PANCREATITIS

By Dr, Alok Verma

ANATOMY OF PANCREAS

Cont..

FUNCTION OF PANCREAS

ENDOCINE

EXOCRINE

PANCREATITIS

Inflammation of pancreatic parenchyma.

On the basis of presentation this may be

ACUTE

CHRONIC

ACUTE PANCREATITIS INCIDENCE 3% of all cases of abdominal pain

among patient admitted in hospital in UK.

The hospital admission rate for acute pancreatitis is 9.8 per year per 1000,000 population in UK.

Worldwide incidence ranges from 5 -50 per 100,000 population.

Peak in young men and older women.

Aetiology

Abuse of ethanol Biliary tract stones Drugs Endoscopic retrograde cholangiopancreatography Hypercalcemia Hyperlipidemia Idiopathic Infections Ischemia Parasites Postoperative Scorpion sting Trauma

Gallstone pancreatitis

CLINCAL PRESENTATION

PAIN * Develops quickly , reaching maximum

limit within minuts rather than hrs. * Appear first in epigastrium , later may be

localized to epigastrium or may be diffuse throughout abdomen.

*Radiation to back in 50% * Relief by sitting or leaning forwards.

Pain relived by leaning forward

Nausea

Repeated Vomitting

Retching

Hiccough

On Examination

Pt. gravely ill with profound shock, toxicity , confusion.

Tachypnea Tachychardia Tem. May be normal or subnormal May be hypotention Mild icterus in case of gallstone pancreatitis Cullen sign positive Grey turner’s sign positive

Grey turner sign

Cullen sign

Abdominal ex. May reveal

Distention

A mass in epigastrium

Rarely ascitis with sifting dullness.

INVESTIGATION

Are done to

To Confirm diagnosis. To Asses severity of attack. To know correct etiology.

Cont….

Routine blood examination

Amylase measurement

Other blood examination( lipase,interleukin [IL]-1, IL-6, tumour necrosis factor-a, and C-reactive protein

Cont….

Imaging Plane chest, abdominal X-Ray Ultrasound does not establish diagnosis

but shoud be done within 24 hr. to make proper D/D

CT MRI MRCP ERCP

सङृ्गह्य पार्श्वोदरपृष्ठनाभीर्य�द्वर्ध�ते कृष्णसिसरावनद्धम् ||8

सशूलमानाहवदुग्रशब्दं सतोदभेदं पवनात्मकं तत् |९| र्यच्चोषतृष्णाज्वरदाहर्युकं्त पीतं सिसरा भान्ति0त च र्यत्र पीताः||९||

पीताक्षि5विवण्मूत्रनखाननस्र्य विपत्तोदरं तत्त्वसिचराक्षिभवदृ्धिद्ध|१०|

Pathophysiology of pancreatitis

Obstruction of the pancreatic duct Injury begins within pancreatic acinar cells Intra-acinar cell activation of digestive

enzyme zymogens, including trypsinogen. Pancreatic necrosis evolving into pancreatic

fibrosis.

ASSESMENT OF SEVERITY

1. APACHE II SCORING SYSTEM

2. RANSONS SCORE

3. GLASGOW SCORE

APACHE II SCORING SYSTEM Used in ICU

score >8 indicate vey ill patient

RANSONS SCORE ON ADMISSION Age >55 yr. WBC count >16x109 B. glucose > 10 mmol / L LDH >700 AST>250 sigma frankel unit % WITHIN 48 HRS.B. Urea nitrogen >5 mg %PaO2 < 8 kPaS.Calcium <2.0 mmol/LBase deficit >4 mmol/LFliud sequestration >6 litr.

Patient is severely ill if score is 3 or more than 3

GLASSGOW SCALE

ON ADMISSION Age >55 yr. WBC count >15x109 B. glucose > 10 mmol / L ( no H/O DM) S. urea > 16 mmol/L ( no reponse to IV fluid) PaO2 < 8 kPa

WITHIN 48 HRS.S. Calcium <2.0 mmol/LS. Albumin < 32 g/LLDH >6 00 unitAST/ALT >600 unitPatient is severely ill if score is 3 or more than 3

