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This document discusses acute pancreatitis and acute cholangitis. It defines acute pancreatitis as a condition caused by pancreatic duct and acinar injury leading to autodigestion. Common causes include gallstones, alcohol use, genetic factors, medications and infections. Symptoms include abdominal pain, nausea and vomiting. Diagnosis requires characteristic pain plus elevated lipase or amylase levels and imaging. Management involves fluid resuscitation, nutritional support, analgesia and treating any underlying causes or complications which can include pancreatic necrosis, fluid collections and systemic effects.

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ACUTE PANCREATITIS AND ACUTE CHOLANGITIS ZERA INERNATIONAL COLLEGE OF HEALTH SCIENCES 1
ZERA INERNATIONAL COLLEGE OF HEALTH SCIENCES 2
ACUTE PANCREATITIS PATHOGENESIS: Pancreatic duct and acinar injury via direct or indirect toxicity 損 impaired secretion and premature activation of digestive enzymes -損 autodigestion and acute inflammation ZERA INERNATIONAL COLLEGE OF HEALTH SCIENCES 3
ZERA INERNATIONAL COLLEGE OF HEALTH SCIENCES 4
ETIOLOGIES: Gallstones (40%): F> M , usually small stones (<5 mm) or microlithiasis/sludge Alcohol(30%):M>F ,1st attack after10y heavy use; usually chronic w/acute flares Anatomic: divisum, annular pancreas, duodenal duplication cysts, Sphincter of Oddi dysfunction. Autoimmune: can p/w chronic disease,pan mass or pan duct strictures, HIGH lgG4,+ANA Drugs: 5-ASA, 6-MP/AZA, ACEI, cytosine, didanosine, dapsone, estrogen, furosemide, Isoniazid, metronidazole, pentamidine, statins, sulfa, thiazides, tetracycline, valproate Familial: associated with mutations in PRSS1, CFTR, SPINK1; suspect if early onset (age <20 y) ZERA INERNATIONAL COLLEGE OF HEALTH SCIENCES 5
Infections: ascariasis, clonorchiasis, coxsackie, CMV, HIV, mumps, mycoplasma ,T B, t oxo Ischemia: vasculitis, cholesterol emboli, hypovolemic shock, cardiopulmonary bypass Metabolic: hypertriglyceridemia (TG >1000; type I and V familial hyperlipemia), hyperCa Neoplastic: panc/ampullary tumors, mets (RCC most common, breast, lung, melanoma) Post ERCP (5%): prophylaxis w/ PR indomethacin (NEJM 2012:366:1414), pane duct stent if high risk Post trauma: blunt abdominal trauma, pancreatic/biliary surgery Toxins: organophosphates, scorpion toxin, methanol ZERA INERNATIONAL COLLEGE OF HEALTH SCIENCES 6
CLINICAL MANIFESTATIONS Epigastric abdominal pain (90%), only 50% p/w classic bandlike pain radiating to back 10% pain-free (due to analgesic/steroid use, immunosuppressed, AMS, ICU, post-op), / amylase/lipase in Pts w / unexplained shock (AmJ Gastro 1991:86:322). Nausea and vomiting (90%) Abdominal tenderness/guarding, increased bowel sounds (ileus), jaundice if biliary obstruction Signs of retroperitoneal hemorrhage (Cullen's = periumbilical; Grey Turners = flank) rare ZERA INERNATIONAL COLLEGE OF HEALTH SCIENCES 7
ZERA INERNATIONAL COLLEGE OF HEALTH SCIENCES 8
DIFFERENTIAL DIAGNOSIS acute cholecystitis perforated viscus Small Bowel Obstruction mesenteric ischemia inferior wall MI AAA leak distal aortic dissection ruptured ectopic pregnancy ZERA INERNATIONAL COLLEGE OF HEALTH SCIENCES 9
DIAGNOSTIC STUDIES Dx requires 2 of 3: characteristic abdominal pain lipase or amylase >3x ULN + imaging Laboratory (AmJGastro2013:108:1400) levels of both amylase and lipase do not correlate w/ severity of disease. HIGH amylase: >3x ULN >90% sensitive, >70% specific for acute pancreatitis /false -ve : acute on chronic (eg, alcoholic); hypertriglyceridemia (decreased amylase activity). false +ve: other abd or salivary gland process, acidemia, renal failure, macroamylasemia . ZERA INERNATIONAL COLLEGE OF HEALTH SCIENCES 10
