Acute Pancreatitis

Ghidirim Gh., Mishin I., Vozian M., Zastavnitsky Gh.

 PHYSIOLOGY
Pancreatic Acinar Cell
Secretion Products

Proenzymes

Enzymes
 PHYSIOLOGY
• Islets of Langerhan’s
– B cells (75%)
– A cells (20%)
– D cells
– Pancreatic polypeptide cells
 Definition
ACUTE PANCREATITIS IS A COMPLEX DISORDER OF THE

EXOCRINE PANCREAS CHARACTERIZED BY ACUTE ACINAR

CELL INJURY AND BOTH REGIONAL AND SYSTEMIC

INFLAMMATORY RESPONSES

ACUTE PANCREATITIS IS A „NON-BACTERIAL

INFLAMMATION, WHICH INITIATES BY PANCREATIC

ENZYMES” (S.SCHWARTZ)
 Definition

 Typical epigastric pain with

 Increased amylase or lipase (3x
greater than normal) or
 Imaging c/w pancreatitis
 Epidemiology
 4.8-38 per 100,000 patients
 Cost of pancreatic diseases= $2.5 billion in 2000
 Acute pancreatitis ranks as the 2nd most common
inpatient principal GI diagnosis
 Classification
 Mild acute pancreatitis:
 Minimal or no organ dysfunction
 Uneventful recovery
 Severe pancreatitis:
 Organ failure
 Local complications (necrosis, abscess, pseudocyst)
 CLASSIFICATION OF ACUTE PANCREATITIS
(ATLANTA, GEORGIA, 1992)

I. EDEMATOUS ACUTE PANCREATITIS

II. NECROTIZING ACUTE PANCREATITIS:
- sterile pancreatic necrosis
- infected pancreatic necrosis
III. COMPLICATIONS OF ACUTE PANCREATITIS:
- parapancreatic infiltrate
- pancreatic abscess
- peritonitis
- retroperitoneal phlegmon
- pancreatic cysts (sterile and infected)
- digestive tract fistulas
- bleeding
 SEVERE FORM
15%
(NECROTISING
PANCREATITIS)

MILD FORM 85%

(EDEMATOUS
PANCREATITIS)

INFECTED
NECROSIS 40%
NO INFECTION
60%

MORTALITY <1%

MORTALITY 10% MORTALITY 30%

 Classification
V. Filin
1) ACUTE EDEMATOUS (INTERSTITIAL)
PANCREATITIS
2) ACUTE NECROTIZING PANCREATITIS
3) SUPPURATIVE-NECROTIZING PANCREATITIS, OR
INFECTED NECROSIS OF THE PANCREAS

FIRST PERIOD: HEMODYNAMICAL DISTURBANCES (1-3 DAYS)

SECOND PERIOD: MULTIORGAN SYSTEM FAILURE (5-7 DAYS)
THIRD PERIOD: LATE SUPPURATIVE COMPLICATIONS (3-4 WEEKS)
CLINICAL CLASSIFICATION OF ACUTE PANCREATITIS
Pancreatic Disease Group, 2005

Mild AP - the same clinical manifestations and biochemical changes as AP,

without functional impairment or local complications, and responds well to
supplementary fluid treatment

Severity scores are:

• Ranson <3 / APACHE II <8
• CT grade A, B or C

Severe AP - the same clinical manifestations and biochemical changes as

AP, plus one of the following:
• the local complication of pancreatic necrosis
• pseudocyst or infected pancreatic tissue
• functional impairment of other organs

Severity scores are :

