Acute and chronic Pancreatitis

DR. Anita Lamichhane

Pancreas

Endocrine function

Exocrine function

Insulin production

Manufactures & secretes digestive enzymes

20%

80%

Retroperitoneal organ Lies between stomach & duodenum

CT Scan pic of normal pancreas

Acute Pancreatitis

Acute focal/diffuse swelling /inflammation of the pancreas Single/recurrent episode of Pain abdomen with elevated level of pancreatic enzymes

Symptoms resolve After an acute attack; blood biochemistry becomes normal

Pancreatitis

Uncommon during childhood Must be considered in every child with unexplained acute or recurrent abdominal pain Good prognosis if not associated with multiorgan failure

Mortality and morbidity

10-15%
Biliary Pancreatitis high mortality rate 30% -(with organ failure)

0%

-(without organ failure)

In the 1st wk of illness, most deaths - multiorgan system failure. In later wks, infection - multisystem organ failure

Etiology
Drugs & toxins Acetaminophen overdose Sodium valproate Azathrioprine (ischemia) Sulphonamides Corticosteroids (increased viscosity of the pancreatic juice ) Tetracyclins Obstructive

Ascariasis
Choledocholithiasis Microlithiasis

Cholelithiasis
Pancreatic ductal abnormalities ERCP complication Pancreatic diversion Ampullary disease

Causes
Viruses Mumps,measles,varicella Hepatitis A EBV CMV Mononucleosis Coxsackie virus Bacteria Mycoplasma pneumoniae Legionella Salmonella Campylobacter species Tuberculosis

ECHO viruses

Contd.
Systemic disease Cystic fibrosis Diabetes mellitus HUS Malnutrition Hyperparathyroidism Alpha1-antitrypsin deficiency Kawasaki disease Traumatic Blunt injury Burns Child abuse Surgical trauma

Pathophysiology

Injury To acinar cell

Cell membrane

Fusion of the lysosomal and Zymogen compartment

extrusion of the secretory vesicles into the interstitium

trypsinogen

trypsin

Activation of the neutrophils

superoxide Zymogen cascade

Proteolytic enzymes

macrophages

mediate local inflammatory response (TNF-alpha, IL-6, IL-8)

Contd

TNF-alpha, IL-6,IL_8

Increased pancreatic Vascular permeability

hemorrhage

edema

Necrosis of the pancreas

Acute respiratory distress syndrome

Excreted into the circulation

bacteremia

GI hemorrhage

Renal failure Pleural effusion

Altered glucose metabolism

Interperitoneal Saphonification Of calcium

Altered calcium metabolism Dec. cardiac contractility

Fat necrosis Stress response

Release of insulin

Acute Pancreatitis

Release of kinins

Vasodilatation

Obstruction of bile flow

Edema, distension of Capsule, Obstruction of Pancreatic flow

Exudation of blood & protein Into the peritoneal space

shock

hypovolemia peritonitis

Altered bilirubin metabolism

fever Pain Decrease GI func.

Summary of the main pathologic events that occur in pancreatitis

Symptoms

Constant & dull aching epigastric pain radiating towards the

back Usually worse when the patient is supine

Nausea & vomiting

Signs
Fever (76%) Tachycardia (65%) Abdominal tenderness/muscular guarding (68%) Distension (65%) Bowel sounds -often hypoactive ( gastric and transverse colonic ileus.) Jaundice (28%)

Contd.
Dyspnea (10%)

irritation of the diaphragm (resulting from inflammation)

pleural effusion ARDS.

Hemodynamic instability (10%)

Hematemesis/ melena (5%) Pale, diaphoretic & listless

Some uncommon physical findings

The Cullen sign - bluish discoloration around the umbilicus resulting from hemoperitoneum

The Grey-Turner sign - reddish-brown discoloration along the flanks resulting from retroperitoneal blood dissecting along tissue planes

Erythematous skin nodules focal subcutaneous fat necrosis 1 cm in size extensor skin surfaces polyarthritis Purtscher retinopathy (funduscopy) ischemic injury to the retina causing temporary/permanent blindness

