Pancreatitis Mohammad Jundy

Anatomy of pancreas: Acute Pancreatitis:

- Retroperitoneal organ in epigastrium & LUQ (at transpyloric line L1) Definition:
- Lies bt duodenal curvature & splenic hilum. - Auto-digestion of pancreas by its own regurgitated enzymes in active form.
- Parts: head, neck, body, tail, uncinate process. - An Inflammatory process not infectious. (NO MOs)
- uncinate process: extension of head, located - Auto-digestion (autolysis), The worst enemy for pancreas is the pancreas.
posterior to superior mesenteric vessels Epidemiology:
- Main pancreatic duct joins CBD & open in 2nd part of duodenum - 3% of abd. pain in UK, can occur at any age.
➔ Ampulla of vater (major duodenal papilla) (Sphincter of Oddi) - high mortality rate, 10-15%.
- Glandular organ: both Exocrine (digestive) & endocrine systems
➔ Endocrine: islets of Langerhans. Etiology: (I GET SMASHED)
▪ Alpha cells (glucagon), Beta (insulin), Delta (somatostatin) - Idiopathic (3rd MC).
➔ Exocrine: Acinar cells. - Gall stones:
▪ pancreatic juice contains digestive proenzymes. ➔ MC cause worldwide & MC in Jordan. (50%)
➔ Stone in the ampulla of vater: (distal to major pancreatic duct)
▪ obstruct pancreatic secretion >> reflux (regurge) of
pancreatic proenzymes & activation >> acute pancreatitis
➔ Called biliary pancreatitis = jaundice + cholangitis
- Ethanol (Alcohol):
➔ 2nd MC cause worldwide & MC cause in USA.
➔ Etiology: Direct cellular damage, stimulate pancreas secretions,
constrict sphincter of oddi, abnormal blood flow.
- Trauma: MC cause in children

Physiology: ➔ Blunt abd. trauma (RTA), MC cause in children.

- Mumps virus:
➔ In children, ass. with parotitis & orchitis.
➔ examine parotid gland in kids with severe abd. pain.
- Autoimmune (SLE & RA)
- Scorpion sting.
- Steroids.
- Hypercalcemia / Hyperparathyroidism:
➔ Cause calcification of pancreas.
➔ Destruction & release of lipase enzyme
➔ saponification process:
▪ Lipase breakdown fatty acids >> fat bind with calcium.
▪ Cause hypocalcemia (as a complication)
Note: ▪ Give Ca supplement.
- amylase & lipase are secreted in active form ➔ Hypoca complications: cardiac arrest (esp. when ca < 8 mg/dl)
 Pancreatitis Mohammad Jundy
- Hypertriglyceridemia: (HyperTAG) - Infective pancreatitis:
➔ Fatty acid accumulation at pancreas >> inflammation & ➔ super added infection + abscess formation.
damage. (TAG > 1000) ➔ Need antibiotics
➔ Atherosclerosis >> pancreas ischemia >> Pancreatitis - Pathology Notes:
➔ Pancreatitis >> pancreas destruction >> ↓ enzymes. ➔ Inflammation & fluid shift into interstitial space (3rd space).
➔ ↓ lipase >> ↑ fat & TAG lvl >> ↑ Hypertriglyceridemia ➔ Third-space fluid loss. (e.g. Peritoneal cavity: ascites)
➔ severe fluid loss + bleeding >> Hypovolemic Shock
➔ Shock >> ↓ end-organ perfusion >> multiorgan damage.
- ERCP.
- Drugs: (SD-AA) 20% Rule of acute pancreatitis:
➔ Steroids. - 20% of cases present with severe abdominal Pain.
➔ Diuretics: Thiazide, furosemide (Lasix). - 20% of them will progress to necrotizing pancreatitis.
➔ Azathioprine, Anticonvulsants (valproic acid) - 20% of those with necrotizing pancreatitis develop infected pancreatitis
- Ischemia: (hypotension, embolism) pancreas:
- Hereditary conditions: Clinical presentation: foregut origin
epigastric pain
➔ Hereditary pancreatitis: PRSS1 gene mutation. - Epigastric Pain: -
➔ Cystic fibrosis ➔ Sudden severe constant pain.
➔ acute pancreatititis at teens > chronic pancreatitis & CA. ➔ Relieved on leaning forwards (↓ stretch) Sudden severe
epigastric pain
➔ Pancreatic divism: ➔ Worse when supine & after meals Relieved by
▪ Congenital malformation where most of
➔ Radiation: back (retroperitoneal)
secretions go into minor duct (high load)
➔ Increase in severity every hour (Crescendo fashion)
- Pancreatic tumor (at head).
➔ Timing: reach max. intensity in minutes, may persist for days.

Subtypes of pancreatitis (pathology): - Nausea, Vomiting, Retching.

