1. โดย พญ. กนิษฐา โชคสวัสดิ์
Acute Pancreatitis
โดย
พญ. กนิษฐา โชคสวัสดิ์

2. Pancreatitis Inflammation of the pancreatic parenchyma
Acute or Chronic
• Acute pancreatitis = A transient inflammation that resolves with or without complications
• Chronic pancreatitis = Continuous inflammation resulting in progressive anatomic and functional damage to the pancreas

3. Acute Pancreatitis • Gallstones (45%) Etiology • Alcohol abuse (35%)
• Others (10%)
• Idiopathic (10%)
** Males (alcohol) > Females (choledocholithiasis)

7. Acute Pancreatitis
Pathophysiology
• Activation of digestive zymogens inside acinar cells 
Acinar cell injury 
inflammatory cell recruitment + activation,
generation + release of cytokines & other mediators

8. Acute Pancreatitis Clinical Presentation Mid epigastric abdominal pain
Steady, boring pain
Radiation to the left upper back
Anorexia, nausea ± vomiting ± diarrhea
Low grade fever
Inflammation or secondary infection
Presentations associated with complications
Shock
Multi-system failure

9. Acute Pancreatitis Exam Findings • Abdominal tenderness • Fever (76%)
• Abdominal guarding (68%)
• Abdominal distension (65%)
• Tachycardia (65%)
• Hypoactive bowel sounds
• Jaundice (28%)
• Dyspnea (10%)
• Hemodynamic changes (10%)
• Melena or hematemesis (5%)
• Cullen’s sign
• Grey-Turner sign
• Left pleural effusion

10. Acute Pancreatitis
Cullen’s sign
Grey-Turner sign

11. Investigation

12. Diagnosis: Biochemical
Serum Amylase elevated
Nonspecific
Returns to normal in hours
Normal amylase does not exclude pancreatitis
Level of elevation does not predict disease severity
Serum Lipase elevated
Specific for pancreatic disease
Returns to normal in 7-14 days
Serum Electrolytes
Hypocalcemia (25%)
Hyperglycemia
Complete Blood Count (CBC)
White Blood Cells increased to 15k-20k
Lipids Elevated
Hypertriglyceridemia
Liver Function Tests
Serum Bilirubin elevated
ALT elevated
AST
Hypoalbuminemia (Poor prognosis)
Lactate Dehydrogenase (LDH) elevated (Poor prognosis)

14. Diagnosis Ultrasound - Most useful initial test for gallstone etiology
Dynamic contrast-enhanced CT (CECT)
- the imaging modality of choice for
diagnosis, staging, and detection of
complications of acute pancreatitis.

15. Severity assessment

16. APACHE II SCORE

17. Ranson's criteria On admission Within 48 hours Age > 55 yrs
WCC > 16,000
LDH > 600 U/l
AST >120 U/l
Glucose > 10 mmol/l
Within 48 hours
Haematocrit fall >10%
Urea rise >0.9 mmol/l
Calcium < 2 mmol
pO2 < 60 mmHg
Base deficit > 4
Fluid sequestration > 6L

18. Ranson criteria - prognosis
Mortality correlates with number of criteria % % % %

19. CT Severity index
serial CT scans are important for following the progression of the disease and for detecting additional complications.
In Balthazar’s series

21. Complication

22. Acute Pancreatitis Mild Severe Overall mortality 10 -15%
- severe disease as high as 30%

23. Severe Acute Pancreatitis - Definition
1. Organ failure
• Shock, pulmonary insufficiency, renal failure, GI bleeding
2. Local complications
• Pseudocyst, abscess, pancreatic necrosis
3. >= 3 Ranson criteria
Overall mortality 30% , Early (MOFS), late (infection)

24. Local Complications • Peri-pancreatic fluid collections
• 57% of patients
• Initially ill-defined
• Usually managed conservatively
• Pseudocysts
• Pancreatic necrosis

25. Acute pseudocyst

26. Pancreatic necrosis

27. Peripancreatic and retroperitoneal edema

28. Treatment

29. Treatment of acute pancreatitis
Supportive 
Eliminating of oral intake
Intravenous hydration
Parenteral analgesia
NG suction : ileus or severe vomiting
Collection of electrolyte and glucose abnormalities
vascular, respiratory and renal support
Removal of factors : drug or alcohol

30. Surgical Kelly and Wagner
Pt who underwent surgery earlier(<48hrs) had higher mortality and morbidity rates than those who underwent surgery later(>48hrs)
This finding was even more pronounced in those with severe pancreatitis

31. Surgical
Stone et al.
No deference in mortality between Pt randomly assigned to early biliary surgery (<72hr) and those assigned to late surgery(3mo after admission)

32. Surgery The traditional indication for surgery  acute abdomen
removal of impact stone from the CBD(emergency or elective)
Drainage of pancreatic fluid collections
Debridement of necrotic tissue

33. Antibiotics Three early controlled trials
Ampicillin did not change the course of mild acute alcoholic pancreatitis
Imipenem reduced the incidence of pancreatitis sepsis in pt with necrotizing pancreatitis

34. Inhibiting pancreatic secretion
Cimetidine
Atropine
Calcitonin
Glucagon
Somatostatin
Fluororacil
 not been shown to change the course of the disease

35. Summary No specific treatment for acute pancreatitis
Supportive therapy
Vigorous intravenous hydration
Parenteral analgesia
Collection of electrolyte and glucose abnormalities and vascular, respiratory and renal support

36. Summary
The use of antiproteases and inhibitor of pancreatic secretion cannot be recommended
Immediate endoscopic removal of impacted stones in pt with severe disease appears to reduce morbidity

37. Summary
Controlled studies are needed to demonstrate whether debridement of sterile necrotic tissue improve outcome
Infected necrotic tissue and infected collections of fluid are best treated by surgical debridement