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pancreatitis

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pancreatitis ferencz baranyay surgical resident royal melbourne hospital 23 y/o M BIBA with epigastric pain is your next patient in the emergency department Pt ... – PowerPoint PPT presentation

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Title: pancreatitis


1
pancreatitis
  • ferencz baranyay
  • surgical resident
  • royal melbourne hospital

2
  • 23 y/o M BIBA with epigastric pain is your next
    patient in the emergency department

3
  • Pt driving along in passenger seat with his mum
    when began to feel worsening pain in abdo
  • thought I was going to die, told his mum to
    stop the car and call an ambulance
  • After 5 mins of beginning to feel the pain, it
    hit a crescendo and stayed until received IV
    morphine
  • Felt pain as stabbing sensation, radiating
    retrosternally, with slight nausea and associated
    shortness of breath
  • thoughts on diagnoses at this stage?

4
  • No fevers or chills, no unusual bowel or urinary
    symptoms, no genital issues.
  • Previous night hed had 14-15 drinks, he is an
    overseas cricketer touring Australia
  • Noted a history of GORD symptoms on occasion but
    is otherwise medically well

5
examination
  • o/e stable afebrile
  • small area of decreased A/E at lung bases
  • Abdo inspection NAD
  • epigastric/RUQ tenderness on deep palpation
  • Murphys -ve
  • No flank tenderness/renal angle tenderness
  • BS ve
  • PR not done and genitals not examined
  • No peripheral oedema, JVPNE

6
lab testing
  • Ix lipase 230 (60 is upper limit N)
  • FBE N EUC N AST 87 GGT 227
  • Erect CXR NAD
  • ECG sinus 96 bpm, no ST/T w abnormalities
  • FWT negative
  • Pt given lignocaine/mylanta preparation, with PPI
    and reported no real benefit.
  • Dx?

7
pancreas anatomy
  • Made up of head, neck body and tail
  • Retroperitoneal
  • Head lies in the C of the duodenum
  • also overlies IVC, L2 vertebra, medial aorta and
    superior mesenteric vessels
  • Behind the neck splenic veins joins superior
    mesenteric vein to form portal vein
  • Pancreatic duct closely related to common bile
    duct

8
Acute pancreatitis
  • Spectrum of

mild
severe
Extensive pancreatic necrosis Multi-organ failure
Mild inflammation of pancreas
75 cases seen in ED
25 cases seen in ED
Mortality 20-30
Mortality lt1
9
pathophysiology
neutrophils
Acinar cell necrosis Pseudocyst
formation Possible abscess development with
multi-organ failure
macrophages and lymphocytes
trypsinogen chymotrypsinogen Proelastase procarbo
xypeptidase
active elastases
autodigestion of pancreas
trypsin cascade
10
causes
  • Gallstones (35-40)
  • ETOH (2nd most frequent cause)
  • Tumours
  • pancreas, ampulla, choledochocele
  • Scorpion sting
  • Microbiological infection
  • Autoimmnune (SLE, crohns)
  • Surgery/trauma (blunt trauma, cardiac surgery,
    ERCP)
  • Hyperlipidaemia (lt11mmol, 3rd most freq cause),
    hypocalcemia, hypothermia
  • Emboli/ischemia
  • Drugs (carbamazepine, valproate, frusemide,
    opiates, estrogens, erythromycin, enalapril,
    rifampicin)
  • Cause is unknown in 15-20 of cases.

11
Clinical presentation acute pancreatitis
  • History
  • Any severe acute pain in the abdomen or back
    should suggest acute pancreatitis.
  • The diagnosis is usually entertained when a
    patient presents with
  • severe and constant abdominal pain (classically
    in epigastrium, radiating through to back)
  • nausea
  • emesis
  • fever
  • tachycardia
  • Examination
  • Fever (76), sinus tachy (65)
  • Dehydration
  • Upper abdo tenderness/epigastric tenderness (68)
  • in severe pancreatitis
  • Pulmonary signs (effusions, tachypnea secondary
    to diaphragmatic irritation)
  • Cullens sign (bluish/red discolouration
    periumbilical wall
  • Grey-turners sign (bluish/red discolouration of
    flanks)
  • peritonitis

12
Cullens Grey Turners sign
13
laboratory testing
  • No gold standard for diagnosis (apart from
    histopathological testing of the pancreas)
  • Lipase and amylase
  • ? amylase
  • fallopian tubes, ovaries,
  • testes, adipose tissue,
  • small bowel, lung, thyroid,
  • skeletal muscle,
  • and certain neoplasms.
  • ? lipase
  • more specific, but still in small intestine
  • Rule out all valid differentials

