1
ACUTE PANCREATITIS
Xu San rong
Department of Gastroenterology
Huashan Hospital
Fudan university
2
DEFINITION
? An acute inflammatory process of the pan-
creas usually associated with sever pain
in the upper abdomen
? in most instances,blood levels of pancrea-
tic enzymes are increased
? sever acute pancreatitis,organs failure
and/or local complications(necrosis,absc-
ess,psuedocyst)
3
PATHOLOGY(1)
? Mild acute pancreatitis(MAP)
characterized by interstitial edema associ-
ated with inflammatory cell within parench-
yma,and microscopic parenchyma necro-
sis can be detectable,
4
PATHOLOGY(2)
? Sever acute pancreatitis(SAP)
Sever necrotizing pancreatitis(SNP)
macroscopic evidence of either focal or
diffuse necrosis and hemorrhage of the
pancreatic parenchyma
5
PATHOGENY AND
PATHOGENESIS(1)
1 common channel and reflux of duodenal juice
gallstones
infection
Bile juice
reflux trypsin
Kinin
systems
elastase
Trypsin
chymotrypsino
Phospho-
lipaseA2
Steatolytic
enzymes
Sever pain
hemorrhage
Free fat
acid
Serum
calcium,
6
PATHOGENY AND
PATHOGENESIS(2)
2 alcoholic and overeat
3 obstruct of main pancreatic duct
4 diseases round the duodenum/ampullary
region
5 postoperative pancreatitis and pancreatic
trauma
7
PATHOGENY AND
PATHOGENESIS(3)
6 infectious agents
7 medications,corticosteroids,estrogens
8 disorders of endocrinology and metabol-
ism,hyperparathyroidism,hyperlipidemia
9 others,
8
PATHOGENY AND
PATHOGENESIS(4)
6 inflammatory media theory
In AP,the leukocytes that appear first in
areas of inflammation are neutrophils,then
macrophages,monocytes,lymphocytes,
and other cells,These cells can secrete a
lot of inflammatory media,
(1) platelet activating factor,PAF
(2)prostaglandins,PGs
9
PATHOGENY AND
PATHOGENESIS(5)
(3) leukotriens,LTs
(4) kallikrein kinin systems,KKS
(5) tumor necrosis factor-?,TNF- ?
(6) nitrogen monoxide,NO
(7) complements
(8) others,nuclear factor ?B(NF- ?B),toll
like receptors(TLRs),
10
DIAGNOSIS(1)
? Clinical characteristics
1 abdominal pain
2 fever
3 nausea and vomiting
11
DIAGNOSIS(2)
4 hypotension and shock
5 jaundice
6 tenderness
7 peritoneal irritation sign
tenderness,rebound tenderness,and
abdominal muscle tenseness
8 Grey-turner sign,cullen sign
9 ascites
12
DIAGNOSIS(3)
? Assistant examination
1 blood examination
(1) blood routine examination(white blood
cell count),
hematocrit(Hct),packed cell volume(PCV)
(2) blood,urine amylase
Salivary-am,P-am
Cam/Ccr
13
DIAGNOSIS(4)
(3) serum lipase
(4) blood glucose(>10mmol/L),
serum calcium(<2.0mmol/L)
(5) * plasma methemalbumin
2 abdominal B-ultrasonography
14
DIAGNOSIS(5)
3 X-ray examination
(1) plane film of the abdomen
(2) chest radiography
(3) abdominal computed tomography
4 magnetic resonance imaging
MR cholangiopancreatography(MRCP)
15
DIAGNOSIS(6)
? Diagnosis
clinical characteristics,
elevated value of serum and urine amylase
ultrasonography and CT,MR
16
DIFFRENTIAL DIGNOSIS
1 perforated hollow viscus
2 biliary colic
gallstone
acute cholangitis,acute cholecystitis
3 acute intestinal obstruction
4 mesenteric ischemia
5 angina pectoris
acute myocardial infarction(AMI)
6 others,
17
PREDICTORS OF SEVERITY(1)
1 Ranson`s criteria of severity
at admission during initial 48 hours
age > 55 years Hct decrease of 10mg/dL
wbc > 16*109/L bun increase of > 5mg/dL
glucose > 11.2umol/L calcium < 8 mg/dL
LDH < 350iu/L PaO2 < 60mmHg
AST > 250u /L base deficit > 4 mEq/L
fluid sequestration > 6 L
3 < mild; ? 3 medial; ? 5 poor prognosis
18
PREDICTORS OF SEVERITY(2)
2 CT grading system of Balthazar and ranson
pancreatic manifestations of CT
grade A normal-appearing pancreas 0
grade B focal or diffuse enlargement of the pancreas 1
grade c gland abnormalities accompanied by mild 2
peripancreatic inflammatory changes
