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ACUTE PANCREATITIS

ACUTE PANCREATITIS. ANATOMY. ACUTE PANCREATITIS. -Acute pancreatitis (AP) are characterized by edematous lesions, eventually necrosis and bleeding inside and in peripancreatic area. Pathology: - 2 types of AP 1. Edematous AP congestion and edema of the pancreas . swelling

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ACUTE PANCREATITIS

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  1. ACUTE PANCREATITIS

  2. ANATOMY

  3. ACUTE PANCREATITIS -Acute pancreatitis (AP) are characterized by edematous lesions, eventually necrosis and bleeding inside and in peripancreatic area.

  4. Pathology: - 2 types of AP • 1. Edematous AP • congestion and edema of the pancreas. • swelling • normal/mild inflammation of the retroperitoneum

  5. 2. Necrotic pancreatitis • Severe +++. • Important swelling of the pancreas, bleeding multiples areas and hematomas till the complete distruction of the gland. • Involvement of all retroperitoneum, fatty necrosis- white spots • Plasmal escape – peripancreatic and retroperitoneal spaces + ascites

  6. ETIOLOGY: 2 MAIN CAUSES • GALLSTONES • ALCOHOL 1. GALLSTONES

  7. 2. ALCOHOL

  8. 3. Rare etiology • Lessthan 10% • Postoperative and postraumatic AP • Billiary ,pancreatic, gastricsurgery • Kidney transplantation • Post- ERCP • Pancreatic tumors • Infections • Leptospirosis • Ascaridiosis • Metabolical factors • Hypercalcemia • Hypertriglyceridemia • Drug induced • Corticotherapy • Chlorothiazide, Isothiazide • Immunosupressors • Oral Contraceptives • Auto-immune AP • Idiopathic factors

  9. C. PATHOPHYSIOLOGY 3 mechanisms STOP the autodigestion of the pancreas 1.enzymes - preserved as zymogenes separates from other proteins 2.enzymes sont secreted – inactive forms 3.inhibitors of proteolitic enzymes in the pancreatic tissu and pancreatic juice • AP= enzimatic autodigestion of the pancreas--- trypsinogen activation in trypsine in the pancreatic cells . • Trypsine --- cascade activation of proenzymes from zymogens granules – pancreatic acinar cell distruction • SIRS --- proinflammatory cytokines(Il-1, TNF) in the pancreatic tissu and other organs (kidney, liver, lung) SEVERE SYSTEMIC EVENTS

  10. PATHOPHYSIOLOGY

  11. D. CLINICAL SIGNS • ABDOMINAL PAIN Describe it!!! • Nausea and vomiting • Abdominal distension- paralitic ileus • +/ tachycardia, low/ high temperature, hypotension, tachypnea- severe forms • Oliguria • Jaundice • Ascites !! Pain intensity vs poverty of clinical signs

  12. 50 %- symptoms are not specific Differential dg: • Acute cholecystitis • Mesenteric infarction • Bowel obstruction • Ruptured abdominal aortic aneurism • Respiratory distress • Oligo-anuria • Peritonitis

  13. E. DIAGNOSTIC • 1. Blood tests • HIGH levels of amylase and lipase (≥ 3 N) ESSENTIAL BUT NOT SPECIFIC!! • CRP > 15 mg/100 ml – SEVERE AP.

  14. 2. IMAGING DG • Plain abdominal X- Ray- localised ileus- sentinel loop, free air, calcifications • Abdominal US- swelling , diffuse hypoechogenity - Eventually the cause - gallstones

  15. CT SCAN SEVERITY EVALUATION criteria Balthasar score- severity and extent of necrosis, peripancreatic fluid collection Correlation with morbidity and mortality

  16. MRCP Non-invasive Safer Faster THAN ERCP but less sensitive WHEN Suspicion of bile duct obstruction

  17. MRI - severity of AP - no iodine contrast - bile obstruction

  18. F. COMPLICATIONS • PANCREATIC NECROSIS • PSEUDOCYST • PANCREATIC ABCESS

  19. PSEUDOCYST- necrosis organising - Wirsung disruption - after aprox 4 w evolution of AP

  20. PANCREATIC ABCESS- pseudocyst infection/ infection of necrotic areas

  21. OTHER COMPLICATIONS Venous thrombosis ( splenic, portal, SMV ) Pleural effusion Ascites Fatty necrosis- cutaneus

  22. G. PROGNOSIS • Good – Edematous AP – mortality< 2% • Bad – Necrotic forms of AP- high mortality Severity prediction RANSON scale- if > 3 crt- AP severe if > 7- 100% mortality AP induced by alcohol

  23. !!! Admission: High levels of CPR – bad prognosis Other severity scales- Glasgow, Apache III

  24. TREATMENT • MEDICAL • NPO - NGT ? • IVF • PPI • PAIN CONTROL - ANTIBIOTICS- ???? • SURGICAL • Indications !!! WHEN WE HAVE THE PROOF OF INFECTION Choosing of the moment!!

  25. ERCP with sphyncterotomy INDICATIONS- gallstones in bile duct

  26. SURGICAL TREATMENT • Surgical infected necrose debridement • Drainage • +/- Laparostomy

  27. SURGICAL TREATMENT- PSEUDOCYSTS INDICATIONS: • IF > 7 cm • Rapidly growing • Bleeding • Compression • Disruption • Pain • Infection

  28. PSEUDOCYST TREATMENT- TRANSPAPILLARY DRAINAGE; IF COMMUNICATING- STENT

  29. PSEUD0CYST TREATMENT-EXTERNAL DRAINAGE

  30. SURGICAL TREATMENT – if proximal duct disrupted- WHIPPLE

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