• Ranson ≥3 / APACHE II ≥8
• CT grade D or E
 Classification
• Working Group Classification – 2007
ACUTE PANCREATITIS
• Interstitial edematous pancreatitis (IEP)
• Necrotizing pancreatitis (pancreatic
necrosis and/or peripancreatic necrosis)
– Sterile necrosis
– Infected necrosis
 Classification
FLUID COLLECTIONS DURING ACUTE
PANCREATITIS
 (<4 weeks after onset of pancreatitis)
• Acute peripancreatic fluid collection (APFC)
– Sterile
– Infected
• Post-necrotic pancreatic/peripancreatic fluid
collection (PNPFC)
– Sterile
– Infected
 Classification
(>4 weeks after onset of pancreatitis)
• Pancreatic pseudocyst (usually has
increased amylase/lipase activity)
– Sterile
– Infected
• Walled-off pancreatic necrosis (WOPN)
(may or may not have increased
amylase/lipase activity)
– Sterile
– Infected
 CLINICAL TERMINOLOGY

The terms ‘acute edematous pancreatitis’ or ‘acute necrotizing

pancreatitis’ are no longer in use unless there are positive
pathologic findings. The terms ‘acute hemorrhagic necrotizing
pancreatitis’ and ‘acute pancreatic cellulitis’ are obsolete.

Clinically, the diagnosis should include the etiology, grade of

disease and complications e.g. AP (biliary in origin, severe
degree, acute respiratory distress syndrome (ARDS)) or AP
(biliary in origin, mild degree).

For clinical purposes only, one can use the Ranson’s score or
CT grading; for clinical research, the APACHE score and CT
grade must always be included.

Pancreatic Disease Group, 2005

 Terminology
 Pancreatic necrosis:
 Focal or diffuse nonviable pancreatic parenchyma and
usually peripancreatic fat necrosis. Can be infected or
sterile.
 Acute fluid collection:
 Fluid in or near the pancreas that lacks a definite wall
and that occurs early in the course of acute pancreatitis.
 Pseudocyst:
 Fluid collection that persists for 4-6 weeks and becomes
encapsulated by a wall of fibrous or granulation tissue
 Terminology
 Pancreatic abscess:
 Circumscribed intra-abdominal collection of pus after an
episode of acute pancreatitis or pancreatic trauma
 It usually develops close to the pancreas and contains
little pancreatic necrosis.
 Natural History
 Mild:
 80% of attacks

 Normal pancreatic morphology and function are the rule

after recovery if there are no further attacks
 Severe:
 20% of attacks

 Commonly accompanied by necrosis of the pancreas

and/or organ failure
 About 25-33% with severe pancreatitis die from their
disease.
 About 50% of deaths occur within the first 2 weeks,
usually from multiorgan failure.
 Natural History
 Patients who are older and have comorbid illnesses have
a substantially higher rate of mortality.
 In those who survive the illness, severe pancreatic
necrosis can scar the pancreas, resulting in a stricture of
the main pancreatic duct with subsequent obstructive
chronic pancreatitis and permanent diabetes and
malabsorption.
 Etiology

Alcoholic
Idiopathic
Other
Biliary
 Etiology
• Autoimmune
• Drug-induced
• Iatrogenic
Alcoholic • IBD-related
Idiopathic
Other
• Infectious
• Inherited
Biliary • Metabolic
• Neoplastic
• Structural
• Toxic
• Traumatic
• Vascular
 Etiology

Class Example Mechanism

Viral Coxsackie Unclear

Parasitic Ascaris Obstructive

Fungal Candida Unclear

Bacterial Salmonella Toxin

 Inherited Causes

Altered enzyme activity

Trypsinogen mutations

Abnormal ion movement

Cystic fibrosis transmembrane
regulator (CFTR) mutations

Metabolic
Familial hypertriglyceridemia
Drug Induced Pancreatitis Sorted by Incidence

Common Uncommon Rare

asparaginase ACE inhibitors carbamazepine
azathioprine acetaminophen corticosteroids
6-mercaptopurine 5-amino ASA estrogens

didanosine (DDI) furosemide minocycline

pentamidine sulfasalazine nitrofurantoin
valproate thiazides tetracycline
 Acute Alcohol Effects

Abnormal blood Toxic metabolites

flow and secretion Non-oxidative
Oxidative

Sensitization to CCK
Zymogen activation
Stimulatio Cytokine generation
n of CCK Sphincter of
and
secretin Oddi spasm
release
 Gallstone Pancreatitis Mechanism