grade D fluid collection in a single location 3
grade E ? 2 fluid collections near the pancreas or 4
gas either within the pancreas or within
peripancreatic inflammation
19
PREDICTORS OF SEVERITY(3)
computed tomography severity index
CT grade score necrosis score
A 0 none 0
B 1 one third 2
C 2 one half 4
D 3 > one half 6
E 4
CT grade(0-4) + necrosis(0-6) = total score
20
Complications
? Local complications
1 pancreatic necrosis
2 pancreatic pseudocyst
3 pancreatic abscess
21
Complications
? Systemic complications
1 major systemic complications
(1) respiratory failure
(2) renal failure
(3) hypotention
2 dangerousest complication
multiple organs failure(MOF)
22
TREATMENT(1)
? Management of internal medicine
1 common management
(1) intensive care unit
(2) fluid resuscitation
(3) nutritional support
23
TREATMENT(2)
2 treatment of infection
MAP SAP
3 relief of pain
(1) anisodamine (654-2)
(2) bucinnazine,pethidine
(3) 0.1% procaine
(4) * morphine
24
TREATMENT(3)
4 inhibition of pancreatic secretion
(1) atropine,anisodamine (654-2)
(2) H2-receptor antagonists(H2RAs)
proton pump inhibitors(PPI)
(3) somatostatin,and
its analog octreotide
25
TREATMENT(4)
5 inhibition of activated pancreatic enzymes
(1) aprotinin
(2) gabexate mesilate(FOY)
6 drugs of anti-inflammatory factors
7 eliminating inflammatory mediators
peritoneal lavage
8 traditional medicine
26
TREATMENT(5)
8 endoscopic sphincterotomy
9 surgery
indications,
(1) with 3 days after diagnosis of gallstone
pancreatitis,
(2) pancreatic abscess and psuedocyst,
(3) perforated hollow viscus,
necrosis of intestine
27
PROGNOSIS
? Mild acute pancreatitis
? sever acute pancreatitis
with focal necrosis(sterile),10%-15%
with focal necrosis(infected),30%-35%
with diffuse necrosis,30%-60%
with multiple organs of failure,> 90%
28
PREVENTION
? Remove the gallstones in the common bile
duct
? avoid drunk
? avoid overeat
? others
29
THANK YOU
ACUTE PANCREATITIS
Xu San rong
Department of Gastroenterology
Huashan Hospital
Fudan university
2
DEFINITION
? An acute inflammatory process of the pan-
creas usually associated with sever pain
in the upper abdomen
? in most instances,blood levels of pancrea-
tic enzymes are increased
? sever acute pancreatitis,organs failure
and/or local complications(necrosis,absc-
ess,psuedocyst)
3
PATHOLOGY(1)
? Mild acute pancreatitis(MAP)
characterized by interstitial edema associ-
ated with inflammatory cell within parench-
yma,and microscopic parenchyma necro-
sis can be detectable,
4
PATHOLOGY(2)
? Sever acute pancreatitis(SAP)
Sever necrotizing pancreatitis(SNP)
macroscopic evidence of either focal or
diffuse necrosis and hemorrhage of the
pancreatic parenchyma
5
PATHOGENY AND
PATHOGENESIS(1)
1 common channel and reflux of duodenal juice
gallstones
infection
Bile juice
reflux trypsin
Kinin
systems
elastase
Trypsin
chymotrypsino
Phospho-
lipaseA2
Steatolytic
enzymes
Sever pain
hemorrhage
Free fat
acid
Serum
calcium,
6
PATHOGENY AND
PATHOGENESIS(2)
2 alcoholic and overeat
3 obstruct of main pancreatic duct
4 diseases round the duodenum/ampullary
region
5 postoperative pancreatitis and pancreatic
trauma
7
PATHOGENY AND
PATHOGENESIS(3)
6 infectious agents
7 medications,corticosteroids,estrogens
8 disorders of endocrinology and metabol-
ism,hyperparathyroidism,hyperlipidemia
9 others,
8
PATHOGENY AND
PATHOGENESIS(4)
6 inflammatory media theory
In AP,the leukocytes that appear first in
areas of inflammation are neutrophils,then
macrophages,monocytes,lymphocytes,
and other cells,These cells can secrete a
lot of inflammatory media,
(1) platelet activating factor,PAF
(2)prostaglandins,PGs
9
PATHOGENY AND
PATHOGENESIS(5)
(3) leukotriens,LTs
(4) kallikrein kinin systems,KKS
(5) tumor necrosis factor-?,TNF- ?
