3 ACUTE PANCREATITIS-Acute pancreatitis (AP) are characterized by edematous lesions, eventually necrosis and bleeding inside and in peripancreatic area.
4 Pathology:- 2 types of AP1. Edematous APcongestion and edema of the pancreas.swellingnormal/mild inflammation of the retroperitoneum
5 2. Necrotic pancreatitis Severe +++.Important swelling of the pancreas, bleeding multiples areas and hematomas till the complete distruction of the gland.Involvement of all retroperitoneum, fatty necrosis- white spotsPlasmal escape – peripancreatic and retroperitoneal spaces+ ascites
6 ETIOLOGY: MAIN CAUSESGALLSTONESALCOHOL1. GALLSTONES
8 3. Rare etiology Postoperative and postraumatic AP Less than 10%Postoperative and postraumatic APBilliary ,pancreatic, gastric surgeryKidney transplantationPost- ERCPPancreatic tumorsInfectionsLeptospirosisAscaridiosisMetabolical factorsHypercalcemiaHypertriglyceridemiaDrug inducedCorticotherapyChlorothiazide, IsothiazideImmunosupressorsOral ContraceptivesAuto-immune APIdiopathic factors
9 3 mechanisms STOP the autodigestion of the pancreas C. PATHOPHYSIOLOGY3 mechanisms STOP the autodigestion of the pancreas1.enzymes - preserved as zymogenes separates from other proteins2.enzymes sont secreted – inactive forms3.inhibitors of proteolitic enzymes in the pancreatic tissu and pancreatic juiceAP= enzimatic autodigestion of the pancreas--- trypsinogen activation in trypsine in the pancreatic cells .Trypsine --- cascade activation of proenzymes from zymogens granules – pancreatic acinar cell distructionSIRS --- proinflammatory cytokines(Il-1, TNF) in the pancreatic tissu and other organs (kidney, liver, lung) SEVERE SYSTEMIC EVENTS
11 D. CLINICAL SIGNSABDOMINAL PAIN Describe it!!!Nausea and vomitingAbdominal distension- paralitic ileus+/ tachycardia, low/ high temperature, hypotension, tachypnea- severe formsOliguriaJaundiceAscites!! Pain intensity vs poverty of clinical signs
12 50 %- symptoms are not specific Differential dg:Acute cholecystitisMesenteric infarctionBowel obstructionRuptured abdominal aortic aneurismRespiratory distressOligo-anuriaPeritonitis
13 E. DIAGNOSTIC1. Blood testsHIGH levels of amylase and lipase (≥ 3 N)ESSENTIAL BUT NOT SPECIFIC!!CRP > 15 mg/100 ml – SEVERE AP.
14 2. IMAGING DGPlain abdominal X- Ray- localised ileus- sentinel loop, free air, calcificationsAbdominal US- swelling , diffuse hypoechogenity- Eventually the cause - gallstones
15 CT SCAN SEVERITY EVALUATION criteria Balthasar score- severity and extent of necrosis, peripancreatic fluid collectionCorrelation with morbidity and mortality
16 MRCP Non-invasive Safer Faster THAN ERCP but less sensitive WHEN Suspicion of bile ductobstruction
17 MRI - severity of AP - no iodine contrast - bile obstruction
18 F. COMPLICATIONSPANCREATIC NECROSISPSEUDOCYSTPANCREATIC ABCESS
19 PSEUDOCYST- necrosis organising - Wirsung disruption - after aprox 4 w evolution of AP
20 PANCREATIC ABCESS- pseudocyst infection/ infection of necrotic areas