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Acute Pancreatitis

Acute Pancreatitis. Prof. Yousri Taher Head Of HPB Unit Alexandria University. Acute Pancreatitis. Is a discrete episodes of inflammation resulting from intrapancreatic activation of digestive enzymes. It is a disease of wide spectrum of severity complications and outcome.

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Acute Pancreatitis

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  1. Acute Pancreatitis Prof. Yousri Taher Head Of HPB Unit Alexandria University

  2. Acute Pancreatitis • Is a discrete episodes of inflammation resulting from intrapancreatic activation of digestive enzymes. • It is a disease of wide spectrum of severity complications and outcome.

  3. Spectrum of the disease • Acute edematous or interstitial Pancreatitis : mild , self limited in most patients Inflammation results in edema of the pancreas • Parenchymal damage is minimal • Pancreas recovers its function after resolution.

  4. Hemorrhagic Pancreatitis (Necrotizing Pancreatitis). • May be extensive with progressive coagulative necrosis of the pancreas and surrounding tissues • Auto digestion of the organ leads to hemorrhage .The mass of inflamed pancreas and surrounding tissues is termed phlegmon.

  5. Complications • Wide spread of inflammatory process • Any of the following organs might be affected : CBD ,duodenum, T colon splenic artery , and vein, spleen, Para renal spaces , lesser sac posterior mediastinum, abdominal wall and diaphragm . • Peritoneal surfaces leading to pancreatic ascites.

  6. Complications • Leakage of protein rich fluid from systemic circulation into peritoneal and retroperitoneal spaces lead to hypovolemia and shock. • Systemic effects of these material include: cardiovascular instability respiratory failure and renal failure.

  7. Complications • Hemorrhage : Cullen’s sign ,Turner’s sign, and DIC. • Pseudo cyst • Pancreatic abscess • Fat necrosis polyserositis and adult respiratory distress syndrome. • Pulmonary alveolar capillary membrane may be disrupted forming hyaline lining of alveoli .

  8. Etiology • Alcoholism • Biliary tract disease • Surgery • Trauma • ERCP • Infections (viral, mycoplasma, Salmonella mycobacterium cryptosporidium.

  9. Etiology *Metabolic disorders (Hypertriglyceridemia,pregancy,hypercacemia, hyperparathyroidism) *Drugs , vasculitis Anatomic abnormality annular pancreas ,choledochal cyst ,penetrating pepticulcer ,parasites ,renal failure ,renal transplantation .

  10. Drug induced Acute Pancreatitis • Sulfonamides ,estrogen , teracycline, pills, azathioprine , furosemide, ethanol, methanol ,ACE inhibitor ,NSAID, isoniasid,rifampin,metronidazole, eryhthromycin .

  11. Clinical Criteria For Severe Pancreatitis • Cardiac : BP < 90,tachycardia,ECG changes • Pulmonary : dyspnea , ARDS PO2< 60mmHg • Renal output less than 50 ml/h • Metabolic calcium < 8mg/dl, albumin < 3.2 mg /dl • Hematological: falling hematocrite and DIC • Abdominal distension, fluid wave ,and ileus

  12. Physical examination • Fever tachycardia ,hypotension • Shock • Jaundice • Abdominal tenderness and rigidity • Ileus • Cullen's sign • Pleural effusion ,pneumonitis subcutaneous fat necrosis ,tetany.

  13. Laboratory Tests • Elevated Serum amylase noted within 24 h persist for 3-5 days • Elevated Serum lipase • Urine amylase remains elevated for 7-10 days from onset. • Leucocytosis • Hyperglycemia • Jaundice • Arterial hypoxemia

  14. Radiology • Plain film ileus, air under diaphragm sentinel loop • USG • CT Scan • ERCP

  15. Differential DIAGNOSIS • ACUTE CHOLECYSTITIS • BILIARY COLIC • CHOLANGITIS • PERFORATED VISCUS • ACUTE HEPATITIS ,ACUTE INTESTINAL OBSTRUCTION • MESNTERIC VENOUS OCCLUSION

  16. Treatment • 85=90 % self limited • Supportive care • Analgesia • Maintain intravascular volume • Monitor vital signs • Treat complications

  17. Drug Treatment And Nutritional Support • PPI , somatostatin or octreotide (sandostatin ) • Prophylactic antibiotics • Intralipid • Enteral feeding is much better • Initial high carbohydrate diet low protein and fat.

  18. For severe case • ICU is highly indicated • Necresectomy • Pancreatectomy • Decompress Biliary tract • CT guided percutaneous drainage of necrotic pancreas , Endoscopic drainage

  19. For Acute Biliary Pancreatitis • Urgent Endoscopic Sphincterotomy is a must as soon as possible within 72 hours of onset of symptoms

  20. CT Of Severe Acute Pancreatitis

  21. ABP Biliary Gravel

  22. ABP Small Papilla

  23. Shotty CBD Stones

  24. Chronic Pancreatitis • Result from progressive destruction of the pancreas by inflammation and fibrosis • Exocrine pancreatic tissue and function are lost earlier • followed by Endocrine parenchyma And function

  25. Classification • Obstructive : Tumors, scar of Parenchymal inflammation , congenital anomalies • Infiltrative and autoimmune diseases such as hemochromatosis, Sjogren syndrome.

  26. Classification • Chronic calcifying Pancreatitis Alcohol, cigarette smoking Hyperparathyroidism Hypocalcaemia Hereditary autosomal dominant CCP • Cystic fibrosis

  27. Clinical Presentation • Abdominal pain • Malabsorption • Vitamin B12 deficiency • DM • Obstructive jaundice

  28. Physical Examination • Epigatric tenderness • Mass, pseudocyst • Weight loss bleeding tendency • Jaundice

  29. Diagnosis • Serum amylase ,lipase • Increased stool fat> 30 -40 g /day • USG and CT scan • ERCP • EUS

  30. Treatment • Stop alcohol or tobacco • Feedback control • Percutaneous injection of alcohol • Surgery • Drainage procedures • Acid suppressant therapy • Nutritional support

  31. Pancreatic cancer • Exocrine pancreatic cancer account for 95% of pancreatic cancer • 75 -85% arise from pancreatic duct epithelium • Islet cell tumor represent 5 % • Manifest themselves by hormone they secrete • Tumors may secrete gastrin, insulin ,glucagon ,VIP, pancreatic peptide somatostatin

  32. Warnings Signs Of Pancreatic Cancer • Unexplained Recent upper abdominal pain • Recent upper abdominal pain with retroperitoneal lesion • Jaundice with weight loss • Weight loss greater than 5 % • Unexplained acute Pancreatitis • Unexplained onset of DM

  33. USG Of Pancreatic Head Tumor

  34. CT Scan Of Pancreatic Tumor At Body Region

  35. CT Scan Of Calcified Chronic Pancreatitis

  36. Diagnostic Tools Of Pancreatic Cancer • CA19.9 • CEA • USG focal pancreatic lesion • CT scan • ERCP • Angiography • Fine needle Aspiration • EUS • Laparoscopy • MRI

  37. Treatment Options • Surgery is the best if early ; 5% are resectable • Chemo radiation • Palliative drainage Endoscopic Percutaneous Surgical

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