2. microscopic view of pancreatic acini pancreatic duct duodenum

3. trypsinogentrypsin chymotrypsin elastase phospholipase carboxypeptidase enterokinase chymotrypsinogen proelastase prophospholipase procarboxypeptidase duodenal lumen Normal Enzyme Activation

4. Exocrine Stimulation

5. Protection

6. Definition

7. Etiology

8. Associated conditions

9. Pathogenesis Acinar cell injury Premature enzyme activation Failed protective mechanisms Audodigestion of pancreatic tissue Local vascular insufficiency Activation of white blood cells Release of enzymes into the circulation Local complicationsDistant organ failure

10. Pathogenesis SEVERITYMildSevere

11. Sterile necrosis – 10% Infected necrosis – 25%

12. Clinical presentation

13. Mild: edema, inflammation, fat necrosis Severe: phlegmon, necrosis, hemorrhage, infection, abscess, fluid collections Retroperitoneum, perirenal spaces, mesocolon, omentum, and mediastinum Adjacent viscera: ileus, obstruction, perforation Cardiovascular: hypotension Pulmonary: pleural effusions, ARDS Renal: acute tubular necrosis Hematologic: disseminated intravascular coag. Metabolic: hypocalcemia, hyperglycemia PANCREATICPERIPANCREATICSYSTEMIC

14. Predictors of severity

15. Scoring systems

16. Scoring systems: Ranson criteria for alcoholic pancreatitis Number Mortality <21% 3-416%5-640%7-8100%

17. Scoring systems: CT severity indexappearancenormalenlargedinflamed 1 fluid collection 2 or more collections gradeABCDE score01234 necrosisnone < 33% 33-50% > 50% score0246 scoremorbiditymortality1-24%0% 7-1092%17% Balthazar et al. Radiology 1990.

18. Severe pancreatitis

19. Additional diagnostic tests: Ultrasonography

20. Additional diagnostic tests: CT-scan

21. Additional diagnostic lab tests SensitivitySpecificity Amylase67-10085-98 Lipase82-10086-100

22. Additional diagnostic lab tests Isenmann et al Pancreas 1993;8:358-61

23. Initial management of acute pancreatitis

24. Initial management of acute pancreatitis: ERCP Neoptolemos et al 1988; Fan NEJM 1993; Folsch NEJM 1997

25. Antibiotics

26. Pancreatic necrosis

27. Infected necrosis – Sepsis (After 3 weeks) Mortality – 20-70%

28. Pancreatic necrosis Infected necrosis – Sepsis (After 3 weeks) Mortality – 20-70%

29. Algorithm Confirm acute pancreatitis Amylase/Lipase Trypsinogetn2 CT scan in atypical cases Initial management Severity stratification IV fluid/pain conrol Scoring systems C-reactive protein Mild acute pancreatitis Severe acute pancreatitis

30. Algorithm Mild acute pancreatitis Severe acute pancreatitis RECOMMENDED Admit to general ward Refeed when pain subsides NOT RECOMMENDED Antibiotics CT scan RECOMMENDED Admit to ICU Antibiotics CT-scan – day 3 NECROSIS Sterile – observe (CT, US) Infection suspected – fine needle aspiration/drainage under US or CT control Infected necrosis – necrosectomy Open drainage of abscesses, retroperitoneal space