Pancreatitis

Fiaz Maqbool Fazili - further reading-references

|2009-04-12 17:27:29

The BISAP score stratifies patients within the first 24 h of admission according
to their risk of in-hospital mortality and was able to identify patients at
increased risk of mortality prior to the onset of organ failure," the study
authors conclude. "The ability to risk-stratify patients early in their
course is a major step to improving future management strategies in acute
pancreatitis."Gu t. 2009;57:1645-1646, 1698-1703

Fiaz Maqbool Fazili - Advantages Of Early Risk

|2009-04-12 17:26:32

The ability to risk-stratify patients early in their disease course has several
important implications.
Early identification of high-risk patients may alert
doctors to institute aggressive resuscitation efforts and to consider specialty
care referral.
A severity index provides standardized criteria for enrolment of
subjects into future clinical studies.
A population-based system of risk
stratification provides an instrument for additional outcomes research.
For
example, identification of factors associated with death among patients with low
BISAP scores may help to lead to improvements in future management strategies in
AP.

Fiaz Maqbool Fazili - BISAP vs APACHEII

|2009-04-12 17:25:05

Studies available presently on BISAP show

Fiaz Maqbool Fazili - BISAP Score

|2009-04-12 17:24:24

Each point on the BISAP score was worth 1 point. There was a steady increase in
the risk for mortality with an increasing number of points:
0 point: observed
mortality rate of 0.1%
1 point: observed mortality rate of 0.4%
2 points:
observed mortality rate of 1.6%
3 points: observed mortality rate of 3.6%
4
points: observed mortality rate of 7.4%
5 points: observed mortality rate of
9.5%

Fiaz Maqbool Fazili - BISAP_ a new score 4mortalit

|2009-04-12 17:23:44

Haemoconcentration (haemoglobin is included as a continuous variable)
Atlanta
Symposium criteria for organ failure systolic blood pressure, creatinine,
partial pressure of arterial oxygen (PaO2).
Altered mental status; defined as
any record of disorientation, lethargy somnolence, coma or stupor in the medical
record.

Fiaz Maqbool Fazili - BISAP_A new score for risk cal

|2009-04-12 17:22:33

Following candidate risk factors in model development:
Individ ual Ranson signs:
age, white blood cell (WBC) count, glucose, aspartate aminotransferase (AST),
blood urea nitrogen (BUN), lactate dehydrogenase (LDH) and serum calcium.

Pleural effusion(on chest radiography or CT).
The Systemic inflammatory
response syndrome (SIRS) defined by the presence of 2 of the following
criteria:

Fiaz Maqbool Fazili - BISAP-A new mortality-based pr

|2009-04-12 17:21:38

BISAP is a simple and accurate method for the early identification of patients
at increased risk for in-hospital mortality.
5 variables identified that
predicted in-hospital mortality, each of which is assigned 1 point if present
during the first 24 hours:
B_blood urea nitrogen more than 25 mg/dL,

I_impaired mental status,
S_systemic inflammatory response syndrome,
A_age
older than 60 years
P_pleural effusion.

Fiaz Maqbool Fazili - BISAP-A new mortality-based pr

|2009-04-12 17:20:24

BISAP-Identification of patients at risk for mortality early in the course of
acute pancreatitis (AP) is an important step in improving outcome,
Current
methods of risk stratification in AP have important limitations;Current methods
of risk stratification in AP have important limitations.
The Ranson and
modified Glasgow score contain data not routinely collected at the time of
hospitalization.
Both require 48 h to complete, missing a potentially valuable
early therapeutic window.
The most commonly utilised prediction scoring system
for clinical research studies in AP is the Acute Physiology and Chronic Health
Examination (APACHE) II.A new mortality-based prognostic scoring system for use
in acute pancreatitis may help identify patients at increased risk for
in-hospital morta

Fiaz Maqbool Fazili

|2008-04-07 20:40:17

Controversy has emerged because of the observation that intravenous contrast
impairs the microcirculation of the pancreas in rats with acute necrotizing
pancreatitis and may increase the severity of the disease. These results could
not be reproduced in the opossum. No prospective human trials have been
published to date. Most experts believe the benefits of detecting necrosis
outweigh any potential risk.

No objective clinical selection criteria exist
that can determine which patients should have CT to assess the risk of severe
pancreatitis. Imaging is clearly indicated when the cause of abdominal pain is
unclear. In patients with known acute pancreatitis, however, CT is reserved for
patients with clinical, biochemical, or physiologic indications of severe
disease. There is no information suggesting that routine CT in patients with
milder disease (low APACHE II or Ranson scores) would result in upstaging a
significant number of patients

Fiaz Maqbool Fazili - ctsacn

|2008-04-07 20:39:55

Furthermore, the integrity of the pancreatic duct can be assessed by means of
MRCP in an MRI study; this is important, since in previous studies pancreatic
duct rupture was reported in about 30% patients with acute pancreatitis. In both
CT and MRI studies of the pancreas, pancreatic necrosis can be diagnosed when
segments of pancreatic parenchyma do not enhance on images obtained following
intravenous contrast administration. These unenhanced areas have been proved to
represent necrotic regions when correlated with findings at pancreatic
debridement. While some have suggested that the site of necrosis within the
pancreas may further predict outcome, others have found no such correlation. The
presence of peripancreatic fluid collections is usually associated with severe
disease. Echo-enhanced US has been recently reported as a new initial imaging
approach; it can be used as an alternative in patients in whom both CT and MRI
are contraindicated.

Co ntroversy has emerged because of the observation that
intravenous contrast impairs the microcirculation of the pancreas in rats with
acute necrotizing pancreatitis and may increase the severity of the disease.
These results could not be reproduced in the opossum. No prospective human
trials have been published to date. Most experts believe the benefits of
detecting necrosis outweigh any potential risk.

No objective clinical selection
criteria exist that can determine which patients should have CT to assess the
risk of severe pancreatitis. Imaging is clearly indicated when the cause of
abdominal pain is unclear. In patients with known acute pancreatitis, however,
CT is reserved for patients with clinical, biochemical, or physiologic
indications of severe disease. There is no information suggesting that routine
CT in patients with milder disease (low APACHE II or Ranson scores) would result
in upstaging...

Fiaz Maqbool Fazili

|2008-04-07 20:38:14

the occurrence of sepsis (r²=0.99), and death (r²=0.99), and it was a better
prognostic indicator than the Ranson criteria for complications and mortality. A
modified CT severity index, which simplifies the evaluation of pancreatic
necrosis, inflammatory changes, and extrapancreatic complications, has also been
proposed. There are isolated reports of clinical scoring systems yielding
equivalent or superior results to imaging tests. However, it also should be
remembered that most clinical systems require a second assessment within 48
hours to monitor progression or stability, as opposed to relatively
instantaneous evaluation at imaging.

Contrast CT and/or gadolinium enhanced MRI
can both be used to assess pancreatic necrosis and evaluate peripancreatic
inflammation and fluid collections. MRI is particularly useful in patients who
cannot receive iodinated contrast material due to prior adverse contrast
reaction or renal insufficiency. Furthermore, the integrity of the pancreatic
duct can be assessed by means of MRCP in an MRI study; this is important, since
in previous studies pancreatic duct rupture was reported in about 30% patients
with acute pancreatitis. In both CT and MRI studies of the pancreas, pancreatic
necrosis can be diagnosed when segments of pancreatic parenchyma do not enhance
on images obtained following intravenous contrast administration. These
unenhanced areas have been proved to represent necrotic regions when correlated
with findings at pancreatic debridement. While some have suggested that the site
of necrosis within the pancreas may further predict outcome, others have found
no such correlation. The presence of peripancreatic fluid collections is usually
associated with severe disease. Echo-enhanced US has been recently reported as a
new initial imaging approach; it can be used as an alternative in patients in
whom both CT ...

Fiaz Maqbool Fazili - Scoring systems

|2008-04-07 20:37:46

Physiologically based scoring systems such as the APACHE II and Ranson's
criteria are designed to identify early prognostic signs that predict severity
of clinical course in an individual patient. In 1985, one study showed that
although clinical scoring systems were highly correlated with increasing CT
severity, disease severity was sometimes underestimated by clinical scoring
alone. The key criterion for identifying patients at higher risk for fatal
pancreatitis is the presence of pancreatic necrosis. The scoring system was
revised in 1990 to account for the significance of pancreatic necrosis, and the
CT severity index was created. The utility of the Ranson's criteria compared
with that of the CT severity index (the Balthazar CT severity index) for
predicting the necessity for admission to an intensive care unit in patients
with acute pancreatitis was analyzed in a recent study. The Balthazar CT
severity index correlated highly with the overall occurrence of complications
(r²=0.96), the occurrence of sepsis (r²=0.99), and death (r²=0.99), and it was a
better prognostic indicator than the Ranson criteria for complications and
mortality. A modified CT severity index, which simplifies the evaluation of
pancreatic necrosis, inflammatory changes, and extrapancreatic complications,
has also been proposed. There are isolated reports of clinical scoring systems
yielding equivalent or superior results to imaging tests. However, it also
should be remembered that most clinical systems require a second assessment
within 48 hours to monitor progression or stability, as opposed to relatively
instantaneous evaluation at imaging.

Fiaz Maqbool Fazili - CT MRI in ac pancreatitis

|2008-04-07 20:37:17

CT is an insensitive detector of biliary calculi, but is superb in delineating
the pancreas and acute pancreatitis-associa ted abnormalities. CT scanning
provides clear images of the pancreas and adjacent structures and allows for the
differentiation of acute pancreatitis from other abdominal diseases. CT findings
helpful for diagnosing acute pancreatitis include pancreatic enlargement,
peripancreatic inflammatory changes, fluid collections, and uneven density of
pancreatic parenchyma.

MRI demonstrates pancreatic enlargement and the
inflammatory changes around the pancreas. It has the advantage of no x-ray
exposure. Nevertheless, it takes a much longer time to scan the pancreas in
comparison with CT. MRCP has a high accuracy in detecting bile duct stones

Fiaz Maqbool Fazili - acute pancreatitis- course

|2008-04-07 20:36:21

endoscopic retrograde cholangiopancreatogr aphy (ERCP) to relieve the cause of
obstruction. US is less successful in diagnosing choledocholithiasis and has
limited applications in the early staging of the disease. Visualization of the
pancreas is often impaired because of overlying bowel gas, and the detection of
intraparenchymal and retroperitoneal fluid collections correlates poorly with
pancreatic necrosis. US with color Doppler is useful to detect venous
complications of acute pancreatitis. In patients with suspected acute gallstone
pancreatitis or with repeating acute pancreatitis, ERCP is used to reach a
definite diagnosis and to investigate the etiology. EUS is useful, when needed
clinically, to detect common duct stones when initial studies are negative. It
can often determine an etiology (usually biliary) in patients initially
diagnosed with idiopathic acute pancreatitis.

CT is an insensitive detector of
biliary calculi, but is superb in delineating the pancreas and acute
pancreatitis-associa ted abnormalities. CT scanning provides clear images of the
pancreas and adjacent structures and allows for the differentiation of acute
pancreatitis from other abdominal diseases. CT findings helpful for diagnosing
acute pancreatitis include pancreatic enlargement, peripancreatic inflammatory
changes, fluid collections, and uneven density of pancreatic parenchyma.

MRI
demonstrates pancreatic enlargement and the inflammatory changes around the
pancreas. It has the advantage of no x-ray exposure. Nevertheless, it takes a
much longer time to scan the pancreas in comparison with CT. MRCP has a high
accuracy in detecting bile duct stones.

Fiaz Maqbool Fazili - acute pancreatitis- course

|2008-04-07 20:35:00

do not correlate with the severity of the disease. Consequently, clinical
scoring systems and imaging tests have been advocated to classify individual
patients. Furthermore, the diagnosis may be overlooked in the absence of typical
enzyme elevation. In some patients, acute pancreatitis may be present in the
absence of enzyme abnormalities.

Imag ing tests available for the diagnosis of
acute pancreatitis include transabdominal US, endoscopic ultrasound (EUS), CT
scanning, MRI, and MRCP. Imaging tests are performed for various reasons,
including detection of gallstones, detection of biliary obstruction, diagnosis
of pancreatitis when the clinical situation is unclear, identification of
patients with high-risk pancreatitis, and detection of complications of
pancreatitis.

US to detect gallbladder stones should be performed in every
patient with acute pancreatitis, even alcoholics. US is also effective in
diagnosing biliary obstruction, which, when present, often prompts endoscopic
retrograde cholangiopancreatogr aphy (ERCP) to relieve the cause of obstruction.
US is less successful in diagnosing choledocholithiasis and has limited
applications in the early staging of the disease. Visualization of the pancreas
is often impaired because of overlying bowel gas, and the detection of
intraparenchymal and retroperitoneal fluid collections correlates poorly with
pancreatic necrosis. US with color Doppler is useful to detect venous
complications of acute pancreatitis. In patients with suspected acute gallstone
pancreatitis or with repeating acute pancreatitis, ERCP is used to reach a
definite diagnosis and to investigate the etiology. EUS is useful, when needed
clinically, to detect common duct stones when initial studies are negative. It
can often determine an etiology (usually biliary) in patients initially
diagnosed with idiopathic acute pancreatitis.
...