High lipase: >3x ULN 99% sensitive, 99% specific for acute pancreatitis false +ve: renal failure, other abd process, diabetic ketoacidosis, HIV, macrolipasemia longer half-life than amylase: useful in Pts w/ delayed presentation after onset of sx lipase >10,000 has 80% PPV for biliary dx,99% NPV for EtOH (D/gD/sSc/2011:56:3376) ALT >3x ULN has 95% PPV for gallstone pancreatitis [Am]Gastro 1994;89:1863) ZERA INERNATIONAL COLLEGE OF HEALTH SCIENCES 11
IMAGING STUDIES Abd U/S: typically not useful to visualize pancreas (obscured by bowel gas) but should be ordered for all pts with AP to r/o biliary etiology (i.e., gallstones, BD dilatation) Abd CT: not rec for initial eval unless dx unclear (local complic. not yet visible & concern for AKI w/ IV contrast). However, if persistent pain and/or clinical deterioration after 48- 72 h, CT(l+) useful to r/o local complications (necrosis, fluid collections). MRI/MRCP: Can detect necrosis; also used to assess for stones & ductal disruption Endoscopic U/S (EUS): limited role; useful for occult biliary disease (microlithiasis) ZERA INERNATIONAL COLLEGE OF HEALTH SCIENCES 12
SEVERITY Severity defined by presence of organ failure (AKI, resp failure, GIB, shock) & local or systemic complic. (pane necrosis, fluid collections, gastric outlet obstruction, splenic & PVT). Mild: 80% of cases. No organ failure or local/systemic complications, low mortality. Moderate: transient (<48 h) organ failure 賊 local/systemic complications, high morbidity Severe: persistent (>48 h) organ failure, very high mortality ZERA INERNATIONAL COLLEGE OF HEALTH SCIENCES 13
ZERA INERNATIONAL COLLEGE OF HEALTH SCIENCES 14
MANAGEMENT Fluid resuscitation: early aggressive IVF, titrate to UOP >0.5 mL/kg/h, goal to lower BUN & Hct over first 12-24 h. LR may be superior to NS (decreases SIRS, CRP at 24 h; avoid if high Ca) Nutrition Early enteral feeding encouraged (maintains gut barrier, decrease bacterial translocation) though new data suggest may not be superior to oral feeding at 72 h (NEJM 2014:317:1983) Mild: Start feeding once pain-free w/o ileus. Low-fat low-residue diet as safe as liquid diet. Severe: early (w/in 48-72 h) enteral nutrition indicated and preferred over TPN b/c it decreases infectious complications, organ failure, surgical interventions, and mortality. Nasogastric feeding shown to be non-inferior to nasojejunal feeding. nasojejunal feeding is preferred. ZERA INERNATIONAL COLLEGE OF HEALTH SCIENCES 15
Analgesia: IV opioids (monitor respiratory status, adjust dosing if worsening renal impairment) Gallstone pancreatitis: urgent (w/in 24 h) ERCP w/ sphincterotomy if cholangitis, sepsis, Or Tbili >5. For mild disease, Cholecystectomy during initial hospitalization to decrease risk of recurrence , defer surgery if necrotizing AP until improvement in inflam., fluid collections. Hypertriglyceridemia: No role for prophylactic antibiotics in absence of infectious complications (World; Gastroenterol 2012:18:279) ZERA INERNATIONAL COLLEGE OF HEALTH SCIENCES 16
COMPLICATIONS Systemic: ARDS, abdominal compartment syndrome, AKI, GIB (pseudoaneurysm), DIC Metabolic: hypocalcemia, hyperglycemia, hypertriglyceridemia Fluid collections: Acute fluid collection: seen early, not encapsulated, most resolve w/in 1-2 wk w/o Rx Pseudocyst: -4 wk after initial attack, encapsulated. No need for Rx if asymptomatic (regardless of size/location). If symptomatic-> endoscopic (Gostro2013:145:583) vs. perc/surg drainage. ZERA INERNATIONAL COLLEGE OF HEALTH SCIENCES 17
Pancreatic necrosis: Nonviable pancreatic tissue. CT-guided FNA if infection suspected Sterile necrosis :if asymptomatic, can be managed expectantly, no role for prophylactic antibiotics Infected necrosis (5% of all cases, 30% of severe): high mortality. Rx w/ carbapenem or MDZ+FQ. "Step-up Rx w/ perc drainage and minimally invasive surg debridement or endoscopic necrosectomy superior to open necrosectomy (NEJM2010:362:1491) Pancreatic abscess: circumscribed collection of pus (usually w/o pancreatic tissue), usually seen >4 wk into course. Rx with abx + drainage (CT-guided if possible). ZERA INERNATIONAL COLLEGE OF HEALTH SCIENCES 18
