د . صدام جراحه عامة 12 / 10 /2015
Lec2
د . صدام جراحه عامة 12 / 10 /2015
Lec2
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ACUTE PANCREATITIS
Acute inflammation of pancreas is one of causes of acute abd.pain. It’s a serious condition that leads to death in 10% of cases.
Aetiology:
1.Bile duct stones. 50%
2.Excess alcohol intake. 20%
3.Trauma . 5% accidental,operative,ERCP.
4.Rare causes :viral,hyperparath,corticosteroid.
5.Idiopathic.
CLINICAL FEATURES
SYMPTOMS
1.Severe agonizing upper abd. Pain radiated to back.
2.Vomting &retching.
SIGNS
May show hypovol. Shock,tinge of jaudice,cynosis.Patient sits leaning forward.mild tenderness &rigiditiy,bruising around umblicus(Cullen sign),& in the loin(Grey Turner sign) are rare late feature.upper abd. Swelling after 2-3 wk (pancreatic pseudocyst).
COMPLICATIONS
SYSTEMIC
1.Shock loss of plasma or blood2.ADRS
3.Renal failure
4.consumption coagulopathy
5.paralytic ileus.stress ulcer
6.tetany
LOCAL
1.Pseudocyst
2.Abscess
DIFFERENTIAL DIAGNOSIS
1.Perforated peptic ulcer2.Acute cholecystitis & biliary colic
3. Acute mesenteric vascular occlusion
4.leaking aortic aneurysm
5. Acute M.I1.
INVESTIGATIONS
Serum amylase elevate within few hours>1000 IU/dl. NR 100-300
2.Arterial blood gases
3.biochemical .bilirubin eleveted.hypocal.hypoprot.eleveted B.urea.hypergl.
4.blood picture .leacocytosis.elevated haematocrit
5.plain x-ray of abdomen shows dilated short segment of small intestine(sentinel loop).colon cut-off sign
6.U/S gall stone
7.CT very helpful shows enlargement of pancreas,oedema ,necrosis.
8.ECG &cardiac enzyme to exclude M.I
TREATMENT
Ranson criteria
At admission:
1-age > 55 years.
2- WBC > 16000 cells/mm.
3- blood glucose > 11 mmol/L (>200 mg/dL )
4- serum AST > 250 IU/L.
5- serum LDH >350 IU/L.
Within 48 hours:
1- serum calcium < 2 mmol/L ( <8 mg/dL ).
2- hematocrit fall > 10%.
3- PaO2 <60% mmHg.
4- BUN increased by 1.8 or more mmol/L( 5 or more mg/dL ) after IV fluid hydration.
5- base deficit > 4 mEq/L.
6- sequestration of fluid > 6 L.
--- If score > or = 3 severe pancreatitis.
--- If score < 3 severe pancreatitis is unlikely.
CONSERVATIVE
Severe cases admitted to ICU.Treatment is supportive to body system.”R”regimen:
1.Relief of pain by pethidine with atropine
2.Replacement of the lost fluids by crystalloids,plasma even blood
3.Rest of pancreas &bowel by nil oral&NG suction.somatostatin
4.Respiratory support by oxygen mask,or mechanical ventilation
5.Resistance of infection by prophylactic antibiotic
6.Reassessment by ERCP
7.If vomiting is prolonged ,IV hyperalimentation
SURGICAL
1.Doubtful diagnosis exploratory laparotomy
2.Drainge of pancreatic abscess ,or persistent pseudocyst
3.excision of necrotic tissue in severe necrotizing pancreatitis.
PANCREATIC PSEUDOCYST
NATUREcollection of pancreatic secretion &inflammatory exudate within a lining of inflammatory tissue
AETIOLOGY
develops in 10% of cases of acute pancreatitis after 2-3 wk.nexet cause pancreatic trauma
SITE
lesser sac
COMPLICATIONS
infection ,haemorrhage,rupture
CLINICAL FEATURES
-Small painless discovered by u/s
-Large cause discomfort ,upper abd. Swelling
INVESTIGATIONS
-Ba-meal forward displacement of stomach
-U/S&CT
TREATMENT
1.Most of cysts resolve spont.
2.persistant cyst .drained after 6wk to stomach or jejunam
Carcinoma of pancreas
Male>femle.Age 55-70.prognosis poorAETIOLOGY unkown.smoking,high protein,high fat food
SPREAD
direct CBD,LYMPH,BLOOD liver lung,Transperitoneal
Clinical features:
1.CA of head painless obst. Jaundice,hepatomegally,palpable GB,anorexia &wt loss
2.CA of body &tail epigastric pain hepatomegally,anorexia &wt loss
INVESTIGATONS
1.LFT elevated direct bil.&alk.ph.low prothombin
2.u/s dilated intra &extra hepatic duct,metastases
3.CT
4.ERCP
Treatment:
1.Unfit for surgery endoscopic stent
2.Fit for surgery & operable Whipple operation
3.Inoperable tumor cholecystojejenostomy