Common channel theory

Opie 1

Obstructed pancreatic duct

Opie 2
 Hypertriglyceridemia
• Rare cause of acute TG
pancreatitis
• Serum triglycerides usually TG lipase
>1000 mg/dL
• May cause chronic disease Free fatty
acids
• Can be drug-induced:
Alcohol, estrogens,
isotretinoin, HIV-protease
inhibitors
Cell damage
 Pathogenesis
Pancreatitis evolves in 3 phases:
 First: Characterized by intrapancreatic digestive enzyme
activation and acinar cell injury.
 Second: Involves the activation, chemoattraction, and
sequestration of neutrophils in the pancreas resulting in an
intrapancreatic inflammatory reaction of variable severity.
 Third: Due to the effects of activated proteolytic enzymes
and mediators, released by the inflamed pancreas, on
distant organs.
Mechanisms Pathogenesis
• Zymogen activation
• Generation of • Systemic
inflammatory mediators inflammatory
• Ischemia response
• Multi-organ
failure
Insult

• Inflammation
• Ischemia

• Neurogenic
• Necrosis stimulation
• Apoptosis
 FAT NECROSIS PARENCHYMAL BLEEDING
NECROSIS

LOCAL PHOSPHOLIPASE A ELASTASE

TRYPSIN

LIPASE

PHOSPHOLIPASE A KALLIKREIN THROMBOPLASTIN

SYSTEMIC
KININS THROMBIN

LUNGS KIDNEYS CIRCULATION CLOTTING

DISORDER
RESPIRATORY ACUTE RENAL SHOCK
FAILURE FAILURE DIC
 Symptoms and Signs

• Abdominal pain • Mortality rate-1% for

• Nausea and vomiting mild acute pancreatitis
• Anorexia 75-90% for severe
• Fever acute pancreatitis.
• Hypovolemia
Overall mortality rate of
• Ileus
• Abdominal tenderness 15-20%
• Left pleural effusion
• Altered mental status
• Jaundice
• ARDS
 Presenting Features

Abdominal pain
Nausea / vomiting
Tachycardia
Low grade fever
Abdominal guarding
Loss of bowel sounds
Jaundice
0 20 40 60 80 100
% patients
• BEREZNIGOVSKI’S SIGN
• MAYO – ROBSON’S SIGN
• MONDOR’S SIGN
• GREY-TURNER’S SIGN
• CULLEN’S SIGN
• BONDE’S SIGN
• MANDEL-RAZDOLSCKI’S SIGN
• GOBIEF’S SIGN
• KERVEN’S SIGN
• KÖRTE’S SIGN
• VOSKRESENSKI’S SIGN
 Lab Diagnosis
• Complete blood count
• Renal function tests
• Liver function
• Serum amylase - 3-4 times increase
(Normal range <115IU)
• Serum lipase - lipase levels may have a
slightly greater sensitivity, particularly
when measured late (> 24 hours) after
initial presentation
• Serum calcium
• Arterial blood gas
 Lab Diagnosis
 Serum and Urine Amylase :
 Pancreas accounts for 40-45% of serum amylase, and
the salivary glands account for the rest.
 The serum amylase value is usually increased on the
first day of symptoms and remains elevated for 3 to 5
days in uncomplicated attacks.
 There is no definite correlation between the severity of
pancreatitis and the degree of serum amylase
elevation.
 Serum amylase value may be normal in
hypertriglyceridemia associated pancreatitis
 Elevated Serum Amylase

