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It's a retroperitoneal structure that lies in the epigastrium & left upper
quadrant, across the transpyloric line.
It's divided into head, neck, body, & tail that are crossed by the main
pancreatic duct, which in turn receives multiple tributaries. The main
pancreatic duct will open (with the common bile duct) into the
posteromedial aspect of the second part of the duodenum.
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ACUTE PANCREATITIS
ACUTE PANCREATITIS
It's one of the most common benign diseases that carry high mortality rate
which can reach 20%.
Pancreatic enzymes when they reach the ampulla of Vater, they will be
activated, so if there is any obstruction in this area due to any cause (e.g:
stones, tumor...), then there will be regurgitation of the active enzymes of
pancreas back into it causing autodigestion of it.
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ACUTE PANCREATITIS
:
1. Biliary tract disease 50% of pancreatitis cases in Jordan are due to biliary
tract diseases (mainly stones)
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ACUTE PANCREATITIS
One of these enzymes is the pancreatic lipase; this enzyme will start
breaking down fatty acids in a process called "saponification process", &
this process actually consumes a lot of calcium, so, as a result leading to
hypocalcemia
Now, calcium is very important for the contraction of the heart. If calcium
levels fall below 8mg/dl (2 mmol/IU) then the heart will stop & your patient
may die from hypocalcemia!
ALWAYAS REMEMBER >>> if you have a patient over 70 yrs old with acute
pancreatitis & renal failure >>> then you should examine the neck for any
parathyroid tumor
If a patient has increased levels of lipids (TAG) >> then this will lead to
atherosclerosis >> thus decreased blood supply to different tissues >>
ischemia of pancreas >>> eventually Pancreatitis
So as a summary…
HYPERcalcemia >>>>>> Pancreatitis >>>>>> HYPOcalcemia
HYPERlipidemia>>>>>> Pancreatitis >>>>>> more HYPERlipidemia
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ACUTE PANCREATITIS
9. Viral infection: Mumps & Coxaki B4 viruses both can cause pancreatitis.
So, if you have a child that comes to you complaining of severe epigastric
pain, examine his parotid glands, & if you find parotitis then immediately
you should suspect that the cause of pain is pancreatitis due to mumps.
Also, you can check his scrotum for orchitis (e.g: inflammation of the testes);
because mumps causes parotitis, orchitis, & eventually pancreatitis. (So
keep in mind that even children could have pancreatitis, not only adults)
Pathology
Then >> Suppuration & super added infection >> abcess formation
Then >> there might be pancreatic necrosis (so release of excessive lipase &
other pancreatic enzymes) >> leading to Fat Necrosis esp. around the elbow
(so the patient might be presented with multiple fat nodules around the
elbow)
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ACUTE PANCREATITIS
Then >> due to exudation & hemorrhage there will be loss of large amounts
of fluids >> Hypovolemia >> consequently Hypovolemic Shock
Also the exuded fluids might accumulate in the lesser sac (area between the
stomach & pancreas) >> producing Pseudocyst.
Signs
Shock: could be: Hypovolemic shock Or Septic shock (if there is super
added infection)
Jaundice: due to obstruction of the common bile duct by the
enlarged edematous head of pancreas.
Left pleural Effusion: because the tail of pancreas is located near the
left diaphragm >> so there will be sympathetic effusion & left pleural
effusion (collection of fluid in the left pleural cavity), this in turn will
cause hypoxia to the patient.
Acute Pulmonary Failure: this is due to:
(lung atelactesis + ischemia of the brain + left pleural effusion)
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ACUTE PANCREATITIS
SYMPTOMS
Patient of acute pancreatitis will come to you with very severe sudden
continuous epigastric pain that increase in severity every hour (Crescendo
fashion). This pain radiates to the back; because pancreas is a
retroperitoneal structure. The patient will come to you walking with his back
leaning forward "Hunched/bizarre position" – or as the Dr. said "Hunchow
Position", Sorry but I'm not sure of its spelling -.
Also, the patient will have nausea with vomiting for several times thus
contributing to the hypovolemia that is often caused by acute pancreatitis
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ACUTE PANCREATITIS
Investigations
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ACUTE PANCREATITIS
Note;
Increased serum amylase (hyperamylasemia) does not always mean
pancreatitis, any acute abdominal case can cause hyperamylasemia.