Fiaz Maqbool Fazili - ACUTE PANCREATITIS _COURSE

|2008-04-07 20:33:11

in any of the above sites of inflammation. Distant organ complications can lead
to organ failure, protracted course, and death. Prediction of which patients
will develop these complications is achieved through clinical scoring systems
and imaging findings. Choice of scoring system is beyond the scope of these
recommendations.

Ac ute pancreatitis is suspected in patients presenting with
epigastric upper abdominal pain that is acute in onset, rapidly increasing in
severity, and persistent without relief. The intensity of the pain almost always
results in the patient seeking medical attention. Differential diagnosis
includes mesenteric ischemia, perforated ulcer, intestinal obstruction, biliary
colic, and myocardial infarction. Serum amylase and/or lipase levels can be
considered diagnostic when the reported value(s) is >3 times normal. Lipase
levels are more specific for acute pancreatitis, as hyperamylasemia may be
present in a variety of conditions. Of note is that serum enzyme levels do not
correlate with the severity of the disease. Consequently, clinical scoring
systems and imaging tests have been advocated to classify individual patients.
Furthermore, the diagnosis may be overlooked in the absence of typical enzyme
elevation. In some patients, acute pancreatitis may be present in the absence of
enzyme abnormalities.

Imag ing tests available for the diagnosis of acute
pancreatitis include transabdominal US, endoscopic ultrasound (EUS), CT
scanning, MRI, and MRCP. Imaging tests are performed for various reasons,
including detection of gallstones, detection of biliary obstruction, diagnosis
of pancreatitis when the clinical situation is unclear, identification of
patients with high-risk pancreatitis, and detection of complications of
pancreatitis.

US to detect gallbladder stones should be performed in every
patient with acute pancreatitis, e...

Fiaz Maqbool Fazili - acute pancreatitis course

|2008-04-07 20:30:07

Determinants of the natural course of acute pancreatitis are pancreatic
parenchymal necrosis, extrapancreatic retroperitoneal fatty tissue necrosis,
biologically active compounds in pancreatic ascites, and infection of necrosis.
Early in the course of acute pancreatitis, multiple organ failure is the
consequence of various inflammatory mediators that are released from the
inflammatory process and from activated leukocytes attracted by pancreatic
injury. Late in the course, starting the second week, local and systemic septic
complications are dominant. Around 80% of deaths in acute pancreatitis are
caused by septic complications.

The infection of pancreatic necrosis occurs in
8%-12% of acute pancreatitis patients and in 30 to 40% of patients with
necrotizing pancreatitis. Pancreatic inflammation may result in enlargement of
the gland, peripancreatic inflammation with or without fluid, solitary or
loculated fluid collections, necrosis of pancreatic parenchyma, and subsequent
infection in any of the above sites of inflammation. Distant organ complications
can lead to organ failure, protracted course, and death. Prediction of which
patients will develop these complications is achieved through clinical scoring
systems and imaging findings. Choice of scoring system is beyond the scope of
these recommendations.

Ac ute pancreatitis is suspected in patients presenting
with epigastric upper abdominal pain that is acute in onset, rapidly increasing
in severity, and persistent without relief. The intensity of the pain almost
always results in the patient seeking medical attention. Differential diagnosis
includes mesenteric ischemia, perforated ulcer, intestinal obstruction, biliary
colic, and myocardial infarction. Serum amylase and/or lipase levels can be
considered diagnostic when the reported value(s) is >3 times normal. Lipase
levels are more specific...

Fiaz Maqbool Fazili

|2008-04-07 20:24:45

his document focuses on the diagnosis and initial evaluation of patients with
suspected or known acute pancreatitis. It does not address interventional
procedures or documentation of complications such as abscess, pseudocyst, or
pseudoaneurysm.

Int erstitial edematous pancreatitis and necrotizing
pancreatitis are the most frequent clinical manifestations of acute
pancreatitis. Fluid collections associated with acute pancreatitis usually
resolve spontaneously. Pancreatic pseudocysts are fluid collections that persist
for 6 weeks or more. Pancreatic abscess is usually a complication of necrotizing
pancreatitis, typically developing after 3 to 5 weeks. Determinants of the
natural course of acute pancreatitis are mediators that are released from the
inflammatory process and from activated leukocytes attracted by pancreatic
injury. Late in the course, starting the second week, local and systemic septic
complications are dominant. Around 80% of deaths in acute pancreatitis are
caused by septic complications.

The infection of pancreatic necrosis occurs in
8%-12% of acute pancreatitis patients and in 30 to 40% of patients with
necrotizing pancreatitis. Pancreatic inflammation may result in enlargement of
the gland, peripancreatic inflammation with or without fluid, solitary or
loculated fluid collections, necrosis of pancreatic parenchyma, and subsequent
infection in any of the above sites of inflammation. Distant organ complications
can lead to organ failure, protracted course, and death. Prediction of which
patients will develop these complications is achieved through clinical scoring
systems and imaging findings. Choice of scoring system is beyond the scope of
these recommendations.

Ac ute pancreatitis is suspected in patients presenting
with epigastric upper abdominal pain that is acute in onset, rapidly increasing
in severity, and persistent wit...

Fiaz Maqbool Fazili - Acute pancreatitis- va;lues of

|2008-04-07 20:22:06

This document focuses on the diagnosis and initial evaluation of patients with
suspected or known acute pancreatitis. It does not address interventional
procedures or documentation of complications such as abscess, pseudocyst, or
pseudoaneurysm.

Int erstitial edematous pancreatitis and necrotizing
pancreatitis are the most frequent clinical manifestations of acute
pancreatitis. Fluid collections associated with acute pancreatitis usually
resolve spontaneously. Pancreatic pseudocysts are fluid collections that persist
for 6 weeks or more. Pancreatic abscess is usually a complication of necrotizing
pancreatitis, typically developing after 3 to 5 weeks. Determinants of the
natural course of acute pancreatitis are pancreatic parenchymal necrosis,
extrapancreatic retroperitoneal fatty tissue necrosis, biologically active
compounds in pancreatic ascites, and infection of necrosis. Early in the course
of acute pancreatitis, multiple organ failure is the consequence of various
inflammatory mediators that are released from the inflammatory process and from
activated leukocytes attracted by pancreatic injury. Late in the course,
starting the second week, local and systemic septic complications are dominant.
Around 80% of deaths in acute pancreatitis are caused by septic
complications.

The infection of pancreatic necrosis occurs in 8%-12% of acute
pancreatitis patients and in 30 to 40% of patients with necrotizing
pancreatitis. Pancreatic inflammation may result in enlargement of the gland,
peripancreatic inflammation with or without fluid, solitary or loculated fluid
collections, necrosis of pancreatic parenchyma, and subsequent infection in any
of the above sites of inflammation. Distant organ complications can lead to
organ failure, protracted course, and death. Prediction of which patients will
develop these complications is achieved through clinical...

Fiaz Maqbool Fazili

|2008-04-07 20:21:26

MAJOR RECOMMENDATIONS

ACR Appropriateness Criteria®

Clinical Condition: Acute
Pancreatitis

Varian t 1: Etiology unknown, first episode of
pancreatitis.
Radiol ogic Exam Procedure Appropriateness Rating Comments
US,
abdomen 8
CT, abdomen 6 With or without contrast
MRI, abdomen, with
contrast 6
MRI, abdomen, MRCP 6
US, abdomen, endoscopic 5

Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most
appropriate

Note: Abbreviations used in the tables are listed at the end of the
"Major Recommendations" field.

Variant 2: Severe abdominal pain,
elevated amylase lipase, no fever or evidence of fluid loss at admission;
clinical score pending.
Radiologic Exam Procedure Appropriateness Rating
Comments
US, abdomen 8
CT, abdomen 7 With or without contrast
MRI,
abdomen, MRCP 7
MRI, abdomen, with contrast 6
Appropriateness Criteria
Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate

Note:
Abbreviations used in the tables are listed at the end of the "Major
Recommendations" field.

Variant 3: Severe abdominal pain, elevated amylase
lipase, 48 hours later assuming no improvement or degradation (assume no prior
imaging).
Radiologic Exam Procedure Appropriateness Rating Comments
CT,
abdomen 8 With or without contrast
US, abdomen 7
MRI, abdomen, with
contrast 7
MRI, abdomen, MRCP 7
Appropriateness Criteria Scale
1 2 3 4 5
6 7 8 9
1 = Least appropriate 9 = Most appropriate

Note: Abbreviations used in
the tables are listed at the end of the "Major Recommendations"
field.

Variant 4: Severe abdominal pain, elevated amylase lipase, fever and
elevated white blood cell count.
Radiologic Exam Procedure Appropriateness
Rating Comments
CT, abdomen 9 With or without contrast
US, abdomen 7
MRI,
abdomen, with contrast 7
MRI, abdomen, MRCP 7
Ap...

Fiaz Maqbool Fazili - Acute pancreatitis recommendat

|2008-04-07 20:20:13

Fiaz Maqbool Fazili - CAUSES OF HYPERLIPASEMIA

|2008-04-07 20:15:40

Causes of hyperlipasemia (high lipase levels) may include:

Pancreatitis - also
known as inflammation of the pancreas, can cause amylase and lipase levels to be
increased up to 3 times normal. Both values should be increased, in order to
carry the diagnosis of pancreatitis.
Lipase may be increased in tumors of the
pancreas, or stomach certain stomach conditions. These conditions are usually
painful.
Gall bladder infection - Inflammation of the gall bladder
(cholecystitis), may cause increased lipase levels (hyperlipasemia).
Kidney
failure can cause hyperlipasemia.
Your doctor or healthcare provider will
diagnose hyperlipasemia by drawing a tube of blood. If there is a suspicion of
gall bladder, pancreas or kidney problems, an ultrasound of the gall bladder or
pancreas, or a CAT scan of your abdomen, may also be performed.
You may be at
risk for pancreatitis if you are:
Extremely overweight (obese)
Have high
triglyceride levels in your blood
Drink too much alcohol
Have been diagnosed
with gall bladder stones (which may block the flow of secretions from the
pancreas to the intestines)
Or have a family history of pancreatitis

fiazfazili - complications of necrosectomy

|212.138.64.xxx |2006-10-12 15:27:44

Complications of Necrosectomy

Necr osectomy by any of the above-mentioned
techniques is always attended by postoperative complications. It is also to be
understood that most of these patients will require multiple laparotomies and
debridement of necrotic tissues along with drainage of intra-abdominal or
retroperitoneal collections.
The usual attendant local complications are
intra-abdominal and retroperitoneal collections, bleeding from pancreatic bed,
pancreatic fistulas, small bowel and colonic fistulas. Pancreatic and
gastrointestinal fistulas occur in about 40% of patients following necrosectomy
and often require additional surgery for closure.] The mortality from
debridement with open or closed techniques is approximately 20%.
Necrotising
pancreatitis also has prominent effects on long- term pancreatic exocrine and
endocrine function in about 50% of patients, but most preserve a good overall
functional status. The development of pancreatic insufficiency varies with the
extent of pancreatic parenchymal necrosis,
(ref-subr atrau)

fiazfazili - Types Of surgical pocedures

|212.138.64.xxx |2006-10-12 15:25:43

Types of Surgical Procedures

The choice of procedure is determined by the
duration from onset, the degree of organ dysfunction and the position of the
necrotic material within the abdomen.Current surgical practice in necrotising
pancreatitis involves necrosectomy of the devitalized pancreatic and
peripancreatic tissues.
There are three main types of surgical debridement. [1.
Conventional drainage.

2. Open or semi-open procedure.

3. Closed
procedure.
Conventi onal drainage involves necrosectomy with placement of
standard surgical drains and re-operation as required by clinical criteria or
lack of improvement according to imaging studies.[
Open or semi-open
(laparostomy) management involves necrosectomy and either scheduled repeated
laparotomies or open packing that leaves the abdominal wound exposed for
frequent changes of dressing
Closed management involves necrosectomy with
extensive intraoperative lavage of the pancreatic bed. The abdomen is closed
over large bore drains for continuous high volume postoperative lavage of the
lesser sac
Comparison of the results of conventional, open/semi open
(laparostomy) and closed techniques from published series showed collective
mortality rates as 42%, 20% and 21% respectively indicating a superiority for
necrosectomy followed by re-exploration or continuous lavage. Studies comparing
conventional relaparotomy with laparostomy after necrosectomy for pancreatic
necrosis offer no difference in terms of morbidity and mortality

fiazfazili - Management; general principles

|212.138.64.xxx |2006-10-12 15:23:07

Patients of acute necrotising pancreatitis are usually very
sick with single or multiple organ dysfunction. Most have a
Ranson's score of more than 3 and APACHE II score of more than 8.
They are usually managed in the intensive care or
therapy units with majority of them requiring ventilation.
As mentioned earlier, roughly 20% patients of
acute pancreatitis will develop necrosis with a
mortality rate exceeding 80%.Management and monitoring of
this group must therefore be more intensive.

