This lecture was conducted during the Nephrology Unit Grand Ground by Medical Student rotated under Nephrology Division under the supervision and administration of Prof. Jamal Al Wakeel, Head of Nephrology Unit, Department of Medicine and Dr. Abdulkareem Al Suwaida, Chairman of the Department of Medicine. Nephrology Division is not responsible for the content of the presentation for it is intended for learning and /or education purpose only.

Pancreatitis Presented by: Ala’a Al Shameri Medical Student December 27, 2008

Anotomy

Acute pancreatitis Is inflammation of the pancreas that occurs suddenly. It can be a life-threatening illness with severe complications. Each year, about 210,000 people in the United States are admitted to the hospital with acute pancreatitis.

Etiology: (GET SMASHED) G: Gallstone.(common) E: Ethanol. T: Truma.. S: Steroid.. M: Mumps. A: Alcoholism (common) or autoimmune. S: Scorpion bits. H: Hyperlipidemia. E: ERCP. D: Drugs: Thiazide, Azathioprine.

***Other: Iodiopathic. Hypercalcemia. Hypothermia. Genetic disorders: acute intermittent porphyria, hereditary coprophyria.

Pathophysiology: When the activation of digestive proenzymes occurs in pancreatic duct system or aciner cells, the inflammation is the result. Oedema or obstruction of ampulla of veter resulting in reflexes Of bile into pancreatic duct or to acinar cells. Pancreas shows edema & necrosis.(10%-30% mortality rate). The release of digestive enzymes lead to fat necrosis in the pancreas &peritoneal cavity.

Clinical Features: Hx : Abdomenal pain: sever, stay 12-24h after eating a large meal or consuming alcohol,rediate to the back or to the shoulder, pain is worse by walking or laying supine & better after sitting or leaning forward. N &V. Shock in sever case. Severe acute pancreatitis may cause dehydration and low blood pressure. The heart, lungs, or kidneys can fail. If bleeding occurs in the pancreas, shock and even death may follow. Abd Ex: Tenderness in epigastric & guarding of Abd muscles. Mild Abd distention( if the purulytic ileus develop). In sever advanced case: Grey turners sign. Cullen’s sign.

DDx: Perforated peptic ulcer. Acute cholecystitis & biliary colic. Acute Int obstruction. Renal colic. DKA.

Investigation: Serum amylase; It stays 48-72h then become normal. Serum lipase; (diagnostic test) It elevated for 7-14 days. Other: -WBC (15000-30000). -LDH>500 U/dl - Glucose. - Albumin. - Ca in serum. - AST.Bilurbin,Alkaline Ph. - ABG show Hypoxia.

Xray of Abdomen: -gall stones. -Sentinel loop: air filled SI in the LUQ. -Colon cut off sign: gas-filled seg of transverous colon abruptly ending at the area of pancreatic inflammation. U/S: -Gall stones. -Bilary obstruction. -Psudocyst.

CT: (is the dignostic even with normal amylase). -enlarged pancreas. -Psudocyst. -Abscess & hemorrhage. -Presence of gas bubbles in CT scan indicate pancreatic abscess.

COMPLICATION: Shock & renal failure:(pancritic necrosis is association with leakage of fluid in the pancreatic bed & also illus with fluid filled the bowl leading to tubular necrosis). Hypo Ca: sequestration of Ca in fat necrosis.(sponification) Hypoalbuminemia: Capillary permeability. Hyperglucemia: due to disruption of pancreatic islets. Hypoxia: Resp distress.

6- Pancreatic : -Necrosis. -Abscess. -Pseudocystis: a circumscribed collection of fluid rich in pancreatic enzymes, blood, and necrotic tissue, typically located in the lesser sac of the abdomen. Pancreatic pseudocysts are usually complications of pncreatitis. The prefix pseudo- (Greek for "false") distinguishes them from true cysts, which are lined by epithelium; pseudocysts are lined with granulation tissues. 7- GI: -UGI Bleeding. -duodenal obstruction. -Gastric or duodenal erosion. -splenic or portal vein thrombosis. - compression by pancreatic mass. - compression of common bile duct.

Assesment of severity (Ranson’s Criteria) 3 or more indicate sever pancreatitis: Age > 55 Y/O. Blood glucose > 200 mg/dl. WBC > 16000 AST > 250 IU/L. Serum LDH >350 IU/L.

Development of the following in the first 48h indicate a worsening porgnosis: (PANCREAS) P: PO2 < 8KPa. A: Age > 55y. N: Neutrophil > 15000000000L. C: Calcium <2 mmol. R: Renal function. (Urea> 16 mmol/L) E: Enzymes: -LDH>600 iu/L. -AST >200 iu/L. A: Albumin:<32 g/L in serum. S: Sugar > 10 mm0l/L.

Mortality rate correlates with the number of criteria present: 0-2 1% 3-4 16% 5-6 40% 7-8 100%

Management: Bed rest & Oxygen. NPO & NG tube. IV saline. Pethidine (75-100 mg) for 3-4 h to control pain ( avoid morphine because it causes spasm of sphincter of oddi) Dopamine ( if shock not respond to the fluid replacement) Ca gluconate IV only if there are hypoCa. Fresh frozen plasma for coagulopathy. Serum albumin. Insulin.

Parenteral nutrition if there are sever pancrititis & illeus for 7-10 d. Antibiotics: prophylaxis to prevent inf.(Cefuroxime 1.5g IV 8h.). ERCP:if sever pancreatitis reslt from stone in bilary duct. Treatment of psudocyst: NPO & Parenteral nutrition . many are resolved spontanously. if it is not resolved after 4-6 weeks,surgery is done. Surgery for all sever cases. Before leaving the hospital: the person will be advised not to smoke, drink alcoholic beverages, or eat fatty meals.

Chronic Pancreatitis: Is chronic inflammatory disease characterized by fibrosis & dustruction of exocraine pancreatic tissues. Both forms of pancreatitis occur more often in men than women. Chronic pancreatitis often develops in people who are between the ages of 30 and 40.

Etiology Alcoholism.(common) Malnutrition. Stnosis of ampulla of veter. CF. Hereditary & Idiopathic: can present in a person younger than age 30, but it might not be diagnosed for several years. Episodes of abdominal pain and diarrhea lasting several days come and go over time and can progress to chronic pancreatitis. A diagnosis of hereditary pancreatitis is likely if the person has two or more family members with pancreatitis in more than one generation.

C/F: Abd pain. Weight loss, Aneroxia, Avoidness of food bcz of post- prandial pain, Malabsorbtion. Steatorrhea. On Ex: Epigastric pain.

Investigation Abd xray : clacified pancreas. U/S Abd CT Abd: : atrophy,clacification. ERCP. Endoscopic U/S.

Complication: Psudocyst. Pancreatic ascites. Obstructive jundice. Peptic ulcer. Duodenal stnosis. Portal or splenic vein thrombosi.

Treatment Pain relief: NSAID & Opitates. Oral pancriatic enzymes supplement: should be taken with every meal to help the person digest food. plan a nutritious diet that is low in fat and includes small, frequent meals. A dietitian can assist in developing a meal plan. Drinking plenty of fluids and limiting caffeinated beverages is also important. Endoscopic therapy: dilatation or stenting of main pancreatic duct or remove of stone. Surgery: Partial pancreatic resection. Pencreato-jejunostomy.

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