Acute pancreatitis refers to an acute inflammatory process of the pancreas, usually accompanied by abdominal pain and elevations of serum pancreatic enzymes. Definition of Acute Pancreatitis Classification (Atlanta 1992) AcutepancreatitisMild acute pancreatitisSevere acute pancreatitisExamples of drug-induced pancreatitisPathogenesis & Pathophysiologyl l Obstruction of intracellular Obstruction of intracellular trafficking of zymogens trafficking of zymogensl l Systemic toxic injury of Systemic toxic injury of the acinar cells the acinar cellsl l Changes in cell and tissue Changes in cell and tissue compartmentalization compartmentalizationl l Intracellular activation of Intracellular activation of intrapancreatic enzyme intrapancreatic enzymel l Inhibition of zymogen Inhibition of zymogen release from acinar cell release from acinar celll l Synthesis of enzymes as Synthesis of enzymes as inactive zymogens inactive zymogens l l Storage of zymogen granules Storage of zymogen granulesl l Inhibitors of protease activity Inhibitors of protease activityl l Serum antiproteases Serum antiproteasesl l Unimpeded drainage of Unimpeded drainage of secretions and lymph secretions and lymphl lBlood perfusion of organsBlood perfusion of organsDefense mechanismTriggering factorPathophysiology (Acinar Cells) (Acinar Cells)GallstonesGallstonesAlcoholAlcoholIntra-acinar triggeringIntra-acinar triggeringIntracellular enzymeIntracellular enzymeactivationactivationExtra-acinar triggeringExtra-acinar triggeringIncreased intraductalIncreased intraductalpressure withpressure with disruption disruption of the ductof the duct barrierbarrierInterstitial enzymeInterstitial enzyme activationactivationl l Inflammation Inflammationl lEnzyme activationEnzyme activationl lDisruption ofDisruption of compartmentalizationcompartmentalizationl l‘Autodigestion’‘Autodigestion’Acute Alcohol EffectsAutodigestionEnzyme EffectsClinical ManifestationSevereSevere acute pancreatitisacute pancreatitisMild Mild acute pancreatitisacute pancreatitisSymptoms and SingsSIRS is present if two or more of the four criteria SIRS is present if two or more of the four criteria are present.are present.Systemic inflammatory response syndrome (SIRS)l l Necrosis Necrosis l l Abscess Abscess l l Pseudocyst Pseudocyst l l Paralytic ileus Paralytic ileus l l Ascites Ascites l l Pleural effusion Pleural effusion l lJaundice Jaundice l l Pulmonary failure Pulmonary failurel l Renal failure Renal failurel l Shock Shockl l Encephalopathy Encephalopathyl l GI Bleeding GI Bleedingl l Septicemia Septicemial l Hyperglycemia Hyperglycemial l Hypocalcemia Hypocalcemial l Metabolic acidosis Metabolic acidosisComplicationsSystemicLocal Systemic ComplicationsOne of the followings:One of the followings:lLocal complications (pancreatic)Local complications (pancreatic)? Necrosis Necrosis ? Pseudocyst Pseudocyst ? Abscess Abscessl Organ failure Organ failurel ≥ 3 Ranson criteria ≥ 3 Ranson criterial ≥ 8 APACHE II points ≥ 8 APACHE II points Definition of Severe acute pancreatitis Ranson Criteria This system uses 14 routinely measured parameters of This system uses 14 routinely measured parameters of physiological activity and biochemical function, and physiological activity and biochemical function, and generates a numerical score that depends on the deviation generates a numerical score that depends on the deviation of those parameters from the normal range.of those parameters from the normal range.The Acute Physiology and Chronic Health The Acute Physiology and Chronic Health Evaluation Evaluation (APACHE) (APACHE) II II Grey Turner sign Acute Biliary Pancreatitisl l C-reactive protein C-reactive protein (>150mg/ml at 48h)(>150mg/ml at 48h)l l Methemalbumin Methemalbumin l l Ribonuclease Ribonuclease l l Procalcitonin Procalcitoninl l Interleukins: IL-6, -8, -10 Interleukins: IL-6, -8, -10l l Complement factors Complement factors l l Phospholipase A2 activity Phospholipase A2 activity l l Adhesion molecules Adhesion moleculesl l PMN elastase PMN elastaseMarkers of severe acute pancreatitisPlasma CRP in Acute PancreatitisTemporal peaks after onset of disease and Temporal peaks after onset of disease and validity ratings of the best markers