REFERENCE: American journal of gastroenterology New England journal of medicine Sanford guide for antimicrobial therapy ZERA INERNATIONAL COLLEGE OF HEALTH SCIENCES 19
THANK YOU ZERA INERNATIONAL COLLEGE OF HEALTH SCIENCES 20

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Acute pancreatitis- zera.pptx

  • 1. ACUTE PANCREATITIS AND ACUTE CHOLANGITIS ZERA INERNATIONAL COLLEGE OF HEALTH SCIENCES 1
  • 2. ZERA INERNATIONAL COLLEGE OF HEALTH SCIENCES 2
  • 3. ACUTE PANCREATITIS PATHOGENESIS: Pancreatic duct and acinar injury via direct or indirect toxicity 損 impaired secretion and premature activation of digestive enzymes -損 autodigestion and acute inflammation ZERA INERNATIONAL COLLEGE OF HEALTH SCIENCES 3
  • 4. ZERA INERNATIONAL COLLEGE OF HEALTH SCIENCES 4
  • 5. ETIOLOGIES: Gallstones (40%): F> M , usually small stones (<5 mm) or microlithiasis/sludge Alcohol(30%):M>F ,1st attack after10y heavy use; usually chronic w/acute flares Anatomic: divisum, annular pancreas, duodenal duplication cysts, Sphincter of Oddi dysfunction. Autoimmune: can p/w chronic disease,pan mass or pan duct strictures, HIGH lgG4,+ANA Drugs: 5-ASA, 6-MP/AZA, ACEI, cytosine, didanosine, dapsone, estrogen, furosemide, Isoniazid, metronidazole, pentamidine, statins, sulfa, thiazides, tetracycline, valproate Familial: associated with mutations in PRSS1, CFTR, SPINK1; suspect if early onset (age <20 y) ZERA INERNATIONAL COLLEGE OF HEALTH SCIENCES 5
  • 6. Infections: ascariasis, clonorchiasis, coxsackie, CMV, HIV, mumps, mycoplasma ,T B, t oxo Ischemia: vasculitis, cholesterol emboli, hypovolemic shock, cardiopulmonary bypass Metabolic: hypertriglyceridemia (TG >1000; type I and V familial hyperlipemia), hyperCa Neoplastic: panc/ampullary tumors, mets (RCC most common, breast, lung, melanoma) Post ERCP (5%): prophylaxis w/ PR indomethacin (NEJM 2012:366:1414), pane duct stent if high risk Post trauma: blunt abdominal trauma, pancreatic/biliary surgery Toxins: organophosphates, scorpion toxin, methanol ZERA INERNATIONAL COLLEGE OF HEALTH SCIENCES 6
  • 7. CLINICAL MANIFESTATIONS Epigastric abdominal pain (90%), only 50% p/w classic bandlike pain radiating to back 10% pain-free (due to analgesic/steroid use, immunosuppressed, AMS, ICU, post-op), / amylase/lipase in Pts w / unexplained shock (AmJ Gastro 1991:86:322). Nausea and vomiting (90%) Abdominal tenderness/guarding, increased bowel sounds (ileus), jaundice if biliary obstruction Signs of retroperitoneal hemorrhage (Cullen's = periumbilical; Grey Turners = flank) rare ZERA INERNATIONAL COLLEGE OF HEALTH SCIENCES 7
  • 8. ZERA INERNATIONAL COLLEGE OF HEALTH SCIENCES 8
  • 9. DIFFERENTIAL DIAGNOSIS acute cholecystitis perforated viscus Small Bowel Obstruction mesenteric ischemia inferior wall MI AAA leak distal aortic dissection ruptured ectopic pregnancy ZERA INERNATIONAL COLLEGE OF HEALTH SCIENCES 9
  • 10. DIAGNOSTIC STUDIES Dx requires 2 of 3: characteristic abdominal pain lipase or amylase >3x ULN + imaging Laboratory (AmJGastro2013:108:1400) levels of both amylase and lipase do not correlate w/ severity of disease. HIGH amylase: >3x ULN >90% sensitive, >70% specific for acute pancreatitis /false -ve : acute on chronic (eg, alcoholic); hypertriglyceridemia (decreased amylase activity). false +ve: other abd or salivary gland process, acidemia, renal failure, macroamylasemia . ZERA INERNATIONAL COLLEGE OF HEALTH SCIENCES 10
  • 11. High lipase: >3x ULN 99% sensitive, 99% specific for acute pancreatitis false +ve: renal failure, other abd process, diabetic ketoacidosis, HIV, macrolipasemia longer half-life than amylase: useful in Pts w/ delayed presentation after onset of sx lipase >10,000 has 80% PPV for biliary dx,99% NPV for EtOH (D/gD/sSc/2011:56:3376) ALT >3x ULN has 95% PPV for gallstone pancreatitis [Am]Gastro 1994;89:1863) ZERA INERNATIONAL COLLEGE OF HEALTH SCIENCES 11
