The document discusses pancreatitis, including: 1. It describes the parts and functions of the pancreas, including exocrine and endocrine functions. 2. It covers the causes, signs, symptoms, investigations, and treatment of acute and chronic pancreatitis. Conservative treatment includes hydration and antibiotics, while surgery may be needed for complications. 3. It lists complications of pancreatitis such as shock, respiratory failure, infections, and pancreatic insufficiency. Chronic pancreatitis involves permanent structural damage and its treatment aims to control pain and manage complications.

1. Pancreatitis

2. Introduction
• Elongated and tapered
organ . A pale grey gland
weighing about 60
grams and about 12-
15cm long situated in
the epigastric and left
hypochondriac region

3. Parts
• Head - the wides right part
of the organ and lies in the
curve oof the duodenum
• Body - Tapered left side
extends slightly upward lies
behind stomach
• Tail - narrowed end
partbliepart lies
infroninfront of the kidney
and just reaches ththe
spleen

4. Functions
• Exocrine parts - secrets
pancreatic juices which helps in
digestion of proteins ,
carbohcarbohydrates and fats
• Endocrine parts- constitutes
islets of pancreas which is more
distributed in tail of pancreas
• - beta cells of islets secrets
insulin
• -Alphabets secretes glucagon
• - delta cells secrets
somatostatin

5. • Function of insulin
• 1. Reduces blood glucose level
• 2. Secretion is stimulated by increased blood glucose
level eg. After eating a meal
• Function Of glucagon
• 1. Increases blood glucose level
• 2. Secretion is stimulated by low blood glucose level
and exercise and decreased by somatostatin and
insulin
• Function of stomatostatin
• Inhibits the secretion of insulin and glucagon in
addition to inhibiting the secretion of growth hormone
fron anterior pituitary

7. Ducts of pancreas
1. Duct of Wirsung ( main duct of the
pancreas)
It begins in the tail of pancreas and run on
the posterior surface of the body and hehead
of the pancreas, receives numerous
tributaries at right angle along its length
(Herring bonbone pattern )
2. Duct of Santorini / Accessory
pancreatic duct
It begins in the lower part of the head and
opens into the duodenum at minor duodenal
Padilla (6-8 cm from the pylorus )

8. Blood supply of Pancreas
Arterial supply
1. Pancreatic branches of splenic artery
2.superior pancreaticoduodenal artery
3. Inferior Pancreaticoduodenal artey
Venous drainage- into Portal Vein
Nerve Supply -
Parasympathetic is from Vagus
Sympathetic innervation is fron Spanish
nerves

9. Causes of pancreatitis

10. Pancreatitis
Pancreatitis is inflammation of the
pancreas , acute, chronic or relapsing
whiwhich may lead to complications
It is one of the most devastating
condition in the abdomen
Marseille's Classification
1. Acute Pancreatitis
2. Acute Relapsing Pancreatitis
3. Chronic Relapsing Pancreatitis
4. Chronic Pancreatitis

11. Acute
Pancreatitis

12. Acute Pancreatitis
Definition- It is defined as acute non- bacterial
infinflammatory condition caused by activation,
interstitial liliberation and auto digestion of
Pancreas presenting as acute abdominal pain
Acute pancreatitis stings like a scorpion (produce
severe pain )
Acute pancreatitis drinks like a fish (produce
dehydration)
Acute pancreatitis eats like a wolf ( pancreatic
necrosis)
Acute pancreatitis burrows like a rodent (produce
fistula)
Acute pancreatitis kills like a rodent (Life
threatening)

13. Aeitiology
• 1. Biliary tract diseases m/c - (50%) - Stones
2. Alcoholism (25%)
3. Other causes-
 Trauma
 Hyperparathyroidism
 Drugs - corticosteroids, tetracycline, estrogen, Valerie
acid, diuretics etc
 Vascular disease
 Pancreatic divisum
 After biliary, splenic, gastric , surgery, ERCP,
 Idiopathic

14. Pathogenesis of pancreatitis

15. Clinical features
• Symptoms
 Severe abdominal epigastric pain
radiating to the back increases over a
period of hours
partially relieved on stopping or bending
forward (Mohammed prayer sign )
A meal or alcohol triggers the pain
 Vomiting- frequent and effortless due to
reflex pylorospasm
 Fever - Low gragrade
 Haematemesis and Melaena may occur
due to necrosis of duodenum ( poor
prognostic sign )

17. Signs
• Febrile , tachypnoic patient in agony
• Cyanosis
• Faint jaundice
• Features of shock - Febrile pulse, tachycardia,
hypotension, cold extremities
Abdominal findings -
 Tenderness in epigastrim
Upper abdominal guarding and rigidity
Mass in epigastrim
Muscle guarding
Abdominal dissension- due to accumulation of blood /
fluid in the peritoneal cavity or due to paralytic ileus

