eMentorSurgery

  Dear students, This is only for your revision and NOT A FULL TEXT.  

Pancreas

•        Retroperitoneal organ that extends obliquely from the duodenal C loop tothe hilum of the spleen.

•        It is divided into 4 portions: head, neck body and tail.

•        The head is intimately associated with the second portion of theduodenum, and they are BOTH supplied by the pancreaticoduodenal arteries.

•        It incorporates endocrine and exocrine function.

ExocrinePancreas

•        The final product of the exocrine pancreas is a clear isotonic solutionwith a pH in the range of 8. The 2 distinct components of exocrine secretionare enzyme secretion and water+electrolyte secretion.

•        Cholecystokinin is the most potent endogenous hormone known to stimulateenzyme secretion.

•        Secretin is the most potent endogenous stimulant of pancreaticelectrolyte secretion.

EndocrinePancreas

•        The release of insulin into the portal blood iscontrolled by the concentration of blood glucose, vagal interactions, and localconcentrations of somatostatin.

•        The major stimulus for glucagon release is a fallin serum glucose.

•        Pancreatic polypeptide appears to function for regulationof pancreatic exocrine secretion and biliary tract motility.

•        Somatostatin has a broad inhibitory spectrum ofgastrointestinal activity

AcutePancreatitis

•        Nonbacterial inflammatory disease caused by activation, interstitialliberation, and autodigestion of the pancreas by its own enzymes.

•        Inconclusive evidence regarding pathogenesis

–       Partial or intermittent ductal obstruction and increased ductal pressure

–       Biliary reflux

–       Duodenal juice reflux

AcutePancreatitis Aetiology

•        Gallstones and Alcohol account for 90%

•        Hyperlipidemia

•        Hypercalcemia

•        Familial

•        Pancreatic duct obstruction

–       Tumour

–       Pancreas divisum

•        Viral infection

•        Scorpion venom

•        Drugs

•        Idiopathic

AcutePancreatitis: Symptoms and signs

•        Midepigastric abdominal pain

•        Radiating to the back

•        Nausea and vomiting

•        Fever and tachycardia

•        Epigastric tenderness

•        Abdominal distention

•        Bluish discoloration in the flank (Grey Turner’s sign)

•        Bluish discoloration periumbilically (Cullen’s sign)

•        .

AcutePancreatitis

Diagnosis

•        It is supported by appropriate laboratory determinations andradiographic findings

•        Serum amylase is the most widely used lab test

•        Hyperamylasemia is commonly observed within 24 hrs. of the onset andgradually returns to normal

Persistenthyperamylasemia beyond the initial week may indicate the development ofpancreatic pseudocyst, phlegmon, abscess or ongoing acute pancreaticinflammation

AcutePancreatitis

Diagnosis

•        Elevated amylase levels may occur in other acute abdominal conditions,though levels rarely exceed 500 IU/dL

•        Urinary amylase excretion is increased and this may be very helpful incases where the serum amylase level has returned to normal.

•        Other lab. Findings

–       Moderate leukocytosis

–       Mild bilirubin elevation (<2mg/dL)

–       Raised Haematocrit

–       Hypocalcaemia (Calcium being complexed with fatty acids)

AcutePancreatitis

Radiographic findings

•        CXR and PFA non-specific findings

–       Sentinel loop

–       Pleural effusion (Left)

•        Abdominal Ultrasonography

–       Lithiasis of biliary tract

–       Pancreatic swelling

•        Computed Tomography with iv contrast

AcutePancreatitis

Clinical course

•        Early identification of patients at greater risk of complications allowsthem to be managed more aggressively, which appears to decrease the mortalityrate.

•        The severity and prognosis of an attack of acute pancreatitis can bepredicted by use of routinely available laboratory determinations.

•        Just the single finding of fluid sequestration exceeding 2 L/d for morethan 2 days is reasonably accurate dividing line between severe and mild tomoderate disease.

AcutePancreatitis

Ranson’s criteria for severity

•        On admission

–       Age >55 years

–       WBC >16000

–       Blood Glucose >200 mg/dL

–       LDH >350 iu/L

–       AST (SGOT) > 250 iu/dL

•        After 24 hours

–       Hematocrit fall >10%

–       BUN rise >8mg/dL

–       Serum Ca <8mg/dL

–       Arterial PO <60 mmHg

–       Base deficit > 4mEq/L

–       Fluid sequestration >600 mL

AcutePancreatitis

Ranson’s criteria for severity

PredictedMortality rates

0-2criteria = 2%

3 or 4criteria = 15%

5 or 6criteria = 40%

7 or 8criteria = 100%

AcutePancreatitis

Treatment

Goals ofmedical treatment

•        Reduction of pancreatic secretory stimuli

•        Correction of fluid and electrolyte derangements

AcutePancreatitis

Medical Treatment

•        Gastric suction

•        Fluid and electrolyte replacement

•        Antibiotics (+/-)

•        Oxygen

•        Octreotide, PPIs

•        Endoscopic sphincterotomy (ERCP)

AcutePancreatitis

Surgical Treatment

Indicatedin 4 specific circumstances

•        Uncertainty of Clinical Diagnosis (rare)

•        Treatment of Pancreatic Sepsis

–       Abscess up to 5%

•        Correction of Associated Biliary Tract Disease

•        Deterioration of Clinical Status (controversial)

Acute Pancreatitis

Complications

•        Abscess

•        Pseudocyst formation

•        Pancreatic ascites

•        Chronic pleural effusion

•        Gastrointestinal bleeding

•        Acute splenic vein thrombosis

•        Chronic Pancreatitis