Cholangitis
Cholecystitis
Pancreatitis
Kidney stone
Peptic ulcer

Intestinal
Ectopic obstruction,
pregnancy ischemia or
perforation
 Lab Diagnosis
 Serum Lipase:
 The sensitivity of measurements for the diagnosis is
similar to that of serum amylase measurements (85-
100%)
 Serum lipase is always elevated on the 1st day of illness
and remains elevated longer than serum amylase
content.
 Is Lipase more specific than amylase?
Conditions Associated with
Hyperamylasemia and Hyperlipasemia
Amylase Lipase
Paroditis yes no
Tumors yes no
Biliary disease yes slight
Pancreatitis yes yes
Renal failure yes slight
Intestinal obstruction, yes yes

ulceration, ischemia
Ectopic pregnancy yes no
Macroamylasemia yes no
Perforated viscus yes yes
 Radiologic Diagnosis
 Abdominal and chest plain film:
 Excludes other causes of acute abdominal pain-obstruction
and perforation.
 AXR - Frequently normal or may demonstrate ileus: multiple
air fluid interphase; pancreatic calcifications, calcified gall
stones, “sentinel loop” sign, “colon cut off” sign, “renal halo”
sign
 Chest radiograph can detect pulmonary complications:
 Atelectasis
 Pleural effusions (most commonly left-sided)
 Infiltrates suggestive of adult respiratory distress
syndrome
Sentinel Loop Sign
Colon Cut Off Sign
 Radiologic Diagnosis
 Abdominal Ultrasound
 Used in 1st 24 hours to search for:
 Gallstones
 Dilatation of the common bile duct due to choledocholithiasis
 Ascites
 Pancreas is usually diffusely enlarged and hypoechoic, interstitial edema,
extra pancreatic fluid collections.
 Evidence of chronic pancreatitis (intraductal or parenchymal calcification)
and dilation of the pancreatic duct, may also be seen.
 Not a good imaging modality to ascertain severity of pancreatitis.
 Limited value due to presence of intestinal gas
 MAIN ECOGRAPHIC SIGNS

FREE FLUID IN THE LESSER SAC

LEFT SIDE RETROPERITONEAL PHLEGMON

FREE FLUID IN ABDOMINAL CAVITY

 Radiologic Diagnosis
 EUS
 Not helpful in acute pancreatitis.
 More sensitive than either abdominal US or CT to
detect common duct stones.
 May exclude a common duct stone in patients with
severe pancreatitis and jaundice (serum bilirubin > 5
mg/dL).
 ERCP, in this situation, may worsen pancreatitis
 Radiologic Diagnosis
 CECT:
 The most important imaging modality for the diagnosis of
acute pancreatitis and intra-abdominal complications.
 3 main indications:
 To exclude other serious intra-abdominal conditions:
mesenteric infarction or a perforated ulcer
 To stage the severity of acute pancreatitis
 To determine whether complications are present
 When to Take a CT
• When the diagnosis is in doubt
• Patients with persisting organ failure
• Signs of sepsis
• Deterioration in clinical status after
admission
• CRP > 110 mg/lt
• Ranson score > 3, APACHE II score > 8
 Radiologic Diagnosis
CT features in interstitial pancreatitis:

 Homogenous contrast
enhancement
 Diffuse or segmental
pancreatic enlargement
 Irregularity
 Heterogeneity
 Lobularity of the pancreas
 Obliteration of the
peripancreatic fat planes
 BALTHAZAR CT Grading

[A] Normal pancreas 0

[B] Edematous pancreatitis 1

[C] Any of the above + peripancreatic inflammation

+ < 30% pancreatic necrosis 2

[D] Any of the above + single extrapancreatic fluid collection

+ 30–50% pancreatic necrosis 3

[E] Any of the above+ extensive extrapancreatic fluid collection,

pancreatic abscess + > 50% pancreatic necrosis 4

CT severity index = CT grade + necrosis score

BALTHAZAR GRADING SYSTEM FOR ACUTE
PANCREATITIS
A – NORMAL PANCREAS (0 POINTS)

B – GLAND ENLARGEMENT, SMALL

INTRAPANCREATIC FLUID COLLECTION (1 POINT)

C – ANY OF THE ABOVE + PERIPANCREATIC

INFLAMMATION (2 POINTS)
 BALTHAZAR GRADING SYSTEM FOR ACUTE
PANCREATITIS

D – ANY OF THE ABOVE + SINGLE

EXTRAPANCREATIC FLUID COLLECTION (3 POINTS)

