Common bile duct

The pancreas is a large gland behind the

stomach and next to the small intestine. The
pancreas does two main things:
It releases powerful digestive enzymes into
the small intestine to aid the digestion of
food.
It releases the hormones insulin and
glucagon into the bloodstream. These
hormones help the body control how it uses
food for energy.
Pancreatitis: is a disease in which the pancreas
becomes inflamed. Pancreatic damage happens when
the digestive enzymes are activated before they are
released into the small intestine and begin attacking
the pancreas.
 ACUTE PANCREATITIS

Definition: Acute pancreatitis is an acute

inflammatory process of the pancreases. The
degree of inflammation varies from mild edema
to severe hemorrhagic necrosis
 ETIOLOGY & RISK FACTORS
 Alcohol abuse

Cholelithiasis

Abdominal trauma and metabolic disorders like-

(hyperparathyroidism, hyperlipidemia, renal failure).

Viral infection, absceses, cysts, certain drugs like

corticosteroids contraceptives, sulfonamides ,metabolic

disorders etc.
 PATHOPHYSIOLOGY:

Etiologic factors (alcoholisim ,biliary tract

disease,infection,drugs etc.)

Injury to the pancreatic cells

Activation of pancreatic enzymes in the

pancreas rather then intestine.

Edema,necrosis,haemorrhage,vascular
permeability,shock
 THE CLINICAL FEATURES
 :

Abdominal pain ,usually constant, mid- epigastric or

periumbical,radiating to the back or flank.
Nausea & vomiting.
Low grade fever.
Epigastric tenderness to deep palpation
Dry mucus membrane, hypotention ,cold,clamy
skin,cyanosis,trachycardia which may reflect mild to
moderate dehydration.
Ecchymosis (bruising) in the flank or around the
umbilicus may indicate severe pancreatic.
Jaundice ,mental confusion and agitation may
occur.
Respiratory distress and hypoxia .
Patient may develop diffuse pulmonary infiltrates,
dyspnoea,trachycardia and abnormal blood gas.
Hypotention is typical and reflect hypovolemia
and shock.
Lungs are frequently involved with crackles
present.
 INVESTIGATION:
Laboratory test Normal finding Abnormal
finding
Serum amylase 53-123unit/l >200u/L
Serum lipase 10-150unit/l ↑
Blood glucose 70-110mg/dl ↑
Serum calcium ↓
Serum 55-139mg/dl ↑
triglyceride
x- ray abdomen shows pancreatic-
calcification or peri-pancreatic gas pattern .
USG & CT Scan identify an increase in the
diameter of the pancreas ,detect pancreatic
cyst, abscesses or pseudo cyst.
Chest x-ray shows pleural effusion.
ERCP& MRCP can be done to identify the
cause of pancreatitis due to blockage or
obstruction of the pancreatic duct.
 MANAGEMENT:
MEDICAL MANAGEMENT:
(1)-Pain management: pain is usually treated with
narcotic analgesics.
Morphin is the drug of choice.
The current recommendation is use of morphin.
Nitro glycerine: Relaxation of smooth muscles and
relief of pain.
Antispasmodics:to decrease vagal stimulation and
pancreatic out flow.
(2)-Maintain fluid volume status,electrolytes
blance and nutritional status:

Ringer lactate solution i/v infusion to

correct fluid and electrolyte balance.
Patient should be treated in ICU those with
severe pancreatitis.
Invasive monitoring include urinary
catheterization,CVP monitoring is indicated.
Injection calcium gluconate, if tetany is
present.
(3)- maintain pancreatic rest:

NPO till the patient is pain free and has

bowel sounds.
Food should be started with clear liquids
then gradually to a regular low fat diet.
Moderate to severe pancreatitis is
supported nutritionally by TPN.
(4) Respiratory care
so the close monitoring of arterial blood gases,
use of humidified oxygen , if necessary
intubation and mechanical ventilation.

