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PANCREATITIS

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ACUTE PANCREATITIS

 

(see Gastroenterology Notes)

 

  1. usually no surgical management in uncomplicated acute pancreatitis 
  2. surgical indications in acute pancreatitis
    • secondary pancreatic infections - abscess, infected pseudocysts/necrosis
    • gallstone-associated pancreatitis
    • uncertainty of clinical diagnosis
    • worsening clinical condition despite optimal supportive care

Complications


Pseudocyst (2-10%)

  1. collection of pancreatic secretions in a cyst lacking true epithelium
  2. risk of rupture, hemorrhage and infection (rare)
  3. 2-3 weeks post-attack: persistent pain, fever, ileus, mass, nausea/vomiting, early satiety, persistent elevation of amylase
  4. 40% resolve spontaneously within 6-12 weeks (keep NPO and on TPN)
  5. Diagnosis: clinical, U/S, CT
  6. Treatment: internal (prefered) or external drainage (latter if infected or sick patient) once pseudocyst matures
  7. biopsy to rule out malignancy
  8. recurrence rate 10%


Abscess (5%)

  1. 1-4 weeks post-attack: fever, toxic, abdominal pain, distention
  2. Diagnosis: increased amylase, increased AST/ ALT (50%), elevated WBC, CT (fluid and gas)
  3. high mortality - requires extensive surgical debridement and broad-spectrum antibiotics

Ascites

  1. secondary to pseudocyst disruption (common) or direct pancreatic duct disruption
  2. diagnose by paracentesis: high amylase, high protein
  3. treatment: NPO, TPN 2-3 weeks, somatostatin
  4. ERCP if not resolved to determine anatomy; Rou-en-Y jejunostomy to site of leak

Necrosis

  1. diagnosis by CT
  2. treatment: debridement


Hemorrhage

  1. erosion of arterial pseudoaneurysm secondary to pseudocyst, abscess, or necrotizing pancreatitis
  2. Clinical presentation: increased abdominal mass, abdominal pain, hypotension
  3. Diagnosis: angiography
  4. Treatment: immediate surgery

sepsis


MOSF

 

prognosis of all complications

  1. 80% improve rapidly
  2. 20% have at least one complication from which 1/3 die

    CHRONIC PANCREATITIS

     

    (see Gastroenterology Notes)


    Surgical treatment

    1. indications for surgical treatment: debilitating abdominal pain, CBD
      obstruction, duodenal obstruction, persistent pseudocyst
    2. ERCP for planning surgical management - dilated ducts with areas of stricture (chain of lakes)
    3. drainage procedure if ducts > 8 mm
    4. Puestow (longitudinal pancreatico-jejunostomy)
      • 80-90% have pain relief, but 5 years post-op only 50-60% remain pain-free
    5. Whipple (pancreaticoduodenectomy) 80% have pain relief
    6. pancreatectomy
      • use when no dilated ducts
      • amount of resection depends on disease focus (i.e. limited vs. subtotal vs. total pancreatectomy)
    7. do not percutaneously access a pseudocyst unless immediate drainage of infection required.  Goal is to allow wall of  pseudocyst to mature (3-4 weeks) followed by internal drainage through stomach

    PANCREATITIS PANCREATITIS Reviewed by Radiology Madeeasy on August 29, 2010 Rating: 5
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