E – ANY OF THE ABOVE + EXTENSIVE

EXTRAPANCREATIC FLUID COLLECTION, PANCREATIC
ABSCESS (4 POINTS)
 Radiologic Diagnosis
 MRI
 Provides information regarding the severity of
pancreatitis similar to CT.
 As good as CT in detecting necrosis and fluid
collections
 Gadolinium, unlike intravenous contrast agents used for
CT, is safe to use in renal failure.
 Less accessible and more expensive than CT.
Predictors of Severity
 Atlanta Criteria for
Severe Acute Pancreatitis
 Ranson’s Criteria
At Admission
• Age in years >55years
• White blood cell count > 16000/mcL
• Blood glucose > 11 mmol/L (>200 mg/dL)
• Serum AST > 250 IU/L
• Serum LDH > 350 IU/L

After 48 Hours
• Haematocrit fall > 10%
• Increase in BUN by 1.8 or more mmol/L (5 or more mg/dL) after
IV fluid hydration
• Hypocalcemia (serum calcium < 2.0 mmol/L (<8.0 mg/dL))
• Hypoxemia (PO2 < 60 mmHg)
• Base deficit > 4Meq/L
• Estimated fluid sequestration > 6L

• If the score >=3, severe pancreatitis likely

• If the score < 3, severe pancreatitis is unlikely
 APACHE II Scores
 May be used daily
 Positive and negative predictive values similar to Ranson
score at 48 hrs after admission.
 Point assignment:

 12 physiologic variables
 Age
 Chronic health status
 Scores on admission and within 48 hours help distinguish
mild from severe pancreatitis and to predict death.
 1st 48 hrs: Scores <9 may survive, scores >13 usually die
 Apache II
A. Total Acute Physiology Score
• Temperature (°C)
• Mean arterial pressure (mmHg)
• Heart rate
• Respiratory rate
• Fi O2
• Serum HCO3-(mmol/L)
• Arterial pH
• Serum sodium (mmol/L)
• Serum potassium (mmol/L)
• Serum creatinine
• Hematocrit (%)
• WBC (x103/ mm3 )
B. Age Points
C. Chronic Health Points
Score of 8 or more indicates severe acute pancreatitis
Acute Pancreatitis

Early Indicators of Severity

• Tachycardia, hypotension

• Tachypnea, hypoxemia

• Hemoconcentration

• Oliguria

• Encephalopathy
Acute Pancreatitis

Hematocrit and Severity

Criteria Incidence of Necrosis

Admission hematocrit >44% 50%

OR fails to fall over
first 24 hours

Neither present 4%

Brown J, et al., Pancreas 2000; 20:367

 CT Findings and Mortality

20

15

%
Mortality 10

0
0 to 3 4 to 6 7 to 10
Total points
Adapted from Balthazar, EJ Radiology 2002; 223:603
 COMPLEXE CONSERVATIVE THERAPY

1. AGGRESSIVE INTENSIVE THERAPY IN ORDER TO CEASE

PANCREATIC SHOCK BY HEMODYNAMIC RECOVERY, FLUID
REPLACEMENT, CORRECTION OF ACID-BASE AND
ELECTROLYTE IMBALANCE, SUPPLEMENTAL OXYGEN TO
GUARANTEE OPTIMAL OXYGEN TRANSPORT

2. ELIMINATION OF ODDI SPASM AND MICROCIRCULATION

DISTURBANCES

3. BLOCKING OF PANCREATIC SECRETORY FUNCTION

4. EXTRACORPORAL DETOXICATION

5. SEPTIC COMPLICATIONS PROPHYLAXIS AND TREATMENT

 Treatment
Patient Management
• Initially, on confirmation of diagnosis admit in
ICU
• General Management:
– Fluid and electrolyte management by CVP line.
• Hourly urine out put
• Monitoring BP, pulse rate, O2 saturation ,
blood gas analysis to determine ventilatory
support. Depending on cardiovascular
changes arterial catheters.
• Strict asepsis
• Nursing
 Treatment
Supportive care Other treatments
• Aggressive fluid and • Acid suppression
electrolyte replacement
• Antibiotics
• Monitoring • NG tube
Vital signs
• Nutritional support
Urine output
• Urgent ERCP
O2 saturation
Pain

