Document

Report
Presented By: Ehsan Arefnia
June 2012
Anatomy
Retroperitoneal Organ
Weighs 75 To 100 G
15 To 20 Cm Long
Head
Neck
Body
Tail
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Physiology
• Three General Functions:
• Neutralizing the acid chyme entering the duodenum from the
stomach
• Synthesis and secretion of digestive enzymes after a meal
• Systemic release of hormones that modulate metabolism of
carbohydrates, proteins, and lipids
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Acute Pancreatitis
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Definition and Incidence
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Inflammatory disease with little or no fibrosis
Initiated by several factors
Develop additional complications
300,000 cases occur in the united states each year leading to over
3000 deaths
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Etiology
• Biliary tract disease
• Alcohol
• Drugs
• 30 meds identified
• AIDS therapy: didanosine, pentamidine
• Anti-inflammatory: sulindac, salicylates
• Antimicrobials: metronidazole, sulfonamides,
tetracycline, nitrofurantoin
• Diuretics: furosemide, thiazides
• IBD: sulfasalazine, mesalamine
• Immunosuppressives: azathioprine, 6mercaptopurine
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Etiology: (GET SMASHED)
G: Gallstone
E: Ethanol
T: Trauma
S: Steroid
M: Mump
A: Alcoholism or Autoimmune
S: Scorpion bits
H: Hyperlipidemia
E: ERCP
D: Drugs
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Differential Diagnosis
•Pancreatitis
•Acute Cholecystitis
•MI
•Cholangitis
•Severe Pneumonia
•Perforated Viscous
•Intestinal Obstruction
•Ruptured Aaa
•Appendicitis
•Diverticulitis
•Caecal Perforation
•Ruptured Ectopic
•Bowel Ischemia
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Clinical Presentation
• Abdominal pain
• Epigastric
• Radiates to the back
• Worse in supine position
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Nausea and vomiting
Tachycardia, Tachypnea, Hypotension, Hyperthermia
Elevated Hematocrit
Cullen's sign
Grey Turner's sign
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Grey Turner sign
Cullen’s sign
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Diagnosis: Biochemical
• serum amylase
• Nonspecific
• Returns to normal in 3-5 days
• Normal amylase does not
exclude pancreatitis
• Level of elevation does not
predict disease severity
• Urinary amylase
• P-amylase
• Serum Lipase
• Serum Electrolytes
• Hypocalcaemia (Poor prognosis)
• Hyperglycemia (Poor prognosis)
• Hypoalbuminemia
• CBC
• Increased Hb
• Thrombocytosis
• Leukocytosis
• Liver Function Test
• Serum Bilirubin elevated
• Alkaline Phosphatase elevated
• Aspartate Aminotransferase elevated
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Assessment of Severity
• Ranson Criteria
• Biochemical Markers
• Computed Tomography Scan
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Ranson Criteria
Criteria for acute gallstone pancreatitis
• Admission
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• During first 48 hours
Age > 70
WBC > 18,000
Glucose > 220
LDH > 400
AST > 250
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Hematocrit drop > 10 points
Serum calcium < 8
Base deficit > 5.0
Increase in BUN > 2
Fluid sequestration > 4L
<2 pos sign: mortality rate is 0
3-5 pos sign: mortality rate is 10 to 20%
>7 pos sign: mortality rate is >50%
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50 year-old woman
Stomach
Liver
V
A
R Kidney
L
Kidney
Spleen
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CT scans of normal kidneys and pancreas
Gallstone-induced pancreatitis in 27 year-old woman
Large, edematous, homogeneously attenuating pancreas (1) . Peripancreatic inflammatory
changes (white arrows). There is no pancreatic necrosis. Calcified gallstones are seen in
gallbladder (black arrow)
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Pancreatic Necrosis
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Treatment of Mild Pancreatitis
• Pancreatic rest
• Supportive care
• fluid resuscitation – watch BP and urine output
• Pain Control
• NG tubes and H2 blockers or PPIs are usually not
helpful
• Refeeding (usually 3 to 7 days) If:
• Bowel Sounds Present
• Patient Is Hungry
