1) Acute pancreatitis is an inflammation of the pancreas that can range from mild to severe. It involves autodigestion of the pancreas by its own enzymes. 2) There are two main types - edematous pancreatitis which is mild and necrotizing/hemorrhagic pancreatitis which is more severe and can lead to loss of pancreatic function. 3) Causes include gallstones, alcohol abuse, medications, trauma, hyperlipidemia and sometimes the cause is unknown. Clinical features include severe abdominal pain, nausea and tenderness on examination. Investigations include blood tests and imaging. Management involves IV fluids, nil by mouth, antibiotics if infected, and sometimes

1. Acute Pancreatitis
Int.Thanit Prasoppokakorn

2. Pancreatitis
Acute Pancreatitis
- Acute Inflammation of pancreas
- Non bacterial infection
- Autodigest of pancreas by its own enzymes
- Pancreas can be recovery after inflammation resolves
Chronic Pancreatitis
- Many recurrent of acute pancreatitis
- Exocrine and endocrine function will decrease

3. Acute Pancreatitis
1) Edematous pancreatitis
- Mild form
- Swelling of tissue and fat necresis
- No pancreatitic necrosis
2) Hemorrhagic pancreatitis/
Necrotizing pancreatitis
- Severe form
- Large area of necrosis
- Hemorrhage in pancreas
- Loss endocrine and exocrine function

4. Function
Exocrine function
Produce enzyme that
breakdown carbohydrate,
protein and fat
Endocrine function
Produce several important
hormones such as Insulin,
Glucagon

5. Cause
Biliary Disease ;
Gall stone
Ethanol Abuse ;
Chronic Alcoholism
Other cause ;
Steroid, Thaizide diuretic, Furosemide, Familial pancreatitis,
Traumatic cause, HyperTG, HyperCa
Post operative pancreatitis
Idiopathic

6. Clinical Manifestation
Severe to persistent epigastric pain
Radiated pain to the back
Pain after meal
Nausea/Vomitting

7. Abdominal Examination
Tenderness at epigastrium
Guarding
Decreased or absent bowel sound
Cullen’s sign
Grey Turner’s sign

8. Grey Turner’s Sign
Hemorrhagic discoloration of flank

9. Cullen’s Sign
Superficial edema and bruising in the subcutaneous fatty
tissue around the umbilicus

10. Lab investigation
Serum amylase
- rising 2.5 times in 6 hours and constant for 3 days
- biliary pancreatitis -> amylase > 1000 iu/dl
Serum lipase
- more specificity and sensitivity than amylase
- increased sensitivity in alcohol-induced pancreatitis

11. Lab investigation
Urine amylase
- > 5,000 iu/24 hr elevated for 7-14 day
ALT
- elevate in gall stone pancreatitis
C-reactive protein
- elevated in necrotic pancreatitis
Electrolytes
- Hyperglycemia, Hypocalemia

12. Radiological Finding
Acute Abdomen Series Film
- Sentinel loop -> dilatation of bowel near pancreas;
duodenum, jejunum, transverse colon
- Colon cutoff sign -> absent of shadow of ascending colon-
transverse colon from colon spasm
- Minimal pleural effusion in CXR

13. Sentinel loop

14. Colon cutoff sign

16. Radiological Finding
Ultrasound
- edematous, swollen pancreas, peripancreatic fluid collection,
pseudocyst
- gall stone
CT scan
ERCP

20. Ranson’s Criteria
Mortality
0-2 = 2%
3-4 = 15%
5-6 = 40%
7-8 = 100%
or use APACHE II scoring system

21. Treatment

22. Treatment
IV fluid resuscitation
-> third space loss
Improved electrolytes imbalance
-> hypokalemia from vomitting
-> hypocalemia
-> hypomagnesium in alcoholic patient
-> metabolic alkalosis

23. Treatment
NPO
-> decreared secretion from pancreas
-> ileus
Oxygen support
-> hypoxia, monitor blood gas
Antibiotic

24. Antibiotic
The proper role of antibiotics in acute pancreatitis remains
controversial
No antibiotics are indicated in mild cases
Infectious complications are an important concern in severe
cases, especially cases of pancreatic necrosis
a recent randomized trial failed to demonstrate differences in
outcome
Some centers use antifungal therapy, but this practice has not
been validated by randomized trials.

25. Antibiotic
Indication for antibiotic
1) Infection associated
- necrosis of gland > 50%
- FNA find organisms
2) Immunocompromised host
3) Biliary pancreatitis
4) Complication
pancreatic abscess, infected pseudocyst

26. Antibiotic
Imipenem
Quinolone (Ciprofloxacin) + Metronidazole
Third genaration cephalosporin (Cef-3, Cefotaxime)
+ Metronidazole

27. Surgery
Indication for surgery
- Cannot exclude from other surgical condition
- Not better after conservative for 24-48 hour
- Biliary pancreatitis
- Complication: pancreatitic abscess, pseudocyst
- Pancreatic necrosis > 50% or have severe infection

