[Music] acute pancreatitis towards the end of this video you'll learn introduction classification etiology microscopic and macroscopic findings diagnosis imaging and treatment of acute pancreatitis let's get started with a brief introduction acute pancreatitis is an acute inflammatory process of the pancreas and it's caused by an inciting event which damages the pancreatic parenchyma leading to a chain reaction pancreatic injury causes enzymes to leak into pancreas resulting in other digestion leading to more injury in enzyme leakage this positive feedback cycle causes significant pancreatic edema and fat necrosis let's talk a little bit about the classification acute pancreatitis is divided into the following mild acute pancreatitis which is characterized by the absence of organ failure and local or systemic complications moderately severe acute pancreatitis which is characterized by transient organ failure which usually resolves within 48 hours and or local or systemic complications without persistent organ failure which is about greater than 48 hours severe acute pancreatitis which is characterized by persistent organ failure that may involve one or multiple organs or organ systems let's talk a little bit about the ideology there are several causes of acute pancreatitis they can be remembered with a mnemonic get smashed G stands for gall stones which is obstruction of the duct resulting in back up into the pancreas gall stones including micro lotuses are the most common cause of acute pancreatitis accounting for about forty to seventy percent of all cases he stands for ethanol damage to acinar cells resulting in thickening of ductal secretions leading to obstruction can be secondary to ethanol consumption alcohol is responsible for about 25 to 35 percent of cases of acute pancreatitis in the United States approximately 10 percent of chronic alcoholics develop attacks of clinically acute pancreatitis that are indistinguishable from the other forms of acute pancreatitis T stands for trauma blunt abdominal trauma can cause mechanical damage to pancreas resulting in acute pancreatitis as for steroids and for moms a for autoimmune painter titus and s for scorpion sting that stands for hypercalcemia or hypertriglyceridemia serum triglyceride concentrations above thousand milligrams per deciliter which is about eleven millimoles per liter can precipitate attacks of acute pancreatitis although lower levels may also contribute to severity hypertriglyceridemia may account for one to fourteen percent of cases of acute pancreatitis both primary which is genetic and secondary which could be acquired disorders of lipoprotein metabolism are associated with hypertriglyceridemia and used pancreatitis acquired causes of hypertriglyceridemia include obesity diabetes mellitus hypothyroidism pregnancy and certain medications like estrogen or tamoxifen therapy and certain types of beta blockers he stands for ERCP in patients who have undergone an endoscopy retrograde cholangiopancreatography which is abbreviated as ERCP acute pancreatitis occurs in about 3% of the patients undergoing diagnostic ERCP 5% undergoing therapeutic ERCP and twenty-five percent undergoing sphincter of Oddi manometric studies multiple operator patient and procedure related factors increase the risk of post ear RCP pancreatitis important risk factors include lack of ERCP experienced sphincter of Oddi dysfunction difficult cannulation and the performance of a therapeutic rather than diagnostic ERCP d stands for drugs certain drugs especially the sulfa group of drugs result in chemical injury to the acinar cells note that ethanol and all stones are by far the most common with an important point to be noted now let's discuss about the pathophysiology of acute pancreatitis ideologically there are different mