أسئلة الخامسة عشر جراحة ثالثة الدلتا

Acute Pancreatitis Etiology

• Biliary tract disease accounts for 50% of cases
• Alcoholism abuse contributes to 25% of cases
• Other causes make up the remaining 25% of cases
• Post-operative complications can lead to pancreatitis after splenectomy, biliary or gastric surgery
• Congenital conditions such as pancreatic divisum can cause pancreatitis
• Trauma, including blunt force, penetration, ERCP, and Aortography, can induce pancreatitis
• Infections like mumps virus, infectious mononucleosis, and coxsackievirus can be causative factors
• Distortion of the ampulla of Vater due to duodenal or ampullary carcinoma may result in pancreatitis
• Metabolic disorders: hypercalcaemia, hyperlipaemia & hyperglycemia
• Certain Drugs e.g. corticosteroids, Thiazide, OCs.
• Hereditary factors involving mutation of the trypsinogen gene are implicated
• Autoimmune diseases, such as sclerosing pancreatitis, can lead to pancreatitis
• Some cases are idiopathic in nature

Pathology of Acute Pancreatitis

• Mild (edematous) pancreatitis involves pancreatic parenchyma that is edematous, congested, and infiltrated with inflammatory cells
• Gross architeratural features are preserved in mild cases
• Severe (hemorrhagic) pancreatitis is a severe form with autodigestion and escape of pancreatic enzymes into the peritoneum
• Severe pancreatitis can lead to erosion of blood vessels with hemorrhagic exudates
• Fat necrosis occurs: digestion of fat by lipase enzyme releasing FFA, reacts with Ca++ in the exudates Ca++ to form soap
• The saponification process results in dull, opaque, yellow-whitish patches in the greater omentum and mesentery
• Necrotizing pancreatitis: a most severe form has diffuse or focal areas of necrosis with bad prognosis and high chance of death

Presentation of Pancreatitis

• Equally affecting both sexes: Males = Females
• Biliary tract disease is more common in middle-aged and older adults
• Alcohol-related pancreatitis typically presents in young adults younger than 40 years old
• Infection, trauma, and drugs are more frequently seen in children and young adults
• Symptoms include acute abdominal pain described as colicky, epigastric, and referred to the back
• Pain intensity is increased when lying supine and relieved by leaning forward
• Vomiting occurs initially as a reflex due to gastric irritation, progressing due to paralytic ileus
• Patients often have a high temperature (fever)
• Tachycardia and hypotension
• Tachypnea and cyanosis may be present
• Tinge of jaundice occurs due to edema of the head of the pancreas
• Abdominal distension results from paralytic ileus

Physical Examination

• Bluish ecchymotic discoloration appears on the skin after 2-3 days

Inspection Observations

• Flanks display the Grey-Turner sign
• The area around the umbilicus shows Cullen’s sign
• The inguinal region presents Fox's sign
• These signs are due to the action of pancreatic ferments on subcutaneous fat, escaping from retroperitoneal tissues

Palpation Findings

• Epigastric tenderness and abdominal rigidity may be present
• Tenderness is often less severe than in cases of perforated peptic ulcer
• A tender palpable mass may indicate a pseudo-pancreatic cyst, appearing at the end of the 2nd week
• A pseudo-pancreatic abscess forms after the 3rd week

Percussion

• Late findings indicate a positive shifting dullness, suggesting free peritoneal fluid

Auscultation

• Bowel sounds are typically absent

General Complications

• Hypovolemic shock can result from loss of GIT fluids into peritoneal, pleural, and retroperitoneal spaces
• Circulating "kinins", formed by trypsin's action on plasma proteins, are potent vasodilators and hypotensive agents
• Hypokalemia is due to loss of GIT fluid via vomiting
• Hypocalcemia is the result of binding of calcium in calcium soaps within areas of fat necrosis and decreased serum albumin
• Serum albumin binds roughly 50% of circulating calcium
• Hypoxia can arise from retroperitoneal edema
• Elevation of the diaphragm, pleural effusion, and reduced ventilation due to pain are factors contributing to hypoxia

Local Complications

• Sepsis occurs from secondary infection of necrotic tissue in the pancreatic bed, forming an abscess after 1-2 weeks
• Acute renal failure presents due to hypovolemic shock
• Consumption coagulopathy can occur
• Haematemsis and melena result from Erosive ulcers and Left-sided portal hypertension
• Stricture of the transverse colon results from scarring of the transverse mesocolon, constricting the colon where it overlies the pancreas
• Paralytic ileus can develop
• Pseudo-pancreatic cysts are formed by the accumulation of pancreatic juice or amylase-rich fluid in the lesser sac
• Obliteration of the foramen of Winslow happens and enclosure by a fibrous or granulation tissue wall happens after 4 weeks.
• Pancreatic abscess occurs with the accumulation of pus near the pancreas with little or no pancreatic necrosis

Lab Investigations for Acute Pancreatitis

• A minimum level of 1000 units supports the diagnosis of acute pancreatitis
• Amylase levels usually normalise within 3-5 days
• Hyperamylasemia lasting more than 1 week indicates complications
• Normal levels are between 30-50 units per day
• Levels between 100-500 units support diagnosis
• Urinary amylase remains elevated longer than serum amylase
• Serum lipase is more specific than amylase for pancreatic issues
• Serum ribonuclease & deoxyribonuclease
• Blood tests may reveal leucocytosis for CBC
• Hyperglycemia due to release of glucagon from pancreatic damaged cells can be found
• Hypocalcaemia and Hypokalemia can occur