MANAGMENT

NILL BY MOUTH ADMISSION IN ICU IV FLIUD ADMINISTRATION CLOSE MONITORING POTENT ANALGESIA WITH

ANTIEMETICS CONFIRM DIAGNOSIS TREAT MENT OF UNDERLYING CAUSE

उदरसिचविकत्सित्सतम् तत्र वातोदरिरणं विवदारिरगन्धादिदसिसदे्धन सर्पिपFषास्नेहयिर्यत्वा, वितल्वकविवपक्वेनानुलोम्र्य,सिचत्राफलतैलप्रगाढेन विवदारिरगन्धादिदकषारे्यणास्थापरे्यदनुवासर्येच्च, साल्वणेन चोपनाहर्येददरं,भोजर्येच्चैनं विवदारिरगन्धादिदसिसदे्धन 5ीरेण जाङ्गलरसेन च, स्वेदर्येच्चाभीक्ष्णम् su.chi. 5

उदरसिचविकत्सित्सतम् विपत्तोदरिरणंतुमर्धुरगणविवपक्वेनसर्पिपFषास्नेहयिर्यत्वा,श्र्यामा

वित्रफलावित्रवृविद्वपक्वेनानुलोम्र्य,शक� रामर्धुघृतप्रगाढेन 0र्यग्रोर्धादिदकषार्येणास्थापरे्यदनुवासर्येच्च,पार्यसेनोपनाहर्ये

दुदरं, भोजर्येच्चैन विवदारिरगन्धादिदसिसदे्धनपर्यसा ||६||

COMPLICATIONS

Systemic Include Multiorgan Failure

Multidisplinary team of ICU is required to manage this condition

LOCAL COMPLICATIONS

Acute fluid collection Sterile and infected pancreatic

necrosis Pancreatic abscess Pancreatic Ascites Pancreatic Effusion Heamorrhage Portaal or splenic vein thromosis Peudocyst

CHRONIC PANCREATITIS

Chronic inflammatory disease of pancrease leading irreversible progressive destruction of pancreatic tissue.

Disease accure more frequently in men than women 4 :1 . Mean age after 40 yr.

AETIOLOGY

Alcohol consumption Pancreatic duct obstruction

secondary to strticture after trauma After acute episode of pancreatitis Congenital abnormalties Hereditary Autoimmune pancreatitis

CLINICAL PRESENTATION

र्यच्छीतलं शुक्लसिसरावनदं्ध गुरु त्सिस्थरं शुक्लनखाननस्र्य ||१०||

स्निस्नग्रं्ध महच्छोफर्युतं ससादं कफोदरं ततु्त सिचराक्षिभवृद्धिद्ध|११|

CLINICAL PRESENTATION

Pain is outstanding symptom Site- depends upon main focus of

disease. Head- Epigastrium, Rt.

Subcostal Body and Tail- Lt.

subcostal , back. Radiation – usually Lt. shoulder character – Dull and Gnawing

Contd…

Pain may accompanies with Nausea and vomiting.

Weight Loss

Steatorrhoea in more than 30% cases.

DM

INVESTIGATION

In early stage rise in serum amylase Test of pancreatic function merely

confirm when more than 70 % of gland is distroyed.

Abdominal X- Ray CT MRI ERCP MRCP

TREATMENT

Along with medical some endoscopic , radiological ,or surgical intervention are indicated mainly to relive obstruction of pancreatic duct, bile duct ,or duodenum , or in dealing with complication. ( pseudocyst, abscess , fistula , ascites or varicel hemorrhage)

SURGERY

If mass in Head- PANCREATODUODENECTOMY or BEGER PROCEDURE

If duct is markedly dilated- LONGITUDINAL PANCEATOJEJUNOSTOMY or FREY PROCEDURE

If disease limited to tail - PANCREATECTOMY

PROGNOSIS

PROGNOSIS

उदरसिचविकत्सित्सतम् श्लेष्मोदरिरणंतुविपप्पल्र्यादिदकषार्यसिसदे्धनसर्पिपFषोपस्नेह्य, स्नुही5ीरविवपक्वेनानुलोम्र्य,वित्रकटुकमूत्र5ारतैलप्रगाढेन , मुष्ककादिदकषार्येणास्थापरे्यदनुवासर्येच्च,

शणातसीर्धातकीविकण्वसष�पमूलकबीजकल्कैश्चोपनाहर्येदुदरं,

भोजर्येच्चैनंवित्रकटुकप्रगाढेन कुलत्थर्यूषेणपार्यसेन वा, स्वेदर्येच्चाभीक्ष्णम्||७||