ACUTE PANCREATITIS Dr Pravin Suryawanshi Deputy Dean Chief

ACUTE PANCREATITIS Dr. Pravin Suryawanshi Deputy Dean Chief Endoscopic , Advanced Laparoscopic Hepato Panceatico Biliary and Liver Transplant Surgeon MGM Medical College and Hospital, Aurangabad Executive Member Association of Minimal Access Surgeons of India President, Marathwada Hospital Association Governing Council Member Association of Surgeons of India Past President Maharashtra state chapter of Association of Surgeons of India MGM’s Medical College & Hospital, Aurangabad

ACUTE PANCREATITIS • Pancreatitis is the inflamation of glandular parenchyma lead to injury or destruction of acinar components. The pathologic process could result in a self limited disease with no sequelae or process could result in catastrophic autodigestion activity with systemic cytotoxic effects and life threatening complicationsin the acute form. MGM’s Medical College & Hospital, Aurangabad

ETIOLOGY • In 75 % of cases - Biliary - alcohol MGM’s Medical College & Hospital, Aurangabad

1. After biliary or gastric surgery - especially after Billroth II partial gastrectomy if the pancreatic duct is injured or if the afferent duodenal loop is obstructed, producing a high duodenal pressure. 2. After trauma, such as a blow to the pancreas. 3. Where there is distortion of the ampulla of vater as a result of peptic ulcer or ampullary carcinoma. 4. As a result of generalized disorders, such as hypercalcaemia, hyperlipaemia, diabetes mellitus and porphyria. 5. In reaction to some drugs, e. g. corticosteroids. 6. Viral infection of the pancreas, e. g. mumps virus. 7. After cardiopulmonary bypass and following hypothermia. MGM’s Medical College & Hospital, Aurangabad

TYPES OF PANCREATITIS 1) Acute pancreatitis : arises in a previously asymptomatic patient and subsides to normalcy after treatment. 2) Acute relapsing pancreatitis is a series of recurrent episodes of acute pancreatitis in an otherwise asymptomatic patient. A quiescent, asymptomatic phase always precedes and follows each attack. 3) Chronic relapsing pancreatitis shows unrelenting symptoms that are due to inflammation of the pancrease with chemical evidence of pancreatitis, which fluctuates in its intensity and does not return to normal. 4) Chronic pancreatitis shows unrelenting symptoms that are due to inflammation and fibrosis of the pancrease; the pancreatic duct and parenchyma usually show calcification. Chronic pancreatitis is often associated with malabsorption and even with pancreatic endocrine insufficiency. MGM’s Medical College & Hospital, Aurangabad

CLINICAL FEATURES : Mild - Mild epigastric pain, discomfort - Nausea vomiting - Mild tenderness MGM’s Medical College & Hospital, Aurangabad

Moderate : - Severe epigastric pain - Vomiting - On examination severe epigastric tenderness with guarding or rigidity MGM’s Medical College & Hospital, Aurangabad

Severe : - Sever epigastric pain - Vomiting - On examination sever epigastric tenderness - Severe rigidity - Abdominal distension - Free fluid - Hypotension shock Grey- Turner's Sign Cullen's sign MGM’s Medical College & Hospital, Aurangabad

Grey turner’s sign Cullen’s sign MGM’s Medical College & Hospital, Aurangabad

COMPLICATIONS • • • Severe hemorrhage Pancreatic Abscess Renal Failure A. R. D. S Ileus Shock Pancreatic psuedocyst Colonic Fistula Psuedoanurysm MGM’s Medical College & Hospital, Aurangabad

DIAGNOSIS : Serum amylase - in 95% of - within 2 hrs. Last for 48 hours then start following down - >1000 s unit indicates biliary pancreatitis - 200 -500 seen in acute on chronic pancreatitis - Other sites - Salivary Amylase Creatinine clearance ratio : > 5 is strongly suggestive of pancreastitis. MGM’s Medical College & Hospital, Aurangabad

X- Ray Abdomen i) Calcification in the area of pancreas ii) Gas in lesser sac iii) Blurred psoas shadows iv) Cutoff sign transverse solon v) Focal ileus MGM’s Medical College & Hospital, Aurangabad

Ultrasound : - Enlarged pancreas - Loss of fat plain - Collection of fluid in peri – pancreatic tissue - Pancreatic Ascites - Gall bladder pathology MGM’s Medical College & Hospital, Aurangabad

C. T. Scan MGM’s Medical College & Hospital, Aurangabad

INVESTIGATIONS • E. R. C. P • M. R. C. P • Se triglycerides • Se Calcium MGM’s Medical College & Hospital, Aurangabad

Prognosis : Ranson's Criteria : Prognosis in acute pancreatitis is aided by certain signs, which are associated with higher mortality rate and are, therefore, useful prognostic indicators. MGM’s Medical College & Hospital, Aurangabad

a. Sings at admission 1) Age over 55 years 2) White blood cell count over 16, 000/mm 3 3) Fasting blood sugar level over 200 mg/dl 4) Lactic dehydrogenase (LDH) over 350 units/ml 5) S. G. O. T > 250 MGM’s Medical College & Hospital, Aurangabad

b. Sings 48 hours after admission 1) A 10% drop in hematocrit 2) An increase of 5 mg/dl in blood urea nitrogen (BUN) 3) Se Calcium < 8 mg % 4) Arterial oxygen partial pressure (Pa. O 2) below 60 mm Hg 5) Anion base deficit greater than 4 m. Eq/L 6) Third - space fluid loss greater than 6 L MGM’s Medical College & Hospital, Aurangabad

c. Determining prognosis : If 0 -2 of the above signs are present, the mortality rate is 0. 9%, if 7 -8 signs are present, it is 100% 1) The poor prognostic signs at 48 hours are generally related to the severe local affects of pancreatitis, which result in massive third- space fluid loss and hemorrage. 2) Systematic effects, such as shock and hypoxia, may also be a consequence of circulating toxins released by the pancreas. MGM’s Medical College & Hospital, Aurangabad

Treatment : i) Medical - Nasogastric suction - Intravenous fluid - Intravenous Antibiotics - Ciprofloxcacin - Imipanum - I. V. Somatostatin ? MGM’s Medical College & Hospital, Aurangabad

SURGERY • IN ALL COMPLICATED CASES MGM’s Medical College & Hospital, Aurangabad

ACUTE PANCREATITIS MGM’s Medical College & Hospital, Aurangabad