Lab studies
CBC Leucocytosis Falling hematocrit Amylase Increased (>3xnormal) in early phase Persists for 72 hrs Hypoamylasemia < 6 months Lipase Elevated 8-14 days longer than amylase Not routinely available Is specific

Trypsin level

Pancreatic isoenzyme determination

Differentiates between pancreatic & non pancreatic causes

Blood glucose - hyperglycemia Alkaline phosphatase Total bilirubin ALT AST Sr calcium hypocalcaemia (Saphonification of fats in the retroperitoneum) Increase in gall bladder disease

Sr Magnesium ,sr. cholesterol Serum triglycerides ( falsely lowered during an episode of acute pancreatitis ) Serum electrolytes Renal function tests Hemoconcentration at admission (an admission hematocrit value > 47%) - a sensitive measure of more severe disease

 Leukocytosis C-reactive protein

represents inflammation /infection

Arterial blood gases dyspneic patient

IgG4 levels - autoimmune pancreatitis

not specific elevated in 10% of pts with acute pancreatitis

Other conditions of hyperamylasemia

Parotitis Sialadenitis Anorexia nervosa Biliary tract disease Peptic ulcer Peritonitis Intestinal obstruction Acute appendicitis Diabetes mellitus Burns Renal insufficiency

Imaging Studies
Abdominal X-ray-

localized ileus
sentinel loop USG abdomendecreased echodensity of the pancreas Pseudocyst formation ERCP/MRCPpatency of the main pancreatic duct done in recurrent Acute pancreatitis/ stones /strictures

Abdominal CT scan severe acute pancreatitis provide prognostic information based on the following grading scale developed by Balthazar: A - Normal B - Enlargement C - Peripancreatic inflammation D - Single fluid collection E - Multiple fluid collections

Grades A &B
virtually nil

- the chances of infection & death are

Grades C,D&E - increase Grade E 50% chance of developing an infection 15% chance of dying.

Dynamic spiral CT scanning

determine the presence & extent of pancreatic

necrosis (loss of enhancement in at least 30% of the pancreatic parenchyma) Magnetic resonance cholangiopancreatography (MRCP) Endoscopic retrograde cholangiopancreatography

(ERCP)
Endoscopic ultrasonography (EUS)

Severe acute pancreatitis evidence of organ failure SBP <90 mm Hg PaO2 <60 mm Hg Serum creatinine >2 mg/dL GI bleeding >500 mL/24 h Local complications ( necrosis, abscess, pseudocyst)

Differential diagnosis
Lesions of the stomach and duodenum
Atypical appendicitis Volvulus

Intussusception

Complications
Shock Fluid & electrolyte imbalance Ileus ARDS Hypocalcaemia 3rd 5th day ATN Pseudocyst- 5-10% (resolve spontaneously in 60- 70 % of cases)

Infection Hemorrhage Rupture Fistula formation Phegmon formation Rare sequelae

Chronic pancreatitis Exocrine pancreatic insufficiency Endocrine insufficiency

Goals of medical management

Aggressive supportive care Decrease inflammation Limit infection / superinfection Identify/treat complications as appropriate.

Presentation of acute pancreatitis

Mild pancreatitis

Clinical assessment of severity

Severe pancreatitis

Supportive therapy Iv fluids Analgesia Nutrition identify the cause

No necrosis

CT with contrast of the abdomen

Clinical deteoration/ no improvement

necrosis present

Antibiotics for 2 weeks. nutrition

Clinical improvement

Antibiotics , Enteral nutrition (or TPN)

Clinical deteoration

CT guided aspiration for Gram stain & culture No clinical improvement

Surgical debridement

infected necrosis

sterile necrosis

Supportive care Elective surgical debridementt

Medical treatment
NPO IV fluids-hydration/correction of electrolyte imbalance Gastric decompression Analgesics-meperidine (Demerol) + an antiemetic is preferred over morphine ( morphine may cause spasm of the sphincter of Oddi) Synthetic Opiod narcotic analgesic

Acid suppression (PPI) Nutrition- Enteral /Parenteral Broad spectrum antibiotics-in necrotizing pancreatitis ,not routinely for fever in early disease ( it is secondary to inflammatory response to cytokines )

The use of gabexate & somatostatin (Zecnil)

Decrease pancreatic secretions Shows a trend towards favorable outcomes in small, uncontrolled studies But not routinely used in acute pancreatitis

Emerging treatments

Cytokines (role in systemic inflammatory response syndrome)

A recent large clinical trial of lexipafant ( a plateletactivating factor antagonist) has shown no benefit in patients with severe acute pancreatitis. Anti-TNF alpha therapy - recently been targeted as a potential therapeutic in acute pancreatitis; however, clinical trials have not begun.