of validity ratings of the best markers of necrotizing pancreatitisnecrotizing pancreatitisl Amylasel Lipase Laboratory Examination –Serum pancreatic enzymesCauses of Increased Serum Amylasel l CRPCRPl l Leukocytes Leukocytesl l Hemoglobin (hematocrit) Hemoglobin (hematocrit) l l Platelet count Platelet count l l Coagulation parameters Coagulation parameters l l Creatinine Creatininel l Alkaline phosphatase Alkaline phosphatasel l Bilirubin Bilirubinl l ALT, AST ALT, ASTl l Glucose Glucosel l Blood gas analysis (pO2, pCO2, BE) Blood gas analysis (pO2, pCO2, BE) l l Serum electrolytes (K, Na, Ca) Serum electrolytes (K, Na, Ca)Laboratory ExaminationUltrasound imaging of acute pancreatitis Normal pancreasNormal pancreas Acute pancreatitis: pancreas is Acute pancreatitis: pancreas is enlarged, enlarged, hypoechoic and hetero-hypoechoic and hetero- geneous geneous L: liver; PC: portal confluenceL: liver; PC: portal confluenceComputerized Tomography : Indicationsl Diagnosisl Prognosisl Detect the complicationsComputed Tomography Severity Index Computed Tomography Severity Index (CTSI)(CTSI) CTSI = grade points + degree of necrosis CTSI = grade points + degree of necrosisCTSI correlates with mortality in acute pancreatitisMild acute pancreatitisSevere acute pancreatitisInfected pancreatic necrosis Pancreatic pseudocystPancreatic NecrosisDay1 Day 7 Day 28  Diagnosis lCharacteristic signs and symptomslThree folds elevation of serum amylase / lipase levellPositive evidence in imaging studiesl l Complications of peptic ulcerComplications of peptic ulcerl Acute cholecystitis/biliary colic Acute cholecystitis/biliary colicl Intestinal obstruction Intestinal obstructionl Mesenteric infarction Mesenteric infarctionl Peritonitis Peritonitisl Colonic diverticulitis/perforation Colonic diverticulitis/perforationl Pleurisy/pneumonia Pleurisy/pneumonial Myocardial infarction Myocardial infarctionl Renal colic Renal colic Differential DiagnosisTreatmentl l Hospitalization Hospitalizationl l NPO, Intravenous fluids NPO, Intravenous fluids l l Monitoring of blood pressure, Monitoring of blood pressure, pulse and temperature pulse and temperaturel l Acid suppression Acid suppressionl l Analgesia Analgesial l Nasogastric intubation Nasogastric intubationl l Central venous catheter Central venous catheterl l Bladder catheter for urinary Bladder catheter for urinary monitoring monitoringl l Parenteral /enteral nutrition Parenteral /enteral nutritionl l Antibiotics Antibioticsl l Urgent ERCP/EST Urgent ERCP/ESTBasic TherapyObligatoryObligatoryOptionalOptional Activities of Antibiotics (Pharmacokinetic studies on concentrations (Pharmacokinetic studies on concentrations in the human pancreas) in the human pancreas)Specific TherapyProtease inhibitors:Protease inhibitors: Aprotinin Aprotinin Gabexate mesylate Gabexate mesylate Hormones/inhibitors of Hormones/inhibitors of pancreatic secretion: pancreatic secretion: Glucagon Glucagon Calcitonin Calcitonin Atropine Atropine Somatostatin Somatostatin Octreotide Octreotide Clinical effect has Clinical effect has not been establishednot been establishedInfected pancreatic necrosis Infected pancreatic necrosis Positive demonstration of Positive demonstration of pathogens (FNA, with pathogens (FNA, with gram staingram stain and culture), and culture), oror Gas bubbles revealed by CT/MRI Gas bubbles revealed by CT/MRIPersistent necrotizing pancreatitisPersistent necrotizing pancreatitis >4 weeks of intensive care, >4 weeks of intensive care, no significant clinicalno significant clinical improvementimprovementFulminant necrotizing pancreatitisFulminant necrotizing pancreatitis Rapidly progressive Rapidly progressive multi organ failure despite multi organ failure despite maximum intensive treatment maximum intensive treatment (last resort)(last resort)Indications for SurgeryWith clinically confirmed successWith clinically confirmed successl l Necrosectomy with closed retroperitoneal Necrosectomy with closed retroperitoneal lavage lavagel l Necrosectomy with wide peripancreatic Necrosectomy with wide peripancreatic drainage drainagel l Necrosectomy with staged re-exploration Necrosectomy with staged re-explorationSurgical ProceduresPrognosis。