28. Surgical Intervention
Differentiate between sterile and infected necrosis
-> CT- or ultrasonography-guided fine-needle aspiration
(FNA) of pancreatic or peripancreatic necrosis
Infected necrosis pancreatitis
- Mortality rate > 30% with risk of multiple organ failure
- Surgery decreased mortality to < 20%
Sterile necrosis pancreatitis
- Conservative approach
- Some have role of surgery

29. Surgical Intervention
Mortality rates of up to 65 % have been described with early
surgery in severe pancreatitis
Prospective and randomized clinical trial comparing early
(within 48 to 72 hr of symptoms) versus late (at least 12 days
after onset) debridement in patients with severe pancreatitis,
mortality rates were 56 %and 27 %
Except patient with severe complications such as massive
bleeding or bowel perforation, early surgery must be
performed

30. Surgical Intervention
Techniques of open pancreatic necrosectomy
4 methods; necrosectomy combined with
1) open packing
2) planned, staged relaparotomies with repeated lavage
3) closed continuous lavage of the lesser sac and
retroperitoneum
4) closed packing

31. Surgical Intervention

32. Surgical Intervention

33. Surgical Intervention
Open surgical debridement is the “goldstandard” for
treatment of infected pancreatic and peripancreatic necrosis
Necrosectomy and subsequent closed continuous lavage of
the lesser sac is the technique with the lowest morbidity.
Consequently, it is the most commonly adopted technique

35. IAP Guidelines
Recommendation
1) Mild acute pancreatitis is not an indication for pancreatic
surgery (recommendation grade B)
2) The use of prophylactic broad spectrum antibiotics reduces
infection rates in CT-proven necrotizing pancreatitis but may
not improve survival (recommendation grade A)
3) FNAB should be performed to differentiate between sterile
and infected pancreatic necrosis inpatients with sepsis
syndrome (recommendation grade B)

36. IAP Guidelines
4) Infected pancreatic necrosis in patients with clinical signs
and symptoms of sepsis is an indication for intervention
including surgery and radiological drainage
(recommendation grade B)
5) Patients with sterile pancreatic necrosis (FNAB negative)
should be managed conservatively and only undergo
intervention in selected cases (recommendation grade B)

37. IAP Guidelines
6) Early surgery within 14 days after onset of the disease is
not recommended in patients with necrotizing pancreatitis
unless there are specific indications (recommendation grade
B)
7) Surgical and other forms of interventional management
should favor an organ-preserving approach which involves
debridement or necrosectomy combined with a postoperative
management concept that maximizes postoperative
evacuation of retroperitoneal debris and exudate
(recommendation grade B)

38. IAP Guidelines
8) Cholecystectomy should be performed to avoid recurrence
of gallstone-associated acute pancreatitis (recommendation
grade B)
9) mild gallstone-associated acute pancreatitis
cholecystectomy should be performed as soon as the patient
has recovered and ideally during the same hospital admission
(recommendation grade B)

39. IAP Guidelines
10) severe gallstone-associated acute pancreatitis,
cholecystectomy should be delayed until there is sufficient
resolution of the inflammatory response and clinical recovery
(recommendation grade B)

40. IAP Guidelines
11) Endoscopic sphincterotomy is an alternative to
cholecystectomy, in those who are not fit to undergo surgery
in order to lower the risk of recurrence of gallstoneassociated
acute pancreatitis. There is, however, a theoretical risk of
introducing infection into sterile pancreatic necrosis
(recommendation grade B).

42. 88 patients with necrotizing pancreatitis with suspected or
confirmed necrotic tissue to undergo primary open
necrosectomy or a step-up approach to treatment
step-up approach consisted of percutaneous drainage
followed, if necessary, by minimally invasive retroperitoneal
necrosectomy
The primary end point was a composite of major
complications (new-onset multiple-organ failure or multiple
systemic complications, perforation of a visceral organ or
enterocutaneous fistula, or bleeding) or death

43. The primary end point occurred in
- 31 of 45 patients (69%) assigned to open necrosectomy
- 17 of 43 patients (40%) assigned to the step-up approach
(risk ratio with the step-up approach, 0.57; 95% confidence interval, 0.38 to 0.87;
P=0.006)
35% of step-up approach were treated with percutaneous drainage only
New-onset multiple-organ failure occurred less often in patients assigned to the
step-up approach than in those assigned to open necrosectomy
(12% vs. 40%, P=0.002)
The rate of death did not differ significantly between groups
(19% vs. 16%, P=0.70)

44. Complication
Systemic complication
Local complication

45. Systemic complication
Neuro
Pulmonary
- Pancreatitic
- Acelactasis
encephalopathy
- Pleural effusions
- ARDS Metabolic
- Hypocalemia
Cardiovascular
- Hypokalemia
- cardiogenic shock
- Metabolic alkalosis
Renal
GI
- Prerenal failure
- Hemorrhage

46. Local complication
Acute fluid collection
- early in acute pancreatitis
- no specific therapy
Pancreatic Pseudocyst
- Collection of pancreatic fluid walled off by granulation
tissue after episode of acute pancreatitis
- Develop more than 4week, detected by CT scan

49. Local complication
Intra-abdominal infection
- within 1-3 week
Pancreatic abscess
- Infected pancreatic pseudocyst may develop to abscess in
3-6 week
Pancreatic necrosis