(6) nitrogen monoxide,NO
(7) complements
(8) others,nuclear factor ?B(NF- ?B),toll
like receptors(TLRs),
10
DIAGNOSIS(1)
? Clinical characteristics
1 abdominal pain
2 fever
3 nausea and vomiting
11
DIAGNOSIS(2)
4 hypotension and shock
5 jaundice
6 tenderness
7 peritoneal irritation sign
tenderness,rebound tenderness,and
abdominal muscle tenseness
8 Grey-turner sign,cullen sign
9 ascites
12
DIAGNOSIS(3)
? Assistant examination
1 blood examination
(1) blood routine examination(white blood
cell count),
hematocrit(Hct),packed cell volume(PCV)
(2) blood,urine amylase
Salivary-am,P-am
Cam/Ccr
13
DIAGNOSIS(4)
(3) serum lipase
(4) blood glucose(>10mmol/L),
serum calcium(<2.0mmol/L)
(5) * plasma methemalbumin
2 abdominal B-ultrasonography
14
DIAGNOSIS(5)
3 X-ray examination
(1) plane film of the abdomen
(2) chest radiography
(3) abdominal computed tomography
4 magnetic resonance imaging
MR cholangiopancreatography(MRCP)
15
DIAGNOSIS(6)
? Diagnosis
clinical characteristics,
elevated value of serum and urine amylase
ultrasonography and CT,MR
16
DIFFRENTIAL DIGNOSIS
1 perforated hollow viscus
2 biliary colic
gallstone
acute cholangitis,acute cholecystitis
3 acute intestinal obstruction
4 mesenteric ischemia
5 angina pectoris
acute myocardial infarction(AMI)
6 others,
17
PREDICTORS OF SEVERITY(1)
1 Ranson`s criteria of severity
at admission during initial 48 hours
age > 55 years Hct decrease of 10mg/dL
wbc > 16*109/L bun increase of > 5mg/dL
glucose > 11.2umol/L calcium < 8 mg/dL
LDH < 350iu/L PaO2 < 60mmHg
AST > 250u /L base deficit > 4 mEq/L
fluid sequestration > 6 L
3 < mild; ? 3 medial; ? 5 poor prognosis
18
PREDICTORS OF SEVERITY(2)
2 CT grading system of Balthazar and ranson
pancreatic manifestations of CT
grade A normal-appearing pancreas 0
grade B focal or diffuse enlargement of the pancreas 1
grade c gland abnormalities accompanied by mild 2
peripancreatic inflammatory changes
grade D fluid collection in a single location 3
grade E ? 2 fluid collections near the pancreas or 4
gas either within the pancreas or within
peripancreatic inflammation
19
PREDICTORS OF SEVERITY(3)
computed tomography severity index
CT grade score necrosis score
A 0 none 0
B 1 one third 2
C 2 one half 4
D 3 > one half 6
E 4
CT grade(0-4) + necrosis(0-6) = total score
20
Complications
? Local complications
1 pancreatic necrosis
2 pancreatic pseudocyst
3 pancreatic abscess
21
Complications
? Systemic complications
1 major systemic complications
(1) respiratory failure
(2) renal failure
(3) hypotention
2 dangerousest complication
multiple organs failure(MOF)
22
TREATMENT(1)
? Management of internal medicine
1 common management
(1) intensive care unit
(2) fluid resuscitation
(3) nutritional support
23
TREATMENT(2)
2 treatment of infection
MAP SAP
3 relief of pain
(1) anisodamine (654-2)
(2) bucinnazine,pethidine
(3) 0.1% procaine
(4) * morphine
24
TREATMENT(3)
4 inhibition of pancreatic secretion
(1) atropine,anisodamine (654-2)
(2) H2-receptor antagonists(H2RAs)
proton pump inhibitors(PPI)
(3) somatostatin,and
its analog octreotide
25
TREATMENT(4)
5 inhibition of activated pancreatic enzymes
(1) aprotinin
(2) gabexate mesilate(FOY)
6 drugs of anti-inflammatory factors
7 eliminating inflammatory mediators
peritoneal lavage
8 traditional medicine
26
TREATMENT(5)
8 endoscopic sphincterotomy
9 surgery
indications,
(1) with 3 days after diagnosis of gallstone
pancreatitis,
(2) pancreatic abscess and psuedocyst,
(3) perforated hollow viscus,
necrosis of intestine
27
PROGNOSIS
? Mild acute pancreatitis
? sever acute pancreatitis
with focal necrosis(sterile),10%-15%
with focal necrosis(infected),30%-35%
with diffuse necrosis,30%-60%
with multiple organs of failure,> 90%
28
PREVENTION
? Remove the gallstones in the common bile
duct
? avoid drunk
? avoid overeat
? others
29
THANK YOU
