Pancreatitis

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Pancreatitis

• What is it?
• Inflammation with or without parenchymal
• and peripancreatic fat necrosis
• Classified as acute or chronic
• Acute acute onset of symptoms in a previously
• healthy individual and the disappearance of those
• symptoms as the attack resolves
• Chronic patients either had prior attacks or
• pancreatic insufficiency symptoms may persist

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Pancreatitis
Why does it happen? Obstruction, trauma,
toxin Acinar cell injury Intrapancreatic
inflammatory response Systemic inflammatory
response
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Buizenstelsel van lever, gal en pancreas
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Pancreatitis acuut versus chronisch

• CHRONISCHE PANCREATIS
• Een geprotraheerde inflammatie gekarakteriseerd
  door permanente veranderingen van de anatomie,
  functionele afwijkingen, ook al is de oorzaak
  weggenomen.
• in voortgeschreden gevallen afname exocriene en
  endocriene functie

ACUTE PANCREATIS 1 Episode van inflammatie, op
zich zelf staand of als begeleidend verschijnsel
van een andere aandoening. 2 Kan volledig
genezen, maar kan ook voortschreiden tot een
hemorrhagische, necrotiserende vorm die
levensbedreigend kan zijn.
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Acute pancreatitis definitie
Acute pancreatitis - may occur as isolated or
as recurrent attacks - is distinguished from
chronic pancreatitis by absence of
continuing inflammation of irreversible
structural changes of permanent
impairment of pancreatic function
Rome 1988
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Acute pancreatitis pathogenese
1. Obstructie van secretie 2. Reflux van
duodenum inhoud 3. Reflux van gal 4. Verhoogde
permeabiliteit van het d. pancreaticus
epitheel 5. Premature zymogeen activatie
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Acute pancreatitis pathogenese
1. Obstructie van secretie 2. Reflux van
duodenum inhoud 3. Reflux van gal 4. Verhoogde
permeabiliteit van het d. pancreaticus
epitheel 5. Premature zymogeen activatie
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Acute pancreatitis pathogenese
1. Obstructie van secretie 2. Reflux van
duodenum inhoud 3. Reflux van gal 4. Verhoogde
permeabiliteit van het d. pancreaticus
epitheel 5. Premature zymogeen activatie
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Acute pancreatitis ethiologie
unknown
biliary
- medication - hyperlipidaemia - ERCP - trauma -
hypercalciaemie - pregnancy - penetrating ulcer -
organ transplantation - hereditary
other causes
alcoholism
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Acute pancreatitis prognosis
RANSONS CRITERIA revision by Hollender et al,
1983 (acute, ethanol-associated) Early
findings Age gt 55 yrs Serum glucose gt 200
mg/dl Leucocytosis gt 16.000 LDH gt 350
U/l Control findings 24-48 hrs after onset of
illness) Ht reduction gt 10 Serum calcium lt 2
mmol/l Base deficit gt 4 mmol/l Arterial pO2 lt 60
mm Hg Fluid deficit gt 6 liter
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Acute pancreatitis prognosis
GLASGOW CRITERIA (acute, non-ethanol-related
) White cell count gt 15.000 Blood glucose gt 10
mmol/l BUN gt 16 mmol/l Arterial PO2 lt 60
mmHg Serum Ca lt 2 mmol/l Serum Albumen lt32
g/l LDH gt 600 U/l ASAT or ALAT gt 200 U/l
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Acute pancreatitis
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Acute pancreatitis
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Acute pancreatitis

• TREATMENT GOALS
• SUPPORTIVE CARE
• REDUCE INFLAMMATION
• ASSESS AND TREAT COMPLICATIONS

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Management of acute necrotizing pancreatitis

• Prophylactic antibiotics ?
• ERCP and Biliary sphincterotomy ?
• Nutritional support TPN or Enteral feeding
  (jejunal feeding) ?
• Surgical debridement (Necrosectomy) ?

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Acute pancreatitis
SUPPORTIVE CARE

• No proven benefit
• antibiotics ?
• atropine
• calcitonine
• glucagon
• somatostatine
• H2 blockers
• antifibrinolytics
• phospholipase A2 inhibitors ?
• IL-10 ?

• Essential
• Close clinical surveillance
• NPO
• IV fluid replacement
• Nutritional support
• Relief of pain

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Chronische pancreatitis

• Chronic pancreatitis pathophysiology
• gt 60-70 alcohol
• 10-30 idiopathic
• hereditary
• miscellaneous (hyperparathyroidism, Sjogrens,
  SLE)

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Chronische pancreatitis

• Chronic pancreatitis clinical presentation
• (severe) pain
• diabetes mellitus
• steatorrhea

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Chronische pancreatitis

• Therapy of chronic pancreatitis
• Avoiding nutritive noxas (in 90 alcohol!)
• Treatment of endocrine and exocrine insufficieny
• Pain control and correction of pancreatic
  complications