- Edematous (interstitial) pancreatitis: - Anorexia
➔ Most common subtype, 85-90%.
- Low grade fever (if high suspect infective)
➔ Inflammation + edema
➔ complete remission (acinar cell don’t die)
- Physical exam:
- Hemorrhagic pancreatitis: General:
➔ distress, hunched back + jaundice (gallstones)
➔ Erosion of blood vessels by elastase >> hemorrhage.
➔ Vitals: hypovolemic shock (tachycardia, hypotension), shallow breathing
➔ Ecchymosis signs:
Abdominal exam:
▪ Cullen sign (around umbilicus)
➔ Inspection:
▪ Grey Turner sign (at flank)
▪ Abdominal distention (ileus or ascites)
▪ Fox sign (over inguinal ligament)
▪ Retroperitoneal hemorrhage signs (Cullen’s, gray turner)
▪ Not specific signs (in any retroperitoneal bleeding)
➔ Palpation: tenderness, guarding. (may be soft)
- Necrotizing pancreatitis: (10%-15%)
➔ Auscultation: ↓ bowel sounds (ileus)
➔ Necrosis = death of acinar cells. (scary)
➔ Excessive autolysis (enzymes) &/or ischemia.
 Pancreatitis Mohammad Jundy
Pancreatitis diagnostic criteria: Imaging:
- Need at least two (≥ 2) out of three: - Abdominal x-ray:
1) Epigastric pain ➔ Radiopaque gallstone, localized ileus.
2) Elevated amylase or lipase > 3x upper limit of normal ➔ Sentinel loop (distended loop + air fluid lvl) 2nd to ileus.
3) Abnormal pancreatic imaging (CT scan) ➔ Colon cut off sign. (gas cutoff at splenic flexure)
- If the first two are found: No need for CT scan. - Ultrasound:
➔ Enlarged (edematous) hypoechoic pancreas.
Investigations: ➔ Not very helpful, bowel gas obscure image.
Labs: ➔ Gallstones & Gallbladder (biliary cause?)
- CBC: - CT scan:
➔ Leukocytosis: ➔ Enlarged (edematous) pancreas, fat stranding,
▪ 15-20 k: Edematous peri-pancreatic fluid, necrosis (↓ enhancement)
▪ > 20K: Infective (↑ WBC: ↑ infective likelihood) ➔ Done for: uncertain diagnosis, necrosis, severe cases, pseudocyst.
➔ Hemoglobin: - MRI:
▪ ↑ (mainly): dehydration/mild bleeding (hemoconcentration)
➔ sensitive for necrosis, but rarely used.
▪ ↓: severe bleeding (hemorrhagic pancreatitis)
DDX (differential diagnosis):
- Serum amylase:
- Perforated peptic ulcer (serious, rule it out)
➔ Low sensitivity but high specificity.
- Inferior MI (serious, rule it out by ECG if suspected)
➔ Released after 6-12 hours. (early cases <6 hr = negative).
- Lower lobe pneumonia (R.t lobe)
➔ No relationship between level & severity. (High lvls ≠ severe)
- Acute Cholecystitis.
➔ Peak: 24-72 hours
- Acute pyelonephritis
➔ fall back down after 72 hours (3 days) - Renal stone (nephrolithiasis)
➔ Hyperlipidemia cases: amylase may not be elevated - Acute intestinal obstruction
- Urinary amylase: - Cholangitis (have jaundice, Charcot triad)
➔ More sensitive. (stay for longer periods) - Others: acute gastritis / esophageal rupture.
- Serum lipase:
➔ very sensitive test. (more sensitive than amylase) Treatment: ("R-Regimen") (conservative)
➔ Not done routinely because it's expensive. Rest the pain ▪ Opioids: pethidine (MC)
- Lipase & amylase need a significant increase > 3x upper limit (Relieve pain) ▪ Morphin S/E: spasm of sphincter of oddi
Rest the pancreas ▪ NPO, IV fluids, electrolytes replacement
- KFT: Acute kidney injury (↑ creatinine): hypovolemia. Rest the bowel ▪ NPO, NG tube.
- LFT: abnormal in biliary cases. Resist enzymatic activity ▪ protease inhibitors, glucagon
Resist infection? ▪ Antibiotics: (answer & why) (both correct)
- Electrolytes: Hypokalemic metabolic alkalosis. (vomiting)
➢ Yes: to prevent infection & septic shock (high mortality)
- Peritoneal fluid analysis (tap): (in ascites) ➢ NO: inflammatory process rather than infectious
➔ If amylase > 100,000/cm3 = pancreatitis Repeated examination ▪ Every 2 hours.
➔ Pancreatitis: exudative ascites Respiratory support
 Pancreatitis Mohammad Jundy
Pancreatic necrosis Tt: - Pseudocyst Clinical features:
- C/P: Toxic, so tired pt. (hypoxic, septic, tachycardia…) ➔ Asymptomatic.
- Need investigation: CT scan. ➔ abdominal mass
- Need surgical Tt. (A catastrophe for surgery) Laparostomy: ➔ Pressure effect (according to location):
- Surgical steps: - leave abd. open ▪ Gastric outlet obstruction: early satiety, recurrent vomiting.
➔ Laparostomy & aspiration of fluid. ▪ Biliary ducts: Jaundice.
➔ peritoneal lavage by normal saline & exploration - Investigations:
➔ Raise stomach to observe black pancreas. (Black = necrosis)
➔ CT abdomen with contrast.
➔ Surgical peeling: by knife until blood appear (blood=living tissue)
➔ Gauze method: roll a ball of gauze inside abd. & leave it open. ➔ Cause persistent hyperamylasemia.
➔ ICU admission with open abdomen. - Tt:
➔ After 48 hours: remove gauze, again black pancreas >> repeat peeling ➔ Conservative (small, Asymptomatic)
➔ Repeat surgery 4-5 time every 48 hours (save 60% of pts) ➔ Drainage (endoscopic (MC), surgical): Sx or large cyst.

