therapy for organ failure if it develops
• If nutritional support is required, consider enteral
feeding
COMPLICATIONS OF ACUTE PANCREATITIS
COMPLICATIONS OF ACUTE PANCREATITIS
PLEURAL EFFUSION

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PSEUDOCYST PANCREAS

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 ACUTE PANCREATITIS
COLLABORATIVE CARE
• Objectives include
o Relief of pain
o Prevention or alleviation of shock
o ↓ of pancreatic secretions
o Fluid/electrolyte balance
o Removal of the precipitating cause
 ACUTE PANCREATITIS
COLLABORATIVE CARE
• Conservative therapy
o Supportive care
• Aggressive hydration
• Pain management
o IV morphine
o Combined with antispasmodic agent
• Management of metabolic complications
• Minimizing stimulation
 ACUTE PANCREATITIS
COLLABORATIVE CARE
• Conservative therapy (cont’d)
o Shock
• Plasma or plasma volume expanders
(dextran or albumin)
o Fluid/electrolyte imbalance
• Lactated Ringer’s solution
o Ongoing hypotension
• Vasoactive drugs: Dopamine (Intropin)
o ↑ Systemic vascular resistance
 ACUTE PANCREATITIS
COLLABORATIVE CARE
• Conservative therapy (cont’d)
o Suppression of pancreatic enzymes
• NPO
• NG suction
o Prevent infections
o Peritoneal lavage or dialysis
• Remove kinin and phospholipase A exudate
 ACUTE PANCREATITIS
COLLABORATIVE CARE
• Surgical therapy indicated if
o Presence of gallstones
o Uncertain diagnosis
o Unresponsive to conservative therapy
o Abscess, pseudocyst, or severe peritonitis
 ACUTE PANCREATITIS
COLLABORATIVE CARE
• Surgical therapy (cont’d)
o ERCP
o Endoscopic sphincterotomy
o Laparoscopic cholecystectomy
ERCP
ERCP
LAPAROSCOPY
 ACUTE PANCREATITIS
COLLABORATIVE CARE
• Drug therapy
o IV morphine
o Nitroglycerin or papaverine
o Antispasmodics
o Carbonic anhydrase inhibitor
o Antacids
o Histamine (H2) receptor
 ACUTE PANCREATITIS
COLLABORATIVE CARE
• Nutritional therapy
o NPO status initially to reduce pancreatic secretion
o IV lipids
• Monitor triglycerides
o Small, frequent feedings
o High-carbohydrate, low-fat,
high-protein diet
o Bland diet
 ACUTE PANCREATITIS
COLLABORATIVE CARE
• Nutritional therapy (cont’d)
o Supplemental fat-soluble vitamins
o Supplemental commercial liquid preparations
o Parenteral nutrition
o No caffeine or alcohol