14
differentials for upper abdo pain and tenderness
  • perforated viscus, especially peptic ulcer
  • Erect CXR
  • acute cholecystitis and biliary colic
  • LFTs, liver/biliary ultrasound, ERCP
  • acute intestinal obstruction
  • Abdo XR
  • mesenteric vascular occlusion
  • CT angiogram of intestinal vessels
  • renal colic
  • Urinanalysis, hourly urine output, serum
    creatinine, CT ureters
  • myocardial infarction
  • ECG, troponin
  • dissecting aortic aneurysm
  • CT angiogram
  • connective tissue disorders with vasculitis
  • ESR
  • Pneumonia
  • CXR
  • diabetic ketoacidosis
  • serum glucose, ABG

15
Assessing severity
...many severity scores
  • Score 0 to 2  2 mortality
  • Score 3 to 4  15 mortality
  • Score 5 to 6  40 mortality
  • Score 7 to 8  100 mortality
  • Ransons criteria
  • At admission
  • age in years gt 55 years
  • white blood cell count gt 16000 cells/mm3
  • blood glucose gt 10 mmol/L (gt 200 mg/dL)
  • serum AST gt 250 IU/L
  • serum LDH gt 350 IU/L
  • At 48 hours
  • Calcium (serum calcium lt 2.0 mmol/L (lt 8.0 mg/dL)
  • Hematocrit fall gt 10
  • Oxygen (hypoxemia PO2 lt 60 mmHg)
  • BUN increased by 1.8 or more mmol/L (5 or more
    mg/dL) after IV fluid hydration
  • Base deficit (negative base excess) gt 4 mEq/L
  • Sequestration of fluids gt 6 L

16
Radiology of acute pancreatitis
U/S ? useful for biliary pathology, 70-80
sensitive for pancreatitis CT more useful for
judging severity and regional effects Try to wait
gt12 hours as early CT is usually unhelpful
17
treating acute pancreatitis
  • mild to moderate pancreatitis
  • usually requires treatment with IV fluids and
    fasting.
  • clear liquid diet is frequently started on the
    third to sixth day
  • regular diet by the fifth to seventh day
  • The decision to reintroduce oral intake is
    usually based on the following criteria
  • a decrease in or resolution of abdominal pain
  • the patient is hungry and
  • Organ dysfunction, if present, has resolved
  • (dont use lipase or amylase! Not indicative of
    resolution if normal levels)
  • Antibiotics controversial, but currently
    recommended
  • unremitting fulminant pancreatitis
  • usually requires inordinate amounts of fluid
  • close attention to complications
  • cardiovascular collapse, respiratory
    insufficiency, and pancreatic infection, as well
    as possible surgical debridement or drainage.

18
Chronic pancreatitis
  • Inflammatory disease of pancreas
  • irreversible morphological changes in the
    pancreatic duct, acinar cell destruction and
    fibrosis
  • Four clinical manifestations include abdominal
    pain, steatorrhoea, diabetes, and calcification
    of pancreas

19
Etiology of chronic pancreatitis
  • Mostly due to ETOH in the Western World
  • Increases viscosity of pancreatic juice
  • Decreased local secretion of lithostatin which
    usu makes calcium salts soluable
  • Precipitation of calcium within gland
  • Direct toxic effect on acinar cells
  • Cytokines recruit stellate cells, causing
    fibrosis
  • Other unusual causes such as cystic fibrosis,
    severe malnutrition, hereditary or idiopathic

20
Investigations
  • AXR
  • U/S
  • CT abdo
  • Secretin test

21
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22
complications of chronic pancreatitis
  • Narcotic addiction
  • Gastrointestinal bleeding
  • Impaired glucose tolerance
  • Jaundice
  • Gastroparesis
  • Cholangitis and/or biliary cirrhosis
  • Effusions with high amylase content
  • Pancreatic cancer

23
Medical treatment of chronic pancreatitis
  • Enzyme replacement (lipase, protease,
    somatostatin)
  • Often require insulin
  • Behaviour modification
  • Analgesia, often difficult

24
Surgical treatment
  • Pseudocyst drainage

25
Surgical treatment
  • Pseudocyst drainage

26
Surgical treatment
  • Whipples procedure

Chronic pancreatitis Head of pancreas
Ca Duodenal Ca Cholangiocarcinoma Ampullary Ca
27
In summary
  • In the patient with an acute abdomen, all
    possible differentials should be considered
  • Diagnosis of acute pancreatitis should rule out
    other differentials, can be life threatening, and
    should be carefully managed
  • Management of chronic pancreatitis requires
    consideration of medical and surgical therapies
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