• Nearly Pain-free (Off IV Narcotics)
• Amylase & Lipase Not Very Useful
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Treatment of Severe Pancreatitis
• Pancreatic Rest & Supportive Care
• Fluid Resuscitation – may require 5-10 liters/day
• Careful Pulmonary & Renal Monitoring – ICU
• Maintain Hematocrit Of 26-30%
• Pain Control – PCA pump
• Correct Electrolyte Derangements (K+, Ca++, Mg++)
• R/O necrosis
• Contrasted CT scan at 48-72 hours
•Prophylactic antibiotics if present
• Surgical debridement if infected
• Nutritional support
• May be NPO for weeks
• TPN vs. enteral support (TEN)
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Complications
• Local
• Phlegmon, Abscess, Pseudocyst, Ascites
• Involvement of adjacent organs, with hemorrhage, thrombosis, bowel
infarction, obstructive jaundice, fistula formation, or mechanical
obstruction
• Systemic
• A. Pulmonary: Pneumonia, atelectasis, ARDS, Pleural Effusion
• B. Cardiovascular: Hypotension, Hypovolemia, Sudden Death,
Nonspecific ST-T wave changes, Pericardial effusion
• C. Hematologic :Hemoconcentration, DIC
• D. GI: Hemorrhage, Peptic ulcer, Erosive gastritis, Portal vein or
splenic vein thrombosis with varices
• E. Renal: Oliguria, Azotemia, Renal artery/vein thrombosis
• F. Metabolic :Hyperglycemia, Hypocalcemia, Hypertriglyceridemia,
Encephalopathy, Sudden Blindness (Purtscher's retinopathy)
• G. CNS: Psychosis, Fat Emboli, Alcohol withdrawal syndrome
• H. Fat necrosis: Intra-abdominal saponification, Subcutaneous tissue
necrosis
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Acute Pseudocyst
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Management
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Chronic Pancreatitis
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Definition and Prevalence
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Incurable, Chronic Inflammatory Condition
5 To 27 Persons Per 100,000
Fibrosis
Alcohol
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Etiology
• Alcohol, 70%
• Idiopathic (including tropical), 20%
• Other, 10%
• Hereditary
• Hyperparathyroidism
• Hypertriglyceridemia
• Autoimmune pancreatitis
• Obstruction
• Trauma
• Pancreas divisum
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Signs and Symptoms
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Steady And Boring Pain
Not Colicky
Nausea Or Vomiting
Anorexia Is The Most Common
Malabsorption And Weight Loss
Apancreatic Diabetes
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Laboratory Studies
Tests for Chronic Pancreatitis
I. Measurement of pancreatic products in blood
A. Enzymes
B. Pancreatic polypeptide
II. Measurement of pancreatic exocrine secretion
A. Direct measurements
1. Enzymes
2. Bicarbonate
B. Indirect measurement
1. Bentiromide test
2. Schilling test
3. Fecal fat, chymotrypsin, or elastase concentration
4. [14C]-olein absorption
III. Imaging techniques
A. Plain film radiography of abdomen
B. Ultrasonography
C. Computed tomography
D. Endoscopic retrograde cholangiopancreatography
E. Magnetic resonance cholangiopancreatography
F. Endoscopic ultrasonography
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Pancreatic calcifications. CT scan showing
multiple, calcified, intraductal stones in a
patient with hereditary chronic
pancreatitis
Endoscopic retrograde
cholangiopancreatography in chronic
pancreatitis. The pancreatic duct and its
side branches are irregularly dilated
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Treatment
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Analgesia
Enzyme Therapy
Antisecretory Therapy
Neurolytic Therapy
Endoscopic Management
Surgical Therapy
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Complications
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Pseudocyst
Pancreatic Ascites
Pancreatic-Enteric Fistula
Head-of-Pancreas Mass
Splenic and Portal Vein Thrombosis
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Management
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References
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Schwartz's Principles of Surgery, Ninth Edition
Sabiston Textbook of Surgery, 18th Edition.
WWW.UpToDate.COM
WWW.MDConsult.COM
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