Surgery for pancreatic disorders Flashcards
Acute pancreatits definition and classification?
An acute inflammatory process of the pancreas, with variable
involvement of other regional tissues or remote organ systems”
Classification:
Mild AP: Associated with minimal organ dysfunction and uneventful recovery
Severe AP: Associated with organ failure or local complication
Acute pancreatitis –Local Complications
Acute fluid collections
Pseudocyst
Pancreatic abscess
Pancreatic necrosis
Acute pancreatitis- Aetiology
Gallstones Alcohol Viral Infection: CMV, mumps Tumours Anatomical abnormalities (P.D.) ERCP Lipid abnormalities Hypercalcaemia Postoperative Trauma Ischaemia Drugs Scorpion venom “Idiopathic”
Acute pancreatitis - Pathophysiology
Alcohol direct injury
increased sensitivity to stimulation
oxidation products (acetaldehyde)
non-oxidative metabolism (fatty acid ethyl esters)
Gallstones passage of gallstone is essential
raised pancreatic ductal pressure
ERCP increased pancreatic ductal pressure
Acute pancreatitis-presentation
Gradual or sudden pain in the upper abdomen that gets worse after eating
(may
radiate to back)
Collapse
Tachycardia and hypovolemic shock
Oliguria, acute renal failure
Nausea and vomiting
Pyrexia
Addominal distension
Abdominal guarding
Paralytic ileus
–
hypoactive bowel sounds
Hypocalcaemia (tetany
–muscle spasms
-rare)
Hypoxia (escalating to respiratory failure)
Hyperglycaemia (occasionally diabetic coma)
Effusions (ascetic and pleural; high amylase)
In severe disease: peritoneal sig
ns. Ascites, jaundice, palpable abdominal mass,
Cullen’s sign, Turner’s sign and signs of hypovolemic shock
Acute pancreatitisInitial resuscitation and management
General supportive care Analgesia Intravenous fluids Cardiovascular } Respiratory } support Renal } Monitoring Pulse, BP Urine output CVP Arterial line HDU / ITU Investigations U/E, glucose serum amylase FBC, clotting LFT ABG CXR AXR USS CT scanning
Acute pancreatitis - Prediction of severity of disease
Modified Glasgow criteria At 48 hours
Glucose > 10 mmol/L Serum [Ca2+] < 2.00 mmol WCC > 15000/mm3 Predicted severe ≥ 3 Albumin< 32 g//L LDH > 700 IU/L Urea > 16 mmol/L AST/ALT > 200 IU/L Arterial pO2 < 60mmHg Predicted severe ≥ 3
Clinical Assessment
Modified Glasgow criteria
CT scanning
Individual markers CXR
CRP(>200, or persists >150)
IL 6
TAP
Acute pancreatitis Identification & management of precipitating factors
Cholelithiasis = ERCP & ES, cholecystectomy
Alcohol = Abstinence, counselling
Ischaemia = Careful support, Correct cause
Malignancy = Resection or bypass
Hyperlipidaemia = Diet, lipid lowering drugs
Anat. Abnormalities = Correction if possible
Drugs = Stop or change
Acute pancreatitis Specific aspects of management
CT scanning Antibiotics Diagnosis of infection ERCP in gallstone pancreatitis Nutrition Manipulation of the inflammatory response
Acute pancreatitis - CT scanning use
Occasionally helpful in diagnosis Useful in severe disease Days 4-10 to identify necrosis Useful for complications Acute fluid collections Abscess Necrosis Monitoring progress of disease
Acute pancreatitis - Antibiotics
controversial
Acute pancreatitis - Diagnosis of infection
? Sepsis or SIRS ? = CT guided FNA of pancreatic necrosis
Acute pancreatitis - ERCP & ES
Still controversial
Reduces complications in severe gallstone AP
Associated with a higher mortality
Definitely indicated in those with jaundice and cholangitis
Acute pancreatitis - Nutrition
Nutrition vitally important, despite previous theories
about “resting the gland”
Enteral feeding is superior to parenteral feeding
Nasogastric feeding is tolerable in most cases, and
not associated with any increase in complications
Acute pancreatitis – Definitive Management
Prevention of recurrent attacks:
Management of Gallstones
Investigations of non-gallstone pancreatitis
Alcohol abstinenece
Fluid collection:
Early collection
Pseudocyst
Pancreatic duct fistula
Management of Necrosis: Sterile necrosis Infected necrosis: Necrosectomy Laparotomy Minimally invasive Abscess Late complications: Haemorrhage Portal hypertension Pancreatic duct stricture