The general
guidelines for management include the following
[
â€¢ General Management

â€¢ Confirmation
of diagnosis

â€¢ Prevention
of infection

â€¢ Nutritional Support

â€¢ Monitoring
of complications General mangement

fiazfazili - timig of surgery in gall stone

|212.138.64.xxx |2006-10-12 15:19:07

In acute gallstone pancreatitis, the ideal point in time for laparoscopic
cholecystectomy with special reference to the severity of the disease has been
prospectively analyzed. Laparoscopic cholecystectomy with preoperative
endoscopic common bile duct clearance is recommended as a treatment of choice
for biliary acute pancreatitis. In mild disease, this is performed safely within
7 days, whereas in severe disease, especially in extended pancreatic necrosis,
at least 3 weeks should elapse because of an increased infection risk.

fiazfazili - Indication of surgery & compli

|212.138.64.xxx |2006-10-12 15:16:23

Surgery INDICATIONS
Surgery is indicated for (i) infected
pancreatic necrosis and (ii) diagnostic uncertainty
and (iii)complications. The most common cause of death
in acute pancreatitis is secondary infection. Infection is
diagnosed based on 2 criteria

Gas bubbles on CT scan (present
in 20 to 50 % of infected necrosis)
Positive bacterial culture
on FNA (fine needle aspiration, usually CT or US guided)
of the pancreas.
Surgical options for
infected necrosis include:

Conventi onal management
- necrosectomy with simple drainage
Closed management -
necrosectomy with closed continuous lavage
Open management
- necrosectomy with planned staged reoperations at definite
intervals (up to 7 reoperations in
some cases)
[edit]
Complicati ons
Complications can be
systemic or locoregional.

Sys temic complications include
ARDS, multiple organ dysfunction syndrome, DIC, hypocalcemia
(from fat saponification), hyperglycemia and insulin
dependent diabetes mellitus (from pancreatic insulin
producing beta cell
damage)
Locoregional complications include
pancreatic pseudocyst and phelgmon / abscess formation,
splenic artery pseudoaneurysms, hemorrhage from erosions
into splenic artery and vein, thrombosis of the splenic
vein, superior mesenteric vein and portal veins (in
descending order of frequency), duodenal obstruction,
common bile duct obstruction, progression to chronic
pancreatitis
Complications null Surgery Indications

fiazfazili - scoring sytems fallacies

|212.138.64.xxx |2006-10-12 15:14:47

Scoring systems have been designed to categorize levels of risk in populations,
allowing comparison of different series. However, they can not identify
accurately the risk that an individual patient will develop a complication The
most widely used systems at the present time are Ranson's, APACHE II, and
Balthazar's.Atlanta

fiazfazili - scoring systems in pancreatiti

|212.138.64.xxx |2006-10-12 15:12:35

SCORING SYSTEMS â€“ Despite the proliferation of scoring systems for grading
acute pancreatitis, none is ideal. In many studies, clinical assessment for
severe pancreatitis (looking for signs of peritonitis, shock, or respiratory
distress) was as accurate as most scoring systems. However, routine clinical
assessment identifies only 34 to 44 percent of patients with severe acute
pancreatitis . With the exception of the APACHE II system ,the other systems
(eg, Ranson, Glasgow, Banks, and Agarwal and Pitchumoni take 48 hours to
complete, can be used only once, and do not have a high degree of sensitivity
and specificity Furthermore, some have limited utility since they focus on
specific complications to be prevented (eg, Banks) or are invasive (eg, Leeds
diagnostic peritoneal lavage) [and are therefore uncommonly used.

fiazfazili - pancreatitis CT scan severity

|212.138.64.xxx |2006-10-12 14:33:10

CT Findings can be classified into the following categories for easy recall
:

Intrapancreatic - diffuse or segmental enlargement, edema, gas bubbles,
pancreatic pseudocysts and phlegmons/abscesses (which present 4 to 6 wks after
initial onset)
Peripancreatic / extrapancreatic - irregular pancreatic
outline, obliterated peripancreatic fat, retroperitoneal edema, fluid in the
lessar sac, fluid in the left anterior pararenal space
Locoregional - Gerota's
fascia sign (thickening of inflamed Gerota's fascia, which becomes visible),
pancreatic ascites, pleural effusion (seen on basal cuts of the pleural cavity),
adynamic ileus,
[edit]
Balthazar scoring
Balthazar Scoring for the Grading
of Acute Pancreatitis