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ACUTE PANCREATITIS
For example.. In KAUH the used unit is the international unit (IU). Normally
this value must be 2-27. If you have a patient with serum amylase 270 IU (10
times the upper limit of your lab), then he's certainly positive for having
acute Pancreatitis
Other hospitals use King Armstrong Unit (KAU). Normally this value must be
1-13 KAU. So if they have a patient with serum amylase 130 KAU (10 times
the upper limit of their lab), then he's certainly having acute Pancreatitis
- Acute cholecystitis
#Causes of death:
1- Hypovolaemic shock
2- Electrolyte disturbances esp. hypocalcemia
3- Toxemia
4- Renal failure
5- Respiratory failure (collapse, consolidation, effusion)
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ACUTE PANCREATITIS
-Where would you admit him; ICU or normal ward? –taking in consideration
that normal ward entrance costs the pt 16 JD, while ICU entrance costs him
600 JD-
-How would you determine the mortality rate of him?..
Ranson's criteria
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ACUTE PANCREATITIS
- LDH & SGOT >> these are liver function tests that don't need more than 10
minutes to get their results
- Hematocrite fall
Suppose that you admit a patient with Hct (or PCV) of 42, & in the next day
his Hct becomes 35.
Or in another way.. if you admit a patient with Hb = 14, & next day his Hb
becomes 10
Suppose that we have a patient with BUN = 16mg/dl in the first 24 hours, &
in the next day it rises into 25
There is a rise of 6 mg/ dl which is more than 5 , so we give him one point
due to BUN rise > 5 mg/dl
- Base Deficit >> if there is decrease of HCO3 of more than 4 meq; that is
acidosis of more than 4 positive result so you give the patient one point.
- Fluid sequestration >> when a patient with acute Pancreatitis comes with
hypovolemic shock, we supply him with large amounts of fluid to correct his
situation, large portion of this fluid will be found in the intestine not
absorbed; mainly due to localized paralytic ileusin surgery we call this
"loss of third space". If we need more than 6 liters to correct the patient's
pressure so fluid sequestration is positive & you give the patient 1 point
for it.
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ACUTE PANCREATITIS
> 7 points test the limits of modern medicine; so your patient will
inevitably die!
If you have a patient with 3 points or more, you should immediately admit
him to the ICU
We call it "R-Regimen"
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ACUTE PANCREATITIS
1-Peritoneal lavage
2-Laparotomy
NOTE… In surgery, when you are in doubt about your patient's case it's
better to open & see rather than to wait.
2-Abdominal mass
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ACUTE PANCREATITIS
R-Regimen is used for all cases of Pancreatitis except the serous one which
is associated with pancreatic necrosis, treatment of this case will be
discussed at the end of the lecture
Complications:
2. Abscess formation
Rx you follow up your patient with ultrasound. In most of the cases the
cyst regresses & disappears spontaneously, but if you notice that the cyst is
increasing in size, then you should do "CT-scan guided aspiration" –this is
the one used nowadays-, or you can do laparotomy>> then open the cyst
into the stomach or jejunum to empty there (e.g: gastrocystostomy or
jejunocystostomy)
5. Chronic Pancreatitis >> here the patient will lose both the exocrine &
endocrine functions, so the patient will have DM & steatorrhea due to
malabsorbtion syndrome caused by loss of pancreatic enzymes.
In the past they used to do total pancreatictomy, which has 100% mortality
rate within 2 days.
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ACUTE PANCREATITIS
You obtain a knife and start to peel the pancreas until blood appear (this
means that you reach the living tissue), this is very bloody operation
After finishing this stage you bring a roll of gauze of 15 m., and immersed
it in aseptic solution, and then you make it as a ball and put it inside the
abdomen
After that you cover the abdomen with dressing (gauze) and send him to
the ICU (his abdomen is still opened) >> this operation called
After 48 hours, you bring your patient back to the theater remove the
ball of gauze look at the pancreas, you'll find it black again >> so you peel
it another time
Laparostomy
Pancreatic necrosictomy
Peritoneal lavage
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ACUTE PANCREATITIS
Chronic pancreatitis
Put in mind that almost all patients with cystic fibrosis develop chronic
pancreatitis.
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