Surgical Care
Reserved for traumatic disruption of the gland Intraductal stone Unresolved/infected pseudocyst/abscess An interventional radiologist, interventional endoscopist, and/or surgeon (alone or in combination). Early Endoscopic decompression of the biliary system

Fine needle aspiration - tap necrotic tissue & peri-pancreatic fluid

Early ERCP with sphincterotomy & stone extraction done in gall stones pancreatitis
Pseudocysts ( peripancreatic fluid collections persisting >4 wks, lack an epithelial layer, not a true cyst, contains organized debris & not fluid)-intervention indicated when becomes symptomatic

Pancreatic abscesses: Occur late Percutaneous catheter drainage & antibiotics Require surgical debridement & drainage

Intestinal florae are the predominant source of

bacteria causing the infection

Escherichia coli (26%) Pseudomonas species (16%)

Staphylococcus species (15%)

Klebsiella species (10%) Proteus species (10%)

Streptococcus species (4%) Enterobacter species (3%),

Anaerobic organisms(16%) Fungal superinfection may occur weeks /months into the course of severe necrotizing pancreatitis.

Prognosis

Clinical assessment and severity of the disease

Several clinical scoring systems genetic markers Recovery within 2- 5 days uncomplicated cases

Chronic Pancreatitis

Recurrent episodes of upper abdominal pain

varying degrees of pancreatic endocrine & exocrine dysfunction

progressive & irreversible structural changes in the pancreas

Malabsorption (diarrhea, fatty stool)

Causes
Hereditary Congenital anomalies of the pancreas / biliary system

Hyperlipidemia
CRF Hypercalcemia

Idiopathic
Autoimmune- autoimmune pancreatitis IBD associated chronic pancreatitis Recurrent & severe acute Pancreatitis Post necrotic ( severe acute pancreatitis ) Obstructive Pancreatitis

Causes
Endoscopy (ERCP)

Sphincterotomy
Stenting of the bile duct Stenting of the pancreatic duct

Gallstone removal
Pancreas stone removal Cyst/pseudocyst operation Drainage operation Partial or complete removal of pancreas

Genetic Cationic trypsinogen mutation

CFTR mutations
SPINK1 mutations 1-Antitrypsin deficiency

Medical therapies
Octreotide Pancreatic enzymes Vitamins and antioxidants

Signs & symptoms

Prolonged h/o upper abdominal pain of variable severity; radiates towards the back Fever& vomiting-not common

Malnutrition (secondary to failure of pancreatic exocrine secretions may also occur

Laboratory findings
Blood biochemistry Pancreatic enzymes Stool tests pancreatic enzymes fecal fat

Pancreatic stimulation (secretin) tests

Diagnostic imaging

X-rays abdomen- pancreatic calcification (30%) diagnostic of chronic pancreatitis even in absence of clinical disease

USG abdomen
Dilatation of the pancreatic/biliary tracts may be noted
Calcification

Complications -

Pseudocysts
calculi

abscess
ascites

ERCP MRCP

Treatment
Medical Easing the pain High carbohydrate diet Enzyme supplementation

Low fat diet

Surgical

Surgery in chronic pancreatitis

To relieve pain, treat complications or both
Types of surgery Sphincteroplasty

Pancreatic drainage via pancreaticojejunostomy /end to end pancreaticojejunostomy

Pancreatogastrotomy and pancreatectomy

Recurrent acute pancreatitis can be a challenging clinical problem

CT scan abdomen CT scan abdomen

MRCP

Better sensitivity for detecting biliary sludge & microlithiasis

EUS

Detects peri Ampullary lesions Missed by CT/MRCP