Complications: Mortality and prognosis:

Early complications: - Ranson's criteria (used in KAUH)
- Pancreatitis subtypes: Hemorrhage, necrosis, infection. - Glasgow Pancreatic Scale (Emrie Scale)
- MOF (multi-organ failure).
Ranson’s Criteria: (Mortality rate & ICU care)
- Paralytic ileus (nerve irritation)
At admission (GA-LAW) 48 hours after admission (C – HOBBS)
- Localized fluid collection. Glucose > 200 mg/dl (No insulin) Ca2+ < 8 mg/dl %
- Hyperlipidemia, hypocalcemia. Age > 55 Hematocrit fall > 10%
- Hypo or hyperglycemia. LDH > 350 IU/L PO2 < 60 mmHg
- Dehydration, Electrolyte Imbalance, Acid-Base Imbalance AST(SGOT) > 250 U/dl Base deficit > 4 meq (HCO3- decrease)
- Ascites. WBC > 16,000/cu.mm BUN rise > 5 mg/dl
- Shock: hypovolemic (mainly) or septic. 5 points Fluid sequestration > 6L
- Portal or splenic vein thrombosis. 6 points
- Ranson results interpretation:
Late complications: (CAP) ➔ 2 or less: (no mortality)
- Chronic Pancreatitis. (DM) ▪ mild pancreatitis, conservative Tt.
- Abscess formation ➔ > 2:
- Pseudocyst. ▪ Severe pancreatitis
▪ ICU admission & consider emergent ERCP In Gallstones.
Pseudocyst: ▪ 3-4 points: 15% mortality
- Pseudo: lined by Fibrous (granulation) tissue (not epithelium) ▪ 5-6 points: 50% mortality
- Cyst filled with Amylase rich fluid. (pancreatic secretions) ▪ ≥ 7 points: 100% mortality inevitably die
- Formation requires 4 weeks or more. (Late)
- MC: single cyst at lesser sac (bt stomach & pancreas) Severity: (Atlanta scale)
 Pancreatitis Mohammad Jundy
Atlanta scale (severity): - CT scan will be abnormal in most pts including mild acute pancreatitis.
- Mild acute pancreatitis: - Pseudocyst inner walls of the lesion is lined by:
➔ NO Organ failure & no local or systemic complications. ➔ Fibrous (granulation) tissue
- Moderate acute pancreatitis: - MC C/P & indication of surgery for chronic pancreatitis:
➔ Transient MOF (< 48 hours) &/or local or systemic ➔ Epigastric pain.
complications. - Elevated amylase:
- Severe acute pancreatitis: ➔ In acute abdomen cases or salivary gland disorders
➔ Persistent organ failure (> 48 hours) - late complications of acute pancreatitis
➔ Chronic pancreatitis (DM), Abscess, Pseudocyst.
Chronic pancreatitis: - Pancreatitis complication:
- long-standing inflammation & fibrosis of the pancreas. ➔ Hypocalcemia: perioral numbness, trousseau & Chvostek sign.
- destruction of exocrine pancreas (1st) & endocrine (late)
- Hallmark: irreversible impairment in pancreatic function.
Etiology:
- Alcohol (Most common)
- recurrent acute pancreatitis.
- Autoimmune, Hereditary, Systemic diz (cystic fibrosis, hyperTAG)
Clinical features: (PS-MD)
- Epigastric pain (MC):
➔ Not severe, initially episodic then persistent
➔ may be painless.
- Steatorrhea (fat diarrhea).
- Malabsorption (AKED vitamins) & weight loss. Pancreatic
insufficiency
- Pancreatic DM (loss of insulin).
Investigations:
- CT scan: Pancreatic atrophy & calcifications -
Treatment:
- Medical: NSAIDS (analgesia), pancreatic enzymes Replacement Oral questions:
- Surgical: destroy sensory nerves, partial/complete resection. - Amount of IV fluid given in pancreatitis: 5-10 ml/kg/hr.
- Why does the pain radiate to back: retroperitoneal organ.
Notes:
- Special test: ECG (rule out MI if suspected)
- MC cause of acute pancreatitis in childhood: trauma. Done by Mohammad jundy.
- Dehydration steps: (oral)
A) decreased oral intake B) loss of appetite ‫هي_قضية_الشرفاء‬
C) vomiting D) hemorrhage E) 3rd space loss