Jasim Al-Abbad, MBBCh, FRCSC Assistant Professor General Surgery Colon and Rectal Surgery [email protected] inflammation of the gland parenchyma of the pancreas Acute vs. Chronic 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 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 Gallstones Alcohol Hypertriglyceridemia Hypercalcemia Post ERCP Trauma Pancreatic duct obstruction Infections Drugs Hereditary 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 Adv Surg 2006; 40:265-284 N Engl J Med 2006; 354:2142-2150 Abdominal pain Nausea / vomiting Low grade fever Dehydration Epigastric tenderness Jaundice Grey Turner Cullen's signs History / physical examination Biochemical workup ◦ ◦ ◦ ◦ CBC RFT LFT Amylase, lipase Imaging 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 Causes of hyper-amylasemia: Acute cholecystitis Bowel obstruction Mesenteric ischemia Trauma Ketoacidosis Ruptured ectopic pregnancy Parotitis Renal failure Salpingitis Cirrhosis More specific than amylase Longer half life 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 Adv Surg 2006; 40:265-284 Plain x-rays Ultrasound CT scan MRCP ERCP EUS Early recognition of severe disease is crucial to optimize care and improve outcome Many scoring systems developed 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 On admission Age > 55 WBC count > 16,000 /mm3 Blood glucose > 11.1 mmol/L AST > 250 U/L LDH > 350 U/L 48 hours Hematocrit Drop by >10% BUN Increase by >1.8 mmol/L Serum Calcium < 2 mmol/L pO2 < 60 mmHg Base deficit > 4 mEq/L Fluid sequestration > 6 Liters 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 12 physiologic measurements It provides a general measure of the severity of disease A score of ≥8 defines severe pancreatitis Balthazar score Based on CT findings Grade Findings Score A Normal pancrease 0 B Focal or diffuse enlargment of the pancreas 1 C Peripancreatic inflammation 2 D 1 fluid collection 3 E 2 or more fluid collections 4 Pancreatic necrosis None 0 ≤ 30 % 2 30 – 50 % 4 > 50 % 6 Mortality 0-3 = 3% 4-6 = 6% 7-10= 17% Radiology 1990; 174:331 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 Organ failure • Shock (SBP <90mmHg) • Pulmonary insuffciency (PaO2 <60 mmHg) • Renal failure (creatinine > 2mg/dL) • GI bleeding (>500 mL/24hr) Systemic complications • DIC (Platelet count ≤ 100,000) • Fibrinogen <1 g/L • Fibrin split products > 80 µg/dL • Metabolic disturbance (calcium < 7.5 mg/dL) Local complications • Necrosis • Abscess • Pseudocyst 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 Surg 1993; 128:586-590 Regardless of the cause or the severity of the disease Aggressive fluid resuscitation Pain control Oral feeding may not be possible Enteral feeding vs. TPN Data controversial No benefit for pancreatitis without necrosis Imipenem reduces pancreatic infections with proven necrosis Cochrane Database Syst Rev. 2010 Routine use of ERCP is not indicated ERCP is indicated for: ◦ Cholangitis ◦ Persistent bile duct obstruction (obstructive jaundice) 30% of patients with acute biliary pancreatitis will have recurrent disease, in the absence of definitive treatment For mild pancreatitis: For severe pancreatitis: ◦ Early laparoscopic cholecystectomy (during the initial admission) is a safe procedure that decreases recurrence of the disease ◦ Early surgery may increase the morbidity and length of stay ◦ Laparoscopic cholecystectomy should be delayed for at least 6 weeks Adv Surg 2006; 40:265-284 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 Sabiston, David C., and Courtney M. Townsend. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. Philadelphia: Saunders/Elsevier, 2008. Print. Persistent inflammation Irreversible fibrosis Atrophy of the pancreatic parenchyma Chronic pain Endocrine and exocrine insufficiency Brunicardi, F. Charles., and Seymour I. Schwartz. Schwartz's Principles of Surgery. New York: McGraw-Hill, Health Pub. Division, 2010. Print. Brunicardi, F. Charles., and Seymour I. Schwartz. Schwartz's Principles of Surgery. New York: McGraw-Hill, Health Pub. Division, 2010. Print. Alcohol (70 - 80%) Genetics (hereditary, CF gene mutation) Hyperparathyroidisim Hypertriglyceridemia Autoimmune pancreatitis Ductal obstruction (trauma, stones, tumors, ?pancreas divisum) Smoking Idiopathic Abdominal Pain Pancreatic insufficiency ◦ Fat malabsorption ◦ Apancreatic diabetes Blood tests: ◦ ◦ ◦ ◦ CBC RFT LFT Serum amylase and lipase levels usually normal Functional tests Fecal fat content Fecal elastase-1 level Imaging: CT scan MRCP EUS ERCP Sabiston, David C., and Courtney M. Townsend. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. Philadelphia: Saunders/Elsevier, 2008. Print. Medical Treatment Multidisciplinary team Stop drinking and smoking Pain control Pancreatic enzyme replacement Endoscopic Treatment ERCP with duct dilatation ± stent Surgical Treatment Resection procedures Drainage procedures Souba, Wiley W. ACS Surgery: Principles and Practice. Hamilton, Ont.: B C Decker, 2007. Print. Biliary strictures (jaundice / cholangitis) Duodenal obstruction Splenic / portal vein thrombosis Pseudocyst Brunicardi, F. Charles., and Seymour I. Schwartz. Schwartz's Principles of Surgery. New York: McGraw-Hill, Health Pub. Division, 2010. Print.