Radiological Investigations

• Abdominal X-rays help exclude other causes of an acute abdomen
• Sentinel jejunal loop: dilated loop of small bowel
• Colon cut off sign:
  • Gas distention of the right colon stops abruptly in the mid-transverse colon due to colonic spasm
• Pancreatic calcification indicates chronic pancreatitis
• Chest X-rays findings include elevation of the diaphragm from collapse and subdiaphragmatic fluid, as well as pleural effusion
• Ultrasound (US) and CT are the most important tools for assessing
• They help evaluate pancreatic enlargement, edema, and damage extent, as well as if calculi in the gallbladder or bile duct are present
• Needle aspiration identifies infected peripancreatic fluid
• MRI & MRCP are non-invasive and accurate assessment methods

Glasgow Criteria

• White blood cell count > 15,000/ mm3
• Blood glucose > 180 mg%
• SGOT > 200 Units/ml
• Serum lactic dehydrogenase > 600 Units / ml
• Blood urea nitrogen (BUN) > 45mg%
• Serum calcium < 8 mg %
• Arterial oxygen tension (PaO2) < 60 mmHg
• Serum albumin < 3.2 gm %
• If 3 or more factors are positive, then severe acute pancreatitis is indicated

Ranson Criteria

• Greater than 55 years of age
• White cell count greater than 16,000
• Fasting blood glucose greater than 200 mg%
• SGOT greater than 250 units/ ml
• Serum LDH is greater than 350 IU/ml
• After an initial 48 hours, hematocrit decreases more than 10% points
• Serum calcium is less than 8 mg %
• Fluid requirements are greater than 6 litres
• Blood urea nitrogen increases more than 5 mg %
• Arterial oxygen tension (PaO2) is less than 60 mmHg
• Base deficit is greater than 4 mEq/1
• If there is 0-2 signs mortality = 9%, 3-4 signs = 18%, 5-6 signs = 50% and finally greater than 6 signs a 90% mortality

Treatment of Acute Pancreatitis

• Admission to the hospital is the first step
• Absolute rest in the correct position in semi-sitting position
• This position relaxes the abdominal wall while lowering intra-abdominal pressure
• Pain is treated by Morphine or pethidine with atropine to prevent spasm of sphincter of Oddi
• Antibiotics can guard against secondary infection during recovery
• Fluid and electrolyte balances are kept in check: parental feeding, Calcium gluconate infusion is most important
• Management of shock involves replacement of crystalloids and plasma
• Blood is used during hemorrhagic cases under strict supervision of vital signs and CVP
• Oxygen mask or mechanical ventilation can aid those with respiratory failure
• Anticholinergic drugs (atropine) and Antisecretory drugs (somatostatine) can be used
• Pancreatic rest achieved by aspiration of gastric contents via nasogastric suction for 1-2 weeks

Surgical Treatment and Observation

• General aspects such as pulse, temperature, vomiting, and pain levels are key to observe
• Monitoring for local tenderness and rigidity
• Early signs indicate the need for Doubtful diagnosis and Failure of conservative treatment where, Known biliary tract disease with failure to improve after 48hr, more proactive treatment is needed
• For Doubtful diagnosis, laparotomy is recommended
• Acute-necrotising pancreatitis and Pseudo-pancreatic cyst are treated surgically as well as Pancreatic abscess

Procedures

• ERCP + sphinciterotomy + stone extraction for a Biliary tract stone
• Total or subtotal pancreatic necrosectomy for Necrotizing pancreatitis
• Cholecystectomy within 6 weeks of the attack for Pancreatitis due to gallstones

Chronic Pancreatitis

• Most often a result from long-term alcohol intake and gall stones are not likely the cause with progressive and irreversible destruction of the pancreas and symptoms include Inflammation, increase pressure within pancreatic duct, ischemia of pancreatic parenchyma
• Classical Triad: Steatorrhea, Weight loss, Diabetes confirmed by laparotomy, Irregularity and Induration

Treatment for Chronic Pancreatitis

• High protein and high caloric diet
• Pancreozymin- Insulin if diabetic- Analgesics drugs
• Avoid alcohol intake
• Surgical Indications: pancreatic duct strictures/stones along with persistent pain and development of complications
• Endoscopic balloon dilation is an Interventional management for bile duct obstruction
• Endoscopic sphincterotomy with endo stent placement
• Transduodenal sphincterotomy or sphincteroplasty is a surgical option for bile duct obstruction
• Cholecystojejunostomy with jeujenojejunostomy
• Roux-en-Y choledochojejunostomy for bile duct obstruction
• Total pancreatectomy and Pancreatic transplantation if required

Laboratory investigations

• Stool analysis detects steatorrhea and the presence of offensive/bulky stool

Radiological investigations

• Laparoscopy and LUS can be used to detect inflammation

Complications

• Common bile duct obstruction is present in 15% of cases due to pressure on the CBD and sphincter of Oddi
• Gut obstruction due to duodenal/pyloric obstruction
• Ascites: pressure on portal vein
• Edema of lower limbs: pressure on IVC
• Hematemsis & melena is caused by portal vein compression and splenic vein thrombosis, ultimately resulting in portal hypertension.
• Chills and fever due to ascending cholangitis.
• Pseudo-pancreatic cyst & abscess formation.
• Recurrent acute pancreatitis.