(5)-Biliary drainage:
Placement of biliary drains and stents in the
pancreatic duct through endoscopy to re-
establish drainage of the pancreas to decrease
pain.
(6) DRUG THERAPY:
Drug
- Morphine.(morphin sulphate
Nitroglycerine
Antispasmodics(dicyclomide)
H2 receptor antagonist/PPI:
(ranitidine,omeprazole)
AntacidS
Carbonic anhydrase
inhibitor(acetazolamide)
somatostatin
Antibiotic
Insulin
Action Side effect
depress pain impulse tramission at drowsiness, dizziness, confusion,
the spinal cord level by interacting blurred vision .
with opioid receptors.
Relaxation of smooth muscle and
relief pain.
Decrease vagal stimulation and
pancreatic out flow.
Decrease Hcl acid secretion Diarrhoea, flatulence,head ache.
Nutralisation of gastric HCLacid
secretion and subsequent decrease
of pancreatic secretion
Reduces volume and bicarbonate
concentration of pancreatic
secretion.
It is a potent hormone, act as a Anxiety, tremor,
vasoconstrictor. thrombophlebitis,CHF,palpitation
.
Bectriocidal action
 SURGICAL MANAGEMENT:
Diagnostic laparotomy may be
performed to establish pancreatic
drainage or to resect a necrotic
pancreatic debride
 CHRONIC PANCREATITIS:

Chronic pancreatitis is a
continuous ,prolonged,inflammatory,
and fibrosing process of the pancreas.
The pancreas becomes progressively
destroyed as it is replaced with fibrotic
tissue. stricture and calcification may
also occur in the pancreas.
 Etiology
1-Chroni obstructive pancreatitis: it is associated
with biliary disease. The most common cause is
inflammation of the sphincter associated with
cholelithiasis. cancer of the ampulla of vater,
duodenum,pancreas can cause this type of
pancreatitis.
 2-Chronic calcifying pancreatitis: there is
inflammation and sclerosis , mainly in the head of
the pancreas and around the pancreatic duct. This
type is common form and also called alcohol-
induced pancreatitis.
 PATHOPHYSIOLOGY:

In chronic calcifying pancreatitis the

ducts are obstructed with protein
precipitates. These precipitates block
the pancreatic duct and eventually
calcify followed by fibrosis and
glandular atrophy. pseudo cyst and
abscesses are commonly develop.
 CLINICAL MANIFESTATIONS
Major clinical manifestation is
abdominal pain, as heavy, gnawing
feeling or sometimes as burning and
cramping not relived by food or
antacid.
Malabsorption with weight loss.
Constipation, Mild jaundice with dark
urine, Diabetes mellitus.
 DIAGNOSTIC STUDIES:
Increased serum bilirubin and alkaline
phosphate.
ERCP report shows gross dilation and
microcytes in the pancreatic duct.
CT, MRI, MRCP show a variety of changes,
including calcifications, ductal dilation,
pseudo cysts and pancreatic enlargement.
 
 MANAGEMENT:
The focus is on prevention of further attack,
relief of pain and control of pancreatic exocrine
and endocrine insufficiency.
Pancreatic enzyme replacement , such as
pancreatin and pancrelipase contain
amylase ,lipase and trypsin are used to replace
the pancreatic enzyme.
Bile salts are some time given to ensure the
absorption of fat-soluble vitamins and prevent
further fat loss.
Diabetes is controlled with insulin and

oral hypoglycemic agent.

Alcohol must be totally eliminated.

Treatment sometimes require surgery ,

e.g choledocho jejunostomy.

 HEALTH EDUCATION:
The patient is informed about the
disease process and the aggravating
factor.
The patient is informed about the
importance of eliminating alcohol.
Information given about the Alcohol
Anonymous group.
Instruct to take pancreatic enzyme with
food.
Teach blood glucose monitoring.
Explain patient and family to
gradually resume alow-fat diet.
Advise to increase activity gradually
with rest periods.
Stress that, no treatment will be
effective, if alcohol consumption is
continued.
THANK YOU