ACUTE PANCREATITIS Xu San rong Department of Gastroenterology Huashan Hospital Fudan university DEFINITION An acute inflammatory process of the pan-creas usually associated with sever pain in the upper abdomen in most instances, blood levels of pancrea-tic enzymes are increased sever acute pancreatitis: organs failure and/or local complications(necrosis, absc-ess, psuedocyst) PATHOLOGY(1) Mild acute pancreatitis(MAP) characterized by interstitial edema associ-ated with inflammatory cell within parench-yma, and microscopic parenchyma necro-sis can be detectable. PATHOLOGY(2) Sever acute pancreatitis(SAP) Sever necrotizing pancreatitis(SNP)  macroscopic evidence of either focal or diffuse necrosis and hemorrhage of the  pancreatic parenchyma  PATHOGENY AND  PATHOGENESIS(1) 1 common channel and reflux of duodenal juice  PATHOGENY AND  PATHOGENESIS(2) 2 alcoholic and overeat 3 obstruct of main pancreatic duct 4 diseases round the duodenum/ampullary region 5 postoperative pancreatitis and pancreatic trauma PATHOGENY AND  PATHOGENESIS(3) 6 infectious agents 7 medications: corticosteroids, estrogens 8 disorders of endocrinology and metabol-ism: hyperparathyroidism, hyperlipidemia 9 others: PATHOGENY AND  PATHOGENESIS(4) 6 inflammatory media theory In AP, the leukocytes that appear first in areas of inflammation are neutrophils, then macrophages, monocytes, lymphocytes, and other cells. These cells can secrete a lot of inflammatory media. (1) platelet activating factor, PAF (2)prostaglandins, PGs PATHOGENY AND  PATHOGENESIS(5) (3) leukotriens, LTs (4) kallikrein kinin systems, KKS (5) tumor necrosis factor-  , TNF- (6) nitrogen monoxide, NO (7) complements (8) others: nuclear factor B(NF- B), toll like receptors(TLRs). DIAGNOSIS(1) Clinical characteristics 1 abdominal pain 2 fever 3 nausea and vomiting DIAGNOSIS(2) 4 hypotension and shock 5 jaundice 6 tenderness 7 peritoneal irritation sign tenderness, rebound tenderness, and abdominal muscle tenseness 8 Grey-turner sign, cullen sign 9 ascites DIAGNOSIS(3) Assistant examination 1 blood examination (1) blood routine examination(white blood cell count),  hematocrit(Hct), packed cell volume(PCV) (2) blood, urine amylase  Salivary-am, P-am  Cam/Ccr DIAGNOSIS(4) (3) serum lipase (4) blood glucose(>10mmol/L),  serum calcium(<2.0mmol/L) (5) * plasma methemalbumin 2 abdominal B-ultrasonography DIAGNOSIS(5) 3 X-ray examination (1) plane film of the abdomen (2) chest radiography (3) abdominal computed tomography 4 magnetic resonance imaging MR cholangiopancreatography(MRCP) DIAGNOSIS(6) Diagnosis  clinical characteristics, elevated value of serum and urine amylase ultrasonography and CT, MR DIFFRENTIAL DIGNOSIS 1 perforated hollow viscus 2 biliary colic gallstone acute cholangitis, acute cholecystitis 3 acute intestinal obstruction 4 mesenteric ischemia 5 angina pectoris acute myocardial infarction(AMI) 6 others: PREDICTORS OF SEVERITY(1) 1 Ranson`s criteria of severity  at admission during initial 48 hours age > 55 years Hct decrease of 10mg/dL wbc > 16*109/L bun increase of > 5mg/dL glucose > 11.2umol/L calcium < 8 mg/dL LDH < 350iu/L  PaO2  < 60mmHg AST > 250u /L  base deficit > 4 mEq/L  fluid sequestration > 6 L  3 < mild;  3 medial;  5 poor prognosis PREDICTORS OF SEVERITY(2) 2 CT grading system of Balthazar and ranson  pancreatic manifestations of CT grade A normal-appearing pancreas  0 grade B  focal or diffuse enlargement of the pancreas  1 grade c  gland abnormalities accompanied by mild 2 peripancreatic inflammatory changes grade D fluid collection in a single location 3 grade E 2 fluid collections near the pancreas or  4  gas either within the pancreas or within  peripancreatic inflammation PREDICTORS OF SEVERITY(3) computed tomography severity index CT grade  score  necrosis score A 0 none  0 B 1 one third 2 C 2 one half 4 D 3 > one half  6 E 4 CT grade(0-4) + necrosis(0-6) = total score  Complications Local complications 1 pancreatic necrosis 2 pancreatic pseudocyst 3 pancreatic abscess Complications Systemic complications 1 major systemic complications (1) respiratory failure (2) renal failure (3) hypotention 2 dangerousest complication multiple organs failure(MOF) TREATMENT(1) Management of internal medicine 1 common management (1) intensive care unit (2) fluid resuscitation (3) nutritional support  TREATMENT(2) 2 treatment of infection MAP SAP 3 relief of pain (1) anisodamine (654-2) (2) bucinnazine, pethidine (3) 0.1% procaine (4) * morphine TREATMENT(3) 4 inhibition of pancreatic secretion (1) atropine, anisodamine (654-2) (2) H2-receptor antagonists(H2RAs) proton pump inhibitors(PPI) (3) somatostatin, and its analog octreotide  TREATMENT(4) 5 inhibition of activated pancreatic enzymes (1) aprotinin (2) gabexate mesilate(FOY) 6 drugs of anti-inflammatory factors 7 eliminating inflammatory mediators peritoneal lavage 8 traditional medicine  TREATMENT(5) 8 endoscopic sphincterotomy 9 surgery indications: (1) with 3 days after diagnosis of gallstone  pancreatitis, (2) pancreatic abscess and psuedocyst, (3) perforated hollow viscus,  necrosis of intestine  PROGNOSIS Mild acute pancreatitis sever acute pancreatitis with focal necrosis(sterile): 10%-15% with focal necrosis(infected): 30%-35% with diffuse necrosis: 30%-60% with multiple organs of failure: > 90% PREVENTION Remove the gallstones in the common bile duct avoid drunk avoid overeat others  THANK YOU * * gallstones infection Bile juice reflux trypsin Kinin systems elastase Trypsin chymotrypsino Phospho- lipaseA2 Steatolytic enzymes Sever pain hemorrhage Free fat acid Serum calcium, * * *