  • 12. IMAGING STUDIES Abd U/S: typically not useful to visualize pancreas (obscured by bowel gas) but should be ordered for all pts with AP to r/o biliary etiology (i.e., gallstones, BD dilatation) Abd CT: not rec for initial eval unless dx unclear (local complic. not yet visible & concern for AKI w/ IV contrast). However, if persistent pain and/or clinical deterioration after 48- 72 h, CT(l+) useful to r/o local complications (necrosis, fluid collections). MRI/MRCP: Can detect necrosis; also used to assess for stones & ductal disruption Endoscopic U/S (EUS): limited role; useful for occult biliary disease (microlithiasis) ZERA INERNATIONAL COLLEGE OF HEALTH SCIENCES 12
  • 13. SEVERITY Severity defined by presence of organ failure (AKI, resp failure, GIB, shock) & local or systemic complic. (pane necrosis, fluid collections, gastric outlet obstruction, splenic & PVT). Mild: 80% of cases. No organ failure or local/systemic complications, low mortality. Moderate: transient (<48 h) organ failure 賊 local/systemic complications, high morbidity Severe: persistent (>48 h) organ failure, very high mortality ZERA INERNATIONAL COLLEGE OF HEALTH SCIENCES 13
  • 14. ZERA INERNATIONAL COLLEGE OF HEALTH SCIENCES 14
  • 15. MANAGEMENT Fluid resuscitation: early aggressive IVF, titrate to UOP >0.5 mL/kg/h, goal to lower BUN & Hct over first 12-24 h. LR may be superior to NS (decreases SIRS, CRP at 24 h; avoid if high Ca) Nutrition Early enteral feeding encouraged (maintains gut barrier, decrease bacterial translocation) though new data suggest may not be superior to oral feeding at 72 h (NEJM 2014:317:1983) Mild: Start feeding once pain-free w/o ileus. Low-fat low-residue diet as safe as liquid diet. Severe: early (w/in 48-72 h) enteral nutrition indicated and preferred over TPN b/c it decreases infectious complications, organ failure, surgical interventions, and mortality. Nasogastric feeding shown to be non-inferior to nasojejunal feeding. nasojejunal feeding is preferred. ZERA INERNATIONAL COLLEGE OF HEALTH SCIENCES 15
  • 16. Analgesia: IV opioids (monitor respiratory status, adjust dosing if worsening renal impairment) Gallstone pancreatitis: urgent (w/in 24 h) ERCP w/ sphincterotomy if cholangitis, sepsis, Or Tbili >5. For mild disease, Cholecystectomy during initial hospitalization to decrease risk of recurrence , defer surgery if necrotizing AP until improvement in inflam., fluid collections. Hypertriglyceridemia: No role for prophylactic antibiotics in absence of infectious complications (World; Gastroenterol 2012:18:279) ZERA INERNATIONAL COLLEGE OF HEALTH SCIENCES 16
  • 17. COMPLICATIONS Systemic: ARDS, abdominal compartment syndrome, AKI, GIB (pseudoaneurysm), DIC Metabolic: hypocalcemia, hyperglycemia, hypertriglyceridemia Fluid collections: Acute fluid collection: seen early, not encapsulated, most resolve w/in 1-2 wk w/o Rx Pseudocyst: -4 wk after initial attack, encapsulated. No need for Rx if asymptomatic (regardless of size/location). If symptomatic-> endoscopic (Gostro2013:145:583) vs. perc/surg drainage. ZERA INERNATIONAL COLLEGE OF HEALTH SCIENCES 17
  • 18. Pancreatic necrosis: Nonviable pancreatic tissue. CT-guided FNA if infection suspected Sterile necrosis :if asymptomatic, can be managed expectantly, no role for prophylactic antibiotics Infected necrosis (5% of all cases, 30% of severe): high mortality. Rx w/ carbapenem or MDZ+FQ. "Step-up Rx w/ perc drainage and minimally invasive surg debridement or endoscopic necrosectomy superior to open necrosectomy (NEJM2010:362:1491) Pancreatic abscess: circumscribed collection of pus (usually w/o pancreatic tissue), usually seen >4 wk into course. Rx with abx + drainage (CT-guided if possible). ZERA INERNATIONAL COLLEGE OF HEALTH SCIENCES 18
  • 19. REFERENCE: American journal of gastroenterology New England journal of medicine Sanford guide for antimicrobial therapy ZERA INERNATIONAL COLLEGE OF HEALTH SCIENCES 19
  • 20. THANK YOU ZERA INERNATIONAL COLLEGE OF HEALTH SCIENCES 20