Acute & Chronic Pancreatitis

1. Acute & Chronic Pancreatitis Jasim Al-Abbad, MBBCh, FRCSC Assistant Professor General Surgery Colon and Rectal Surgery jasim.alabbad@hsc.edu.kw

2. inflammation of the gland parenchyma of the pancreas • Acute vs. Chronic

3. Acute Pancreatitis

4. Introduction • The incidence of acute pancreatitis is increasing • > 300,000 hospital admissions annually in USA • 10 – 20 % of patients develop life-threatening form • Direct cost > 2 billion USD N Engl J Med 2006; 354:2142-2150 Gastroenterol Clin N Am 41 (2012) 1–8

5. Mortality rate reach up to 30% with severe pancreatitis • Mortality is due to: • Multi-system organ failure (1st 2 weeks) • Septic complications (after 2 weeks) World J Gastroenterol 2007; 13:5043-5051

6. Etiology • Gallstones • Alcohol • Hypertriglyceridemia • Hypercalcemia • Post ERCP • Trauma • Pancreatic duct obstruction • Infections • Drugs • Hereditary

8. Gallstone Pancreatitis • The overall incidence in patients with symptomatic gallstones 3 – 8 % • Small gallstones are associated with an increased risk • 2 theories: • Obstructive • Pancreatic duct obstruction  excessive pressure  pancreatic injury • Reflux • Stone in ampulla of Vater bile reflux into pancreas  direct necrosis AdvSurg 2006; 40:265-284 N Engl J Med 2006; 354:2142-2150

9. Pathophysiology

11. Clinical Manifestations • Abdominal pain • Nausea / vomiting • Low grade fever • Dehydration • Epigastric tenderness • Jaundice • Grey Turner • Cullen's signs

12. Diagnosis • History / physical examination • Biochemical workup • CBC • RFT • LFT • Amylase, lipase • Imaging

13. Serum amylase • It rises within 6 to 12 hours of onset • Remains elevated for three to five days • There is no correlation between the magnitude of serum amylase elevation and severity of pancreatitis

14. Causes of hyper-amylasemia: • Acute cholecystitis • Bowel obstruction • Mesenteric ischemia • Trauma • Ketoacidosis • Ruptured ectopic pregnancy • Parotitis • Renal failure • Salpingitis • Cirrhosis

15. Serum lipase • More specific than amylase • Longer half life

16. The elevation of ALT levels in the serum in the context of acute pancreatitis has a positive predictive value of 95% in the diagnosis of acute biliary pancreatitis AdvSurg 2006; 40:265-284

17. Imaging • Plain x-rays • Ultrasound • CT scan • MRCP • ERCP • EUS

18. Assessment of Severity of Disease • Early recognition of severe disease is crucial to optimize care and improve outcome • Many scoring systems developed

19. Ranson’s criteria • Developed in 1974 • Score based on 11 parameters • Mortality • 0 to 3 % when the score <3 • 11 to 15 % when the score ≥3 • 40 % when the score ≥6

21. It needs 48hrs to calculate • Meta-analysis of 110 clinical studies found Ranson's score to have a poor predictive power Crit Care Med. 1999;27(10):2272

22. APACHE II score • 12 physiologic measurements • It provides a general measure of the severity of disease • A score of ≥8 defines severe pancreatitis

23. CT severity index • Balthazar score • Based on CT findings

24. Mortality 0-3 = 3% 4-6 = 6% 7-10= 17% Radiology 1990; 174:331

25. C-Reactive Protein • Acute phase reactants made by the liver • Levels correlates with disease activity • Level ≥ 150 mg/mL defines severe pancreatitis Br J Surg. 1989;76(2):177

26. Atlanta's Criteria for Acute Pancreatitis • The International Symposium on Acute Pancreatitis (1992) • Severe pancreatitis is defined by the presence of any evidence of organ failure or a local complication. Arch Surg1993; 128:586-590

27. Treatment • Regardless of the cause or the severity of the disease • Aggressive fluid resuscitation • Pain control

28. Nutritional support • Oral feeding may not be possible • Enteral feeding vs. TPN

29. Prophylactic antibiotics • Data controversial • No benefit for pancreatitis without necrosis • Imipenemreduces pancreatic infections with proven necrosis Cochrane Database Syst Rev. 2010

30. ERCP • Routine use of ERCP is not indicated • ERCP is indicated for: • Cholangitis • Persistent bile duct obstruction (obstructive jaundice)

31. Laparoscopic Cholecystectomy • 30% of patients with acute biliary pancreatitis will have recurrent disease, in the absence of definitive treatment • For mild pancreatitis: • Early laparoscopic cholecystectomy (during the initial admission) is a safe procedure that decreases recurrence of the disease • For severe pancreatitis: • Early surgery may increase the morbidity and length of stay • Laparoscopic cholecystectomy should be delayed for at least 6 weeks AdvSurg 2006; 40:265-284

32. Complications

33. Acute Fluid Collections • Occur during the early stages of severe pancreatitis in 30% to 50% of patients • No wall of granulation or fibrous tissue, and more than half regress spontaneously. Pancreatic Necrosis • Areas of nonviable pancreatic tissue • either sterile or infected Pancreatic Pseudocyst • collections of pancreatic fluid enclosed by a non-epithelialized wall composed of fibrous and granulation tissue • Not present before 4 to 6 weeks after the onset of an attack Pancreatic Abscess • Collections of pus, usually in proximity to the pancreas

34. Sabiston, David C., and Courtney M. Townsend. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. Philadelphia: Saunders/Elsevier, 2008. Print.

35. Chronic Pancreatitis

36. Persistent inflammation • Irreversible fibrosis • Atrophy of the pancreatic parenchyma • Chronic pain • Endocrine and exocrine insufficiency

37. Brunicardi, F. Charles., and Seymour I. Schwartz. Schwartz's Principles of Surgery. New York: McGraw-Hill, Health Pub. Division, 2010. Print.

38. Brunicardi, F. Charles., and Seymour I. Schwartz. Schwartz's Principles of Surgery. New York: McGraw-Hill, Health Pub. Division, 2010. Print.

39. Etiology • Alcohol (70 - 80%) • Genetics (hereditary, CF gene mutation) • Hyperparathyroidisim • Hypertriglyceridemia • Autoimmune pancreatitis • Ductal obstruction (trauma, stones, tumors, ?pancreas divisum) • Smoking • Idiopathic

40. Clinical Manifestations • Abdominal Pain • Pancreatic insufficiency • Fat malabsorption • Apancreatic diabetes

41. Diagnosis • Blood tests: • CBC • RFT • LFT • Serum amylase and lipase levels usually normal • Functional tests • Fecal fat content • Fecal elastase-1 level

42. Imaging: • CT scan • MRCP • EUS • ERCP

43. Sabiston, David C., and Courtney M. Townsend. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. Philadelphia: Saunders/Elsevier, 2008. Print.

44. Treatment Medical Treatment • Multidisciplinary team • Stop drinking and smoking • Pain control • Pancreatic enzyme replacement

45. Endoscopic Treatment • ERCP with duct dilatation ± stent Surgical Treatment • Resection procedures • Drainage procedures

46. Souba, Wiley W. ACS Surgery: Principles and Practice. Hamilton, Ont.: B C Decker, 2007. Print.

47. Complications • Biliary strictures (jaundice / cholangitis) • Duodenal obstruction • Splenic / portal vein thrombosis • Pseudocyst

48. Prognosis Brunicardi, F. Charles., and Seymour I. Schwartz. Schwartz's Principles of Surgery. New York: McGraw-Hill, Health Pub. Division, 2010. Print.