18. Cullen's sign - bluish ecchymotic
discoloration seen around
umblicuumblicus
Grey Turner's sign- Bluish
discoloration in the flanks
Evidence of respiratory sign-
tachypnoea , dullness, effusion,
creations, rhonci

19. Investigation
• Haemogram
• Serum Amylase >100 somogyi unit
• Serum lipase
• Amylase creatinine clearence >6%
• Serum lactescence
• Serum trypsin
• Trypsinogen activated polypeptide- reveals the severity
• CRP (>150mg/dl)
• Phospholipase A2 , LDH level
• Liver function tests - serum bilirubin , albumin, prothrombin time, alkaline phosphates
• Bllod urea serum creatinine
• Blood glucose (hyperglycemia is seen)
• Serum calcium level ( hypocalcaemia occurs)
• Urinary lipase estimation
• Peritoneal tap fluid- high amylase and protein levels

20. Plain X-ray shows -
 sentinel loop of dilated proximal small bowel
 Distension of transverse colon with collapse of
descending colon
 Air fluid level in the duodenum
 Renal halo sign
 Obliteration of psaos shadow
 Localise ground glass apperance
US Abdomen
CECT -
 Gold Standard
 Should be done after 1st week not in initial period
 Asseses the severity, detects local complications
CT guided Aspiration - unless diagnosis is in Doubt

21. Treatment
Conservative, 70-90%
Surgical treatment when indicated , 10-
30%
Management of complications like acute
pseudocyst, abscess, fistula hemorrhage;
systemic complications like ARDS, renal
failure , MODS

22. Risk assessment stratification
Ranson score
On Admission
• Age >55years
• WBC count >16×1000/mm cube
• Blood glucose >10mmol/L
• LDH > 700units/L
• AST >250sigma Frankel unit
within 48 hours
Within 48 hours
Increase in BUN levels >15mg%
Drop in hematocrit >10%
Arterial oxygen saturation (PaO2<60mmHg)
Serum calcium <2mmol/L
Base deficit >4mmol/L
FlFluid sequestration >6 L
Glasgow scale
• Age >55years
• WBC count -15×1000/mmcube
• Blood glucose>10mmol/L
• Serum urea >16 mmol/L
• PaO2<60mm Hg
Serum Calcium <2mmol/L
Serum Albumin <32g/L
LDH >600 units/L
AST/ALT >600 Units /L

23. Conservative treatment
Assessment of haemodynamic status and early resuscitation
 Aggresive early hydration in first 24hours using 400ml/hour
crystalloids (Ringer lactate , normal saline) to achieve rapid
repletionof the severe volume depletion
 Risk assessment sstratification
 Patient with organ failure or SIRS should have ICU care in anticipation
of ventilation and organ support (haemodialysis)
 Prevention or treatment of abdominal compartment syndrome (ACS)
which carries high mortality ;ACS is intra-abdominal
pressure>12mmhg , It can occur during fluid therapy also, it requires
often decompression by percutaneous catheter insertion or
laparotomy
 Infection control , elecelectrolytelectrolyte management

24. Management principles of acute Pancreatitis
Acute
oedematous
( Mild-80%)
Necrotising
pancreatitis
(Sterile necrosis-
10%)
Infected necrosis
(Very severe-5%)
Admission Acute wardvwith
monitoring of
vitals
Intensive care unit Intensive care unit
IV
fluids/hypotensio
n
Early correction of
hypotension ,
hypovolaemia-
crystalloids
IIV fluids and
inotropic support
maybe required
May require
inotropes and
vasopressors for a
long period
Blood transfusion Rarely required May be required Definitely
required
Antibiotics No antibiotics Early antibiotic
prophylaxis is
required
Broad spectrum
Antibiotics

25. Oral/nutrition Oral fluids, soft diet
by 3-4 days , once
pain and illusion
settle down
If pain is still present
even after 4 days ,
nasojejunsl feeding
to be done
Enter
all/nasojejunal
feeding. If calories
are not sufficient,
Total Parental
nutrition is required
Hypomagnesaemia
/ hypocalcaemia
Usually will not ibe
a problem
Correction is
required
Correction is
required
Oxygen By nasal cannula/
face mask may be
required
EarEarly ARDS-
ventilators support
Ventilators support
may be required
Role of surgery /
Natural course
Majority of patients
will not require
surgery
Resolve completely
by 10-15 days or
may develop into
pseudocyst or
infected necrosis
which require
surgery
Ideal time to
operate is after 4
weeks when
necrosis is
demarcated well

26. Surgery
Indications of surgery (10%)
If the condition of the patient decorates inspire of good
conservative treatment
If there is pancreatic Infected necrosis
In severe necrotising pancreatitis as a trial to save the life
of the patient which has got very high mortamortality

27. Surgical management
 Surgery removes intra and
exextra-abdominal necrotic
materials, pancreatic fluids
,and toxins . It permits
preservation of viable
pancreatic tissue
 Open surgery is the gold
standard for infected
pancreatic necrosis
 Conventional closed method
- nnecrosectomy , wide
debridement , adequate
drainage, cholecystectomy,
closure