Grad e A - normal CT
Grade B - focal or diffuse
enlargement of the pancreas
Grade C - pancreatic gland abnormalities and
peripancreatic inflammation
Grade D - fluid collection in a single location

Grade E - two or more collections and/or gas bubbles in or adjacent to
pancreas

fiazfazili - acute pancreatitis-Ct scan sev

|212.138.47.xxx |2006-04-25 14:39:04

CT abdomen
CT abdomen should not be performed before the 1st 48 hours of onset
of symptoms as early CT (

fiazfazili - acute pancreatitis-assessment

|212.138.47.xxx |2006-04-25 14:35:33

Investigations
Bloo d Investigations - Full blood count, Renal function tests,
Liver Function, serum calcium, serum amylase and lipase, Arterial blood gas

Imaging - Chest Xray (for exclusion of perforated viscus), Abdominal Xrays
(for detection of "sentinel loop" dilated duodenum sign, and gallstones
which are radioopaque in 10 %) and CT abdomen
[edit]
Amylase and
lipase
Serum amylase rises 2 to 12 hours from the onset of symptoms, and
normalises within 1 week
Serum lipase rises 4 to 8 hours from the onset of
symptoms and normalises within 8 to 14 days.
Serum amylase may be normal (in
10 % of cases) for cases of acute on chronic pancreatitis (depleted acinar cell
mass) and hypertriglyceridemia
Reasons for false positive elevated serum
amylase include salivary gland disease (elevated salivary amylase) and
macroamylasemia
If Lipase level is about 2.5 to 3 times that of Amylase, it is
an indication of pancreatitis due to Alcohol[1].
[edit]
CT abdomen
CT
abdomen should not be performed before the 1st 48 hours of onset of symptoms as
early CT (

fiazfazili - watch pancreatitis on this sit

|212.138.64.xxx |2006-04-15 12:04:27

World's Largest Medical Academic Website. Journals, Congresses ...... 86k. Acute
Necrotizing Pancreatitis, Fiaz Maqbool Fazili, MD, 356k. ... 86k. Acute
Necrotizing Pancreatitis, Fiaz Maqbool Fazili, MD, 356k. ...

www.muratalper.com /linkler/hematosunum .asp - 97k - Supplemental Result
dr
Fiaz Fazili

fiazfazili - pancreatitis

|212.138.64.xxx |2006-04-15 10:08:41

dear doctors ; view slide show at thsi site "what surgeons should know
baout pnacreatitis
Medind ia-Download / View SlidesDr. Fiaz M.Fazili Contact
Author, 6/22/2005 5:46:10 AM. 14. urinary infection in children & vesico
ureteric reflux. Dr.Ramesh Babu Contact Author, 2/8/2004 ...
www.medindia.ne
t/slides/download. asp?name=&service=&p age=2&startpage=1
Dr Fiaz Maqbool
Fazili MbBBS;MS;MAMs; FICA:FICS(USA)Surgeo n KFH medinah

regilam

|203.212.250.xxx |2006-02-06 16:50:22

dane	\|212.138.47.xxx \|2005-09-11 22:43:06

please add to this tutorial classification&diagn ostic features of each when
classified seprately

baker

|168.187.0.xxx |2005-08-08 13:57:12

pancreatitis mnemonics;
the fatter the worse the course
ranson's
eleven=ocean's eleven

admin

|217.155.232.xxx |2005-06-06 20:51:41

Thanks, thats a nice addition

myat25 - Principles of treatment

|161.142.87.xxx |2005-06-06 08:15:24

P = Pain killer
A = Antibiotics in severe cases
N = Nasogastric intubation
in acute cases
C = CVP line in severe cases
R = Resuscitation with Fluids
E
= Electrolytes balance
A = Arterial Blood Gas analysis
S = Surgical
intervention

Surgeons Net Focusing on Surgical Education

Main Menu

User Login

Syndicate

Aetiology

Diagnosis

Treatment

Complications

3.26 Copyright (C) 2008 Compojoom.com / Copyright (C) 2007 Alain Georgette / Copyright (C) 2006 Frantisek Hliva. All rights reserved."