• Analgesia, anti-emetics
 Naso-gastric Suction

Use for:
• Persistent vomiting
• Obstruction

Does not alter

disease course
 Fluid Resuscitation
 Maintaining adequate intravascular volume in severe
disease may require 5-10 liters of fluid daily for the 1st
few days.
 Experimentally: hemodilution to a hematocrit value of
30% with dextran 60 solution improved pancreatic
microcirculation and oxygenation
 If hematocrit decreases to 25%, packed red blood cells
should be infused, maintain hematocrit close to 30%.
 Nutrition
• Mild acute pancreatitis
– Allow oral fluids from day 1 until
appetite returns
• Severe acute pancreatitis
– Begin fluids as early as 72 hrs
 Factors Supporting Early Enteral
Nutrition
• Mucosal integrity is important in ASP
– Glutamine, arginine, ω-3 fatty acids,
nucleotides have important role in
critically ill pts in maintenance of
mucosal integrity and immune status

• Early parenteral nutrition harmful

 Nutritional Support
Route of Alimentation

TPN Enteral
Cost – high Cost – moderate
No pancreas stimulation May stimulate pancreas
Increased infections Reduced infections
Electrolyte disturbances Electrolytes undisturbed
Detrimental to gut May retain gut integrity
integrity
Acute Pancreatitis
Nutritional Support and Infection
Favors Favors
Study enteral TPN
Abou-Assi
Gupta
Kalfarentzo
McClave
Olah
Windsor

Total (95% CI)

0.01 0.1 1 10 100
Infections
Marik PE, Zaloka GP. BMJ 2004; 328:1407
 Enteral Feeding Sites

Nasogastric

Jejunal
 Enteral Nutrition: Infusion Site

Gastric Jejunal
• Easy placement • Difficult placement

• Stable positioning • Frequent dislodgement

• Pancreatic stimulation • Pancreatic stimulation

probable unlikely

• Maybe tolerated in • Tolerated in severe

severe acute acute pancreatitis
pancreatitis
Outcomes may be similar
Eatok FC et al. AJG 2005; 432
 Antibiotics
 Randomized trials: benefit for early initiation of broad-
spectrum antibiotics- may prevent pancreatic infection
 Antibiotics with good pancreatic tissue penetration:
 Imipenem (500 mg IV every 8 hours)
 Cefuroxime (1.5 g IV every 8 hours)
 Ciprofloxacin (400 mg IV every 12 hours)
 Potential drawbacks:
 Development of resistant organisms
 Fungal infections
 Antibiotics
 Have been shown to decrease infection rates, but have
not consistently demonstrated a mortality benefit.
 ACG guidelines: "in patients with necrotizing
pancreatitis associated with organ failure, it is
reasonable to initiate treatment with antibiotics with
good spectrum of activity against aerobic and anaerobic
bacteria."
 Antibiotics
• Prophylactic antibiotics have shown no decrease in
mortality in severe acute pancreatitis.

Conditions where antibiotics are justified are:

1. Gas in retroperitoneal space
2. Needle aspiration of necrotic material confirms infection
3. Presence of necrosis – 15 -> 50%
4. CRP of > 120 mg/L
5. Peripancreatic fluid collection
6. APACHE II score of > 6
7. Organ dysfunction
 Endoscopy
 Urgent Removal of Gallstones in Gallstone
Pancreatitis:
 Consensus that severe acute gallstone pancreatitis
with ascending cholangitis (jaundice and fever) is an
indication for urgent ERCP.
 In patients with acute biliary pancreatitis but without
obstructive jaundice, early ERCP and papillotomy were
not beneficial
 Endoscopy
No
Biliary origin? No ERCP
Yes
Yes
Jaundice sepsis? Urgent ERCP
No
Yes
Suspicion of retained stone? Elective ERCP