28.  Endoscopic necrosectomy
 Laparotomy -
necrosectomy - wide
debridement - wash wide ,
packing
 Zip technique - Bradley's
repeated laparotomies
and wash
Continuous close peritoneal
lavage - Beger's lavage
 Further management is
important to prevent
recurrence

29. Complications
 Shock- hypovolaemic , septic
 Respiratory failure and ARDS - Common in 7 days
 Septicaemia - commmon after 7 days
 Hypocalcaemia
 Disseminated intramuscular coagulation (DIC)
 Acute renal failure
 Pancreatic pleural effusion (left sided 20%)
 Pancreatic pseudoaneurysm
 Pancreatic ascites
 Colonic stricture
 Pseudocyst of pancreas
 Chronic pancreatitis
 Splenic vein thrombosis
 Abdom8nal compartment syndrome (ACS)
 Pancreatic endocrine (15%) and eexocrine (20%) insufficiency as late
squealae can occur

30. Chronic pancrea

31. Chronic Pancreatitis
Definition - Diffuse inflammatory process of pancreas
involving head, body and tail resulting in permanent
structural and functional damage to the Pancreas
Causes -
 Alcohol
 Idiopathic /fibrocalculous pancreatic diabetes
• Common in warm climates
• Common in young age
• High incidence of diabetes
• High incidence of stone in the duct
• Increased chances of parenchymal calcification
• Increased chances of pancreatic cancer
 Hereditary pancreatitis
 Cystic fibrosis
 Hyperparathyroidism
 Autoimmune Pancreatitis

32. Triad of Chronic Pancreatitis

33. Clinical features

34. In right knee chest position , if
left hypochondrium is palates
tenderness can be evoked in
case of chronic relapsing
Pancreatitis. In this position
bowel loops are being shifted to
right so as to have direct
palpation of Pancreas
Mallet-Guys sign

35. Clinical presentation
Stage A - 85%
Recurrent/Acute episodic pain with weight
loss
Stage B -
Severe prolonged progressive pain with
impaired pancreatic function with
Cholestasis , pseudocyst, sinister portal
hypertension
Stage C-
severe endocrine/exocrine deficiency . Less
severe pain complication like
pseudocpseudocyst and obstruction

36. Differential Diagnosis
Aortic aneurysm
Retroperitoneal cyst or tumor
Cystadenocarcinoma of pancreas
Cyst of the liver
Mesentric cyst
Hydatid cyst

37. Investigations
• Plain X-ray abdomen -to seasoned
in the pancreatic duct or
parenchymal calcification
• USG- to detect stone stricture,
dilation and associated cyst
• ERCP- to see
 Ductal dissension or Ductal
strictures
Dilated pancreatic duct ( normal 4-
6mm)
Demonstration of stone
• CT-scan - 95% specificity , Reliable
to seeductal anatomy, head mass,
size and configuration of pancreas

38. Aim of the Treatment
Control of pain
Improvement in maldigestion and nutrition
Management of complications

39. Treatment
 Conservative
• Avoid alcohol, smoking, and tobacco consumption
• Low fat, high protein , high carcarbohydrate diet ,
small and more frequent meals
• Pancreatic enzyme supplements , vitamins and
minerals, medium chain fatty acids
• For Pain - analgesics or splanchnic nerve /
coeliacplexus block
• Control of Diabetes

40. Indication of surgery
• Unreleived pain
• Suspicion of carcinoma
• Complications -
Cyst
Ascites
Abscess
GI bleeding
Obstructive Jaundice
Duodenal obsobstruction

41. Types of surgery
 Chronic pancreatitis involving
tail of pancreas
- Distal Pancreatomy with
removal of spleen
 Diffuse chronic Pancreatitis with
Dilated pancreatic duct
- Puestow's Operation
- It is a bypass procedure which
preserve both endocrine and
exocrine function

42.  Chronic pancreatitis with head mass
- Pancreaticoduodenectomy

43.  Chronic Pancreatitis with bile duct obstruction
- CHOLEDOCHOJEJUNOSTOMY - ideal
- PANCREATICODUODENAL RESECTION , can
also be done
 Chronic pancreatitis with duodenal obstruction
- resection of head mass/ Gastrojejunostomy
Is the treatment of choice
 Chronis pancreatitis with Ascites
- Puestow's Operation


44.  Resection - Hans Berger's procedure
 Frey procedure

45. Complications of chronic pancreatitis
 Pseudocyst of pancreas
 Pancreatitis ascites
 CBD strictures due to oedema or inflammation
 Duodenal stenosis
 Portal thrombosis- segmental portal hypertension
 Peptic ulcer
 Carcinoma pancreas
 Pancreatic pleural effusion
 Pancreatic fistula
 Splenic vein thrombosis
 Pancreatic enteric fistula