1. Acute pancreatitis Kamal Bani-Hani FRCS (Glasgow), M.D. (Leeds)
King Abdullah University Hospital
Department of Surgery – Faculty of Medicine
Jordan University of Science & Technology

2. Acute pancreatitis
Autodigestion of the pancreas by its escaped enzymes

3. Etiological Factors 1 Biliary tract disease 7 Scorpion venom 2 Alcohol8
Drugs 3
Ischemia (hypotension, cardio-pulmonary by-pass, atheroembolism, vasculitis) 9
Pancreatic duct obstruction (tumor, pancreatic divisum, ampullary stenosis, ascaris infestiopn) 4
Duodenal obstruction 10
Metabolic (hypercalcemia, hyperthyroidism, Hyperlipidemia) 5
Trauma (external, operative, ERCP) 11
Viral infection (mumps, coxsaki B4) 6
Familial 12
Idiopathic

4. Drug Induced pancreatitis
Azathioprine*
L-asparaginase
Estrogenes*
Phenformin
Corticosteroids
Procainamide
Thiazide diuretics
Valproic acid
Furosemide
Clonidine
Ethacrynic acid
Pentamidine
Sulfonamides
Dideoxyinosine
Tetracycline
H2 antagonist

5. Surgical Pathology Edema Exudation Hemorrhage Suppuration Necrosis
Fat necrosis (combination of liberated fatty acids from hydrolized fat with calcium)
Fluid loss  Hypovolemia
Pseudocyst

6. Clinical features (Symptoms)
Pain (sudden,intense,continuous, upper abdomen back, bizarre position)
Nausea and Vomiting

7. Clinical features (Signs)
General
Local
Shock
Peritonitis
Fever
Paralytic ileus
Jaundice
Abdominal mass
Left pleural effusion
Cullen’s sign. Grey Turner sign
Acute pulmonary failure
Subcutaneous necrosis
Cerebral abnormalities

8. Investigation General Laboratory Tests Radiology CBC S. amylase
Chest X-ray
S. electrolytes
S. amylase isoenzymes (P+S types)
Abdominal X-ray
Lft
Urinary amylase
Ba. Meal
S. Ca+2
Amylase-creatinine clearance ratio US
Blood glucose
S. lipase
CT scan
S. methemalbumin
MRI
Peritoneal fluid analysis

9. Intra-abdominal Disorders associated with Hyperamylasemia
Pancreatic disorders
Non pancreatic disorders
Acute pancreatitis
Ruptured aortic aneurysm
Chronic pancreatitis
Ruptured ectopic pregnancy
Trauma
Intestinal obstruction
Carcinoma
Acute appendicitis
Pseudocyst pancreatic ascites
Perforated peptic ulcer
Abscess
Biliary tract disease
Mesenteric infarction
Afferent loop syndrome

10. Extra-abdominal Disorders associated with Hyperamylasemia
Salivary gland disorders + Impaired amylase excretion
+Miscellaneous
Mumps
Pneumonia
Parotitis
Pancreatic pleural effusion
Trauma
Mediastinal pseudocyst
Calculi
Cerebral trauma
Irradiation sialadenitis
Severe burns
Renal failure
Diabetic ketoacidosis
Macroamylasemia
Pregnancy
Drugs
bisalbuminemia

11. D Dx MI
Perforated peptic ulcer
Acute cholecystitis

12. Mortality and Prognosis
Mortality rate is 6-20%
Causes of death:
Hypovolaemic shock
Electrolyte disturbances
Toxaemia
Renal failure
Respiratory failure (collapse, consolidation, effusion)

13. Ranson’s Criteria At admission During initial 48 hours Age >55
Hematocrite fall > 10%
WBC > 16000/cu.mm
BUN rise 5mg/dl
Glucose > 200mg/dl
Ca+2 < 8 mg/dl
LDH > 350 IU/L
PO2 < 60 mm.Hg
SGOT > 250 U/dl
Base deficit > 4 meq/L
Fluid sequestration > 6 L

14. Mortality and Prognosis (3)
¨      <2  no mortality
¨      3-4  15% mortality
¨      5-6  50% mortality
¨       7  test the limits of modern medicine

15. Treatment (When diagnosis certain
Rest the patient (Relief pain)
Pethidine 100mg/4hr + antispasmodic
Rest the pancreas
NPO, IV fluid, electrolytes replacement
Rest the bowel
NG tube
Resuscitation
Replacement therapy
Resist enzymatic activity
Protease inhibitors, Trasylol , H2 antagonist, glucacon ?
Resist infection
Antibiotics ?
Repeated examination
General features, abd signs, fluid balance
Repeated serum estimations
Daily Ca+2 , WBC ( fibrinogen, methaemalbumin, Mg+2 )
Respiratory support
O2 , assisted respiration

16. Treatment (When diagnosis uncertain)
Peritoneal lavage
Laparotomy

17. Treatment (When complications become apparent )
Toxic patient
Abdominal mass
Persistently high gastric aspiration

18. Complications MOF Abscess formation Cyst formation
Recurrent acute attacks
Chronic pancreatitis