No

No ERCP
 GALLSTONE PANCREATITIS
Timing of Cholecystectomy

• In mild pancreatitis, it is advisable to

undertake laparoscopic cholecystectomy
with intraoperative cholangiogram within
10 days.
• In severe cases, endoscopic
cholangiopancreatography + endoscopic
sphincterotomy(<48h) followed by LC once
the inflammatory process is resolved.
Surgery for Acute
Pancreatitis
 Role of Surgery
• Surgery has no immediate role in patients
with mild acute pancreatitis.
• The development of infected pancreatic
necrosis is an indication for intervention,
with surgery or an alternative technique
• Early surgery (within the first 14 days)
should be avoided because it is
associated with increased mortality.
Pancreatic Necrosis

Treatment Strategies
Infected
Sterile

• Antibiotics
• Medical therapy
• Debridement
• Debridement for
persistent organ
failure?
necrosis
 Management of necrosis
• Sterile necrosis does not usually require therapy.
• The development of infected necrosis should be
suspected in those patients with preexisting sterile
pancreatic necrosis who have persistent or worsening
symptoms or symptoms and signs of infection, typically
after 7–10 days of illness.
• The finding of gas within the pancreas in CECT is highly
suggestive, although not diagnostic, of infected necrosis
• Fine-needle aspiration guided by CT imaging should be
performed and the sample should be cultured and Gram
stained to document infection
 Management of necrosis
• The standard approach to infected necrosis has been
open surgical debridement.
• Increasing trend to delay surgery as long as possible,
even in the face of a positive result on FNA, if the clinical
situation allows.
• This delay has the advantage of allowing necrotic
material to demarcate and begin to liquefy, making
complete initial necrosectomy more likely, and reducing
the need for repeated debridement.
• The delay-until liquefaction strategy also allows
nonsurgical therapies
 Indication for Surgical Management of
Necrotizing Pancreatitis and Pancreatic Abscess

Clinical Criteria
• Persistant sepsis
• No response to intensive care treatment (> 3 days),
• Persisting or increasing local or systemic
complications
Surgery in necrotising pancreatitis
• Debridement with closure over drains
• Debridement with open packing
• Debridement with closure over irrigation drains and
postoperative lavage.(Beger surgery)
• Minimally invasive surgery
 Timing of Surgery
• Delaying surgery till the second to third
week from the onset of disease is ideal
• Early intervention is unavoidable
– In the presence of uncertain diagnosis.
– Complications like hemorrhage associated
with pancreatic necrosis
 Acute Necrotising Pancreatitis
ICU Care

CECT
Focal necrosis Extended necrosis

Antibiotics

Response Sepsis No response

FNAC
Infected necrosis
Nonsurgical Surgery Surgery
SURGICAL TREATMENT
SURGICAL TREATMENT
 SURGICAL TREATMENT

VIEW OF LESSER SAC THROUGH BURSOOMENTOSTOMY IN NECROTIZED PANCREATITIS

(FIRST DEBRIDMENT)
 400-600 µm

Open-package of the lesser sac using

vacuum sealing technique

KCI Medical
Ltd

Dressing in situ
VIEW OF LESSER SAC THROUGH BURSOOMENTOSTOMY IN NECROTIZED PANCREATITIS
(SECOND DEBRIDMENT)
The original V.A.C. system in situ
VIEW OF LESSER SAC THROUGH BURSOOMENTOSTOMY IN NECROTIZED PANCREATITIS
(BEFORE CLOSURE)
 Fluid Collections in Acute Pancreatitis

• Acute collections

• Necrosis

• Pseudocysts

• Abscesses
• Acute Fluid Collections
– Develops in 30-50% of patients with
severe pancreatitis
– Usually peripancreatic or
intrapancreatic
– Unlike psuedocyst lacks a wall
– Either regresses or evolves into
psuedocyst
Acute Fluid Collections

