Pancreatitis

ACUTE PANCREATITIS

الدكتور خلدون ذنون- كلية طب نينوى
المرحلة الرابعة
Objectives
1. To know causes of acute and chronic pancreatitis.
2. To focus on clinical presentations, abdominal pain is a prominent symptom.
3. Biochemical tests and imaging are important in the diagnosis.
4. How to evaluate prognosis.
5. How to manage pain and correction of all of the abnormalities imposed by the disease.

Pathophysiology

Acute inflammatory process of the pancreas involving also the surrounding tissues & remote organs.
Different abnormal stimuli activate pancreatic enzymes which digest pancreatic tissue.
There is imbalance between released proteolytic enzymes & anti- proteolytic factors.

Causes

A- Common causes 90%: gall stones, alcohol, idiopathic, post ERCP
B- Rare causes: post surgical or trauma, drugs (azathioprine, thiazide, sodium valproate), hypercalcaemia, ( triglyceride, mumps, hereditary & organ transplant, sphincter of Oddi dysfunction, renal failure, hypothermia, petrochemical exposure.


Clinical features
Severe constant upper abdominal pain which radiate to the back.
Nausea, vomiting is common.
Marked epigastric tenderness, but in the early stages, guarding & rebound tenderness are absent as the pancreas is retroperitoneal.
Diminished or absent bowel sounds due to paralytic ileus.
Severe cases( hypoxia, shock with oliguria.
Discolouration of the flanks (Grey Turners sign) or the periumbilical region (Cullens sign) are features of severe pancreatitis with HR.

D.D : perforated viscus, acute cholecystitis, myocardial infarction.

Complications
A- Systemic: SIRS, ARDS( hypoxia, hyperglycaemia, hypocalcaemia, ( albumin.
B- Pancreatic: necrosis, abscess, pseudocyst, pancreatic ascites, pleural effusion.
C- GIT: upper GIT bleeding, variceal HR (splenic or portal vein thromb- osis), erosion into colon, duodenal obstruction, obstructive jaundice.

Diagnosis

( Serum amylase &( urinary amylase : creatinine ratio
Persistent elevation of s.amylase suggests pseudocyst formation.
Pancreatic ascites( massive(of peritoneal amylase concentration.
S.amylase also ( in: intestinal ischaemia, perforated peptic ulcer, ruptured ovarian cyst & parotitis.
( s.amylase has no prognostic value.
( Serum lipase (greater diagnostic accuracy).
Plain radiograph: exclude perforation, obstruction & pulmonary complication.
Ultrasound: swollen gland, gall stones, biliary obstruction & pseudocyst.
CT scan contrast enhanced: diagnose necrotising pancreatitis (i.v contrast shows ( enhancement), gas within pancreas suggest infection & impending abscess, shows also involvement of colon, blood vessels & other adjacent structures.
Serial C-reactive protein assesses progress of the disease, CRP>210 mg/L in the 1st 4 days predicts severe acute pancreatitis.


Adverse prognostic factors in acute pancreatitis
Age > 55 years
P02 < 8kpa
WBC > 15(109 / L
Albumin < 32 gm/ L
s.calcium < 2mmol / L
Glucose > 10 mmol/ L
urea > 16 mmol/ L
ALT>200 U/ L
LDH > 600 U/ L

Management

analgesia e.g pethidine
Correct hypovolaemia e.g normal saline, colloids.
Severe cases: intensive care unit, central venous line, Swan-Ganz catheter, urinary catheter, are used to monitor shock.
Oxygen for hypoxia, ARDS needs ventilation.
Insulin for hyperglycaemia.
Tetany : i.v calcium.
Paralytic ileus needs nasogastric aspiration.
Enteral feeding (nasogastric or nasojejunal tube) in severe pancreatitis.
Prophylaxis of thromboembolism: low dose sc heparin.
Prophylactic i.v broad spectrum antibiotics e.g imipenem, cefuroxime in severe cases.
Cholangitis & jaundice with severe pancreatitis need urgent ERCP to diagnose & treat choledocholithiasis, in less severe cases ERCP is done after resolution of the acute phasem, cholecystectomy done 2 weeks after resolution of pancreatitis.
Management of complications:
a- necrotising pancreatitis or pancreatic abscess: urgent surgery.
b- Pancreatic pseudocyst: drainage into the stomach or duodenum.


Prognosis
Mortality 10-15%
80% of all cases are mild with 5% mortality.
Early mortality due to multiorgan failure, later due to sepsis.

CHRONIC PANCREATITIS

Chronic inflammatory disease with fibrosis & destruction of exocrine pancreatic tissue, diabetes occur in advanced cases.

Causes

Alcoholism (80% from alcohol in the west).
Tobacco
Hypercalcemia
Chronic renal failure
Tropical (calcific in India)
Hereditary and cystic fibrosis
Autoimmune
Post necrotic and recurrent acute pancreatitis
Obstructive: ductal carcinoma, pancreas divisum, sphincter of Oddi stenosis.

Clinical features

Middle aged alcoholic men.
Slowly progressive chronic abdominal pain or may occur as episodes of acute pancreatitis.
Some has no pain & present with diarrhoea.
Pain may be relieved by leaning forwards, drinking alcohol or opiates.
Weight loss: due to anorexia, postprandial pain, malabsorption or D.M.
Steatorrhea: when > 90% of exocrine tissue has been destroyed.
30% develops diabetes, ( to 70% in chronic calcific pancreatitis.
Examination: thin malnourished patient with epigastric tenderness.
Skin pigmentation over abdomen & back due to hot water bottles (erythema ab igne).
Features of other alcohol & smoking related diseases.
Features of complications: - pseudocyst & pancreatic ascites. - Obstructive jaundice due to common bile duct stricture. - Duodenal stenosis. - Portal or splenic vein thrombosis( portal hypertension & gastric
varices.
- Peptic ulcer.
Investigations
A- Establish diagnosis:
- Abdominal ultrasound
- CT: atrophy, calcification or ductal dilatation.
- Abdominal radiograph: calcifications.
- MRCP
- Endoscopic ultrasound.
B- Pancreatic function:
- Secretin injection (seldom used).
- Pancreolauryl or PABA test: assess pancreatic exocrine function.
- Feacal pancreatic elastase.
C- Test of anatomy prior to surgery: MRCP


Management
( Alcohol avoidance
( Pain relief:
NSAIDs
Opiates: severe cases (addiction) .
Oral pancreatic enzymes: may reduce analgesic supplements.
Severe chronic pain: surgical e.g coeliac plexus neurolysis, partial pancreatic resection, pancreatico-jejunostomy, total pancreatectomy (some still suffer pain).
Endoscopic therapy : dilatation or stenting of main pancreatic duct,
removal of calculi, drainage of pseudocyst.

( Steatorrhea: dietary fat restriction with medium chain triglyceride
therapy. Oral pancreatic enzymes + ppi to optimize duodenal PH.
( Diabetes: ( carbohydrates + insulin.
( Management of complications
- Surgical or endoscopic therapy for : pseudocyst, pancreatic ascites,
CBD or duodenal stricture, portal hypertension. - Treatment of other alcohol & smoking related diseases. - Treatment of self-neglect & malnutrition.










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