COMPLICATIONS OF

ACUTE
PANCREATITIS
Graciana Mapurisa
Tinomutenda Mpofu
OBJECTIVES
• To give a general overview of Acute Pancreatitis
• To outline the complications of Acute Pancreatitis
• To discuss major complications in detail
• To discuss the management of the various complications
Acute pancreatitis
• Inflammation of the pancreas
• Most common cause in Zimbabwe is alcohol, worldwide common
cause is biliary obstruction
• Presents with acute epigastric pain radiating to the back relieved by
bending forward
• Management is mostly conservative and surgery is usually reserved
for complications
……complications…..
Acute fluid collections
• Collection of fluid in or near the pancreas
• Ill defined or lacks fibrin wall or granulation
• Mostly peripancreatic
• >50% of the collection regresses spontaneously
• Remaining may form pseudocyst
CT guided aspiration at 1 puncture site to confirm it hasn’t
formed an abscess
Pancreatic pseudocyst

• persistent, post-inflammatory fluid collections, containing

enzyme-rich fluid, surrounded by a thick, mature wall

• -Lack an epithelial lining

• -Generally occur in the setting of pancreatitis or external

trauma
• - Traditionally, a pseudocyst was defined as any fluid collection
that persisted for longer than 4-6 weeks
• *D’Egidio classification of pseudocysts(homework)
Clinical Presentation
• - Intraparenchymal vs. peripancreatic
• Asymptomatic vs. symptomatic
• Symptomatology- failure to clinically progress (5-7 days)
- abdominal pain
- GI dysmotility (early satiety, nausea, vomiting,
obstruction)
-biliary obstruction
-pancreatic ascites/effusion
-hemorrhage
Diagnostic Evaluation
• US- cost-effective, limited in evaluation of pancreas and
retroperitoneum
• CT- primary modality used for the evaluation of cystic pancreatic
lesions
• MRI- may distinguish cystic neoplasm from pseudocyst
• MRCP- noninvasive, permit duct visualization; less sensitive as duct
may be obscured by pseudocyst
• ERCP- invasive, may exacerbate pancreatitis or seed sterile
collection with GI flora
• EUS/FNA- assess pancreatic enzymes, cytology, tumor and genetic
markers, mucin; risk of contaminating sterile collections
• Ductography- useful intraoperatively or with surgically or
percutaneous drains
 Indications for surgery
• Size> 6cm
• Formed pseudocyst
• Infected pseudocyst
• Cyst persisting after 6weeks
• Multiple cysts
• Communicating cysts/cysts with severe pain
• Thick walled pseudocyst
….complications…
• Rupture into bowel or peritoneum
• Infection(20%)
• Bleeding from the splenic vessels(7%)
• Duodenal obstruction
• Cholestasis due to CBD block
• cholangitis
 Therapeutic Options
• Open vs. laparoscopic procedures:

a. Cystic drainage procedures:

Cystogastrostomy
Cystoduodenostomy
 Roux-en-Y cystojejunostomy

b. Ductal drainage procedures:

Puestow(longitudinal pancreaticojejunostomy)
 Frey,
 Beger

c. Resection:
 distal pancreatectomy +/- splenectomy,
 cyst resection

Endoscopic:
 cystogastrostomy,
 Cystoduodenostomy
 trans papillary stent placement
Percutaneous drainage- less invasive, risks prolonged drainage, bacterial colonization
cystogastrostomy
cystojejunostomy
Puestow (longitudinal
pancreaticojejunostomy
Beger/Frey Procedures
Pancreatic Necrosis

• Focal or diffuse area of non viable parenchyma associated with

peripancreatic fat necrosis
• Sterile initially but eventually gets infected
• More necrosis correlates with likelihood of infection
• Diagnosis based on opacification of pancreatic tissue during a CT
scan with IV contrast
• Necrotic tissue indistinguishable from inflamed tissue for first 72-96h
• Infected necrosis diagnosed by the presence of gas or FNA cultures
• Clinical condition guides intervention

• Attempt to delay operative intervention to permit demarcation of

necrosis and compartmentalization of infection
Management

OPEN SURGERY IS GOLD STANDARD

• Laparatomy; necrosectomy with debridement done once with
continuous lavage(Beger’s Lavage)
• Necrosectomy(may need to be done several times) then
jejunostomy done after for nutritional purposes
• Procedure can be one lapascopically
• Endoscopic necrosectomy with ERCP
Pancreatic abscess
• Collection of pus in the lesser sac with less or no pancreatic
pancreas
• May slough off the splenic vessel causing torrential
hemorrhage
• Multiple in 60% cases
• May rupture into viscera or extend to the other part of the
abdomen
cont….
• Features of sepsis
• Tender palpable mass in the epigastric region
• Leukocytosis
Management:
• antibiotics
• US/CT guided aspiration
pseudoaneurysm
• Elastase action on vessel wall causing weakening and
aneurysmal dilatation
• Splenic(50%), gastroduodenal(15%) and
pancreaticoduodenal(10%) vessels
• Risk of rupture causing life threatening hemorrhage
• Upper GI bleeding when it ruptures into stomach or
duodenum
• Hemosuccus pancreatitis-rupture into the pancreatic
parenchyma
• Ix- CT angiogram
Management:
• Critical care
• Transfusion
• Emergency angiographic embolization
• Open surgery an ligation of the affected vessel
Pancreatic fistula
• Can occur due to ductal wall disruption or necrosis of post
necrosectomy
• Pancreaticoenteric or pancreaticocutaneous fistula
• Can be low output(<200ml) or high output(>200ml)
• Can be straight or curved
• Confirmed by biochemical analysis, CT Fistulogram
• If fistula persists for >6months the a sphincterectomy,
resection of fistula with pancreatic resection and
pancreaticojejunostomy done
Chronic pancreatitis

• The histologic hallmark of chronic pancreatitis is the persistent

inflammation and irreversible fibrosis associated with atrophy
of the pancreatic parenchyma
• Associated with chronic pain and endocrine (HgA1C) and
exocrine insufficiency (fecal elastase); may be associated with
jaundice, persistent N/V
• CT useful for diagnosis; ERCP- gold standard for defining ductal
anatomy- should be considered a therapeutic modality for
ductal complications
Other local Cx…..
• Splenic vein thrombosis
• Pancreatic ascites
• Paralytic ileus
• Mechanical small bowel obstruction
• Intestinal ischemia/necrosis
• Colonic stricture
Systemic complications
due to the enzyme activation and inflammation in the
pathophysiology of the disease
• Hypovolemic and septic shock
• CVS- hypotension, arrhythmias, DIC
• Respiratory system-ARDS, pulmonary edema, pancreatic
pleural effusion(Lt >Rt)
• Acute kidney injury (prerenal)
• Protein energy malnutrition
Cont….
Metabolic:
• Hypocalcemia
• Hyperglycemia
• Hypertriglyceridemia esp. in patients with dyslipidemias
…management…
• Continuous monitoring: Vitals, ECG, Urine output
• IV Fluids
• Ventilatory support
• FFPs and Platelet concentrate
• 10% calcium gluconate
• Antibiotics
• H2 e.g. IV Ranitidine or PPIs e.g. Omeprazole to prevent stress
ulcers and erosive bleeding
• Nasoenteric /Total parenteral nutrition with carbohydrate, amino
acids, vitamins and other essential elements
conclusion
• An effort should be made in making a correct, immediate
diagnosis and treatment of acute pancreatitis and to prevent
progression to developing its complications.
Moynihan described acute pancreatitis as “The most terrible of
all calamities that occur that occur in connection with abdominal
viscera”