• Common
fluid
• May be complex
pancreas
• Usually resolve
spontaneously
• Drain if infected or
symptomatic
 Pancreatic fluid collections and
pseudocyst

• Acute fluid collections around the pancreas in the setting

of acute pancreatitis require no therapy in the absence of
infection or obstruction of a surrounding hollow viscus
• Approximately half of these fluid collections will resolve
within 6 weeks, and up to 15% will persist as
encapsulated pseudocysts
• Pseudocysts can be managed conservatively,
particularly if they are small (6 cm) and asymptomatic
• Psuedocyst of Pancreas
• Features
– Cyst wall lacks epithelial lining. It is
predominantly formed by granulation tissue
and fibrosis.
– Most psuedocysts communicate with ductal
system.
– Persistently raised S.amylase levels
– Most cases regress by themselves
Pseudocysts
• Localized
collections

• > 4 weeks after

disease onset

• Ductal disruption or
previous necrosis

• Not lined by
epithelium
PANCREATIC PSEUDOCYST ON CT-SCAN
 Pseudocysts
• Pseudocysts may produce symptoms (generally
abdominal pain), obstruct surrounding organs
(duodenum, stomach, or bile duct), become infected,
rupture, or bleed
• Surgical, radiologic, and endoscopic options are
available for the management of large or symptomatic or
complicated pseudocysts.
• The choice of approach depends on location, size,
pancreatic ductal anatomy, and, most importantly, local
expertise
 Intervention in Pseudocyst
• Symptomatic
• Enlarging
• Size > 6 cm
• Duration more than 6 weeks
• Infected pseudocysts
• Complications due to pressure
symptoms
GOO/obstructive jaundice
• Haemosuccus pancreaticus
Pseudocyst Management
Pseudocyst
Symptomatic
Asymptomatic Rapidly enlarging
Complication
Follow

Persists
6 - 12 months Drain

Drain * Observe

*Large cysts can be safely followed, but are more likely to require
drainage
 Pseudocyst Treatment

• Aspiration

• Internal drainage

• External drainage

• Trans-papillary
drainage
 Pseudocyst Treatment
• Percutaneous drainage - for poor risk
patients only
• Open procedures
– Distal pancreatectomy
– Cystogastrostomy
– Cystoduodenostomy
– Roux – en – y cystojejunostomy
– Whipple procedure
• Endoscopic procedures – stenting
• Laparoscopic procedures
 DRAINAGE PROCEDURES IN PSEUDOCYSTS

2 1 4

1. CYSTOGASTROSTOMY
2. CYSTODUODENOSTOMY
3. CYSTOJEJUNOSTOMY
4. EXTERNAL DRAINAGE
 Pseudocyst Drainage
Pros Cons
Aspiration Easily performed; Often recur; risk fistula
minimally invasive

Endoscopic Easily performed; Technical expertise;

Internal moderately effective location of cyst

Surgical Internal Most effective Requires surgery

External stents Easily performed; drain Risk of fistulae

multiple cysts

Trans-papillary Moderately effective Limited to lesions in

pancreatic head
 Summary
• S. lipase is more useful than amylase in
diagnosing acute pancreatitis
• Prognosticate the patient
• Single and multiple prognostic factors can be
used
• Identify acute mild and severe pancreatitis
• Timely resuscitation and invasive monitoring
are standard
• No role for nasogastric tube
 Summary
• Early enteral feeding
• Immune enhancing feeds has a role
• Prophylactic antibiotics for selected cases
• Early ERCP in severe biliary pancreatitis
• Surgery in selected cases of necrotising
pancreatitis
• Delayed surgery is ideal unless indicated for
early surgery
 Summary
• For patients needing debridement, open
surgical techniques remain the "gold
standard" of management
• Debridement with open packing and lavage
in early cases
• Debridement with closed drainage in elective
cases
• Advances in minimally invasive technology
hold promise as adjuncts to open
procedures in the future