AN UPDATE ON ACUTE PANCREATITIS 11.01.2017

2. Sir Berkeley Moynihan Ann Surg 1925
• “Acute Pancreatitis is the most terrible of all
the calamities that occur in connection with
the abdominal viscera.”

4. Diagnosis
Clinical
Symptoms Signs
Investigation
For
confirmation
of diagnosis
For
assessment
of severity
For diagnosis
of
complications

5. • Onset : Acute
• Site : Epigastrium or upper
abdomen ( mostly left)
• Character: Agonizing,
burning,continuous, refractory
• Degree : excruciating
• Aggravating factor : Supine
position
• Relieving factor : Sitting and
leaning forward
• Radiation : Towards the back,
chest, Lower abdomen

6. • Severe nausea,vomiting &
retching
• Abdominal distension
• Haematemesis & malena
• Dyspnoea
• Sudden blindness
• Skin rashes
• Decreased urine output

7. • Agonized look
• Dehydration
• Features of shock
Tachycardia
Hypotension
Cold clammy extremities
Altered mental status
• Hyperpyrexia
• Jaundice
• Skin changes
(Pancreatic panniculitis )

8. • Distension of abdomen
• Features of peritonitis
Abdominal Tenderness
Rebound tenderness
Muscle guard & rigidity
• Palpable pseudocyst
• Ascites
Abdominal signs

9. Cullen’s sign : Bluish discolouration around the umbilicusGrey Turner’s sign : Greenish brown discolouration of the
flanks
Fox’s sign : Bruising seen over the inguinal region

10. Respiratory system
• ALI : Cyanosis
Widespread crepts
• Pleural
Effusion : dullness
Decreased breathe
sounds
• Basal
Atelectasis : Basal crepts
• Features of pericadial
effusion
Eye
• Exudates and haemorrhages in
the region of optic disc &
macula
CNS
• Altered mental status

11. • P :
• A :
• N :
• C :
• R :
• E :
• A :
• S :
Pain, Pyrexia
Alimentary tract features
Nausea , Nervous system features
Circulatory features , CVS features
Respiratory features
Eye features
Abdominal examination findings
Skin features

12. INVESTIGATIONS
INVESTIGATIONS
For
confirmationn of
diagnosis
For assessment
of severity
For diagnosis of
complications

13. For confirmation of diagnosis
Serum amylase ( 23 – 140 U/L )
Non specific elevation
Relation of amylase level with severity
Relation with hyperlipidemia
Urinary amylase level
Serum lipase ( 0 – 160 U/L )
More specific and sensitive ( 90% )
0
1
2
3
4
5
6
Day0 Day1 Day2 Day3 Day4 Day5
Amylase
Lipase
Folds of
increase

14. • Serum ALT ( 7 – 56 U/L )
• Serum AST ( 10 – 40 U/L)
• Serum LDH (140 – 280 U/L)
• Bilirubin level
• Trypsinogen activation peptide
For confirmation of diagnosis

15. • USG Abdomen
• Shows increase in the size of pancreas
• Any intra-abdominal fluid collection
For confirmation of diagnosis
• Merits
• GB stone ( 95% sensitivity)
• Easily available
• Cost effective
• Portable
• Pancr Enz + LFT + USG
= 97% sensitivity and 100%
specificity
• Demerits
• Obstruction of view
• Choledocholithiasis
(50% sensitivity)

16. For confirmation of diagnosis
– Rule out hollow viscus
perforation
– Multiple air fluid levels
– Colonic cut off sign
• X- Ray abdomen

17. • CT Scan Abdomen
For confirmation of diagnosis
Normal abdomen
Acute pancreatitis

18. – Acute interstitial oedematous
pancreatitis
– Acute necrotising pancreatitis
(CECT)
– Acute emphysematous
pancreatitis
For confirmation of diagnosis
Merits
• 100% sensitivity after 4th day
• Better delineation of inflammation,
fluid collection, viability
• Wide availability
• Ct guided FNAC
Demerits
• Less sensitive before 24 hours
• Contrast enhanced CT is
contraindicated in renal failure
• CT Scan Abdomen

19. • MRCP
Indication:
unexplained or recurrent
pancreatitis
For confirmation of diagnosis
• Merits :
1. Can be used in patient with renal
failure
2. 90% sensitive and 95% specific
for choledocholithiasis
• Demerits
1. Can’t be used in patient with
pacemakers
Ferromagnetic aneurysm clips
Metallic spinal fusion rods
• ERCP
• EUS

20. For assessment of severity
• Scoring on
pathophysiological
basis
1. Ranson’s scoring
2. Modified Glassgow
scoring
Modified glasgow score
• P - PaO2 < 8kPa (60 mm hg)
• A - Age > 55 years
• N - Neutrophils : WBC> 15x 10^9/L
• C – Calcium < 2 mmol/L
• R – Renal function(Urea > 16mmol/L
• E – Enzymes : (AST/ALT > 200 IU/ L
LDH > 600 IU/ L )
• A – Albumin < 32 g/L
• S – Sugar ( Glucose > 10mmol/L)
• Phospholipase A
• Trypsin
• Trypsinogen activation peptide
• IL-6 , IL - 8
• Pancreatitis associated protein
• CRP
• Procalcitonin
• Plasma Dimer

21. For diagnosis of complications
• CT scan abdomen
– Pancreatic pseudocyst
– Pancreatic abscess
– Pancreatic necrosis
– Pancreatic phlegmon
– Pancreatic ascites
• X- ray chest ( PA view)
• Pleural effusion
• Pericardial effusion
• ECG
• Investigations for DIC
• GI endoscopy
• Serum Urea/Creatinine
• Blood:
Sugar, calcium, albumin

22. • Pancreas :
• Liver :
• Show :
• Rapid :
• Contrast :
• Material :
• Enhancement :
in
• CT :
• Scan :
• Pancreatitis enzymes
• Liver function tests
• Sonography abdomen
• Radiologic evidence( X-ray abdomen
and chest
• CT scan abdomen
• MRCP
• EUS, ERCP
• For Dx of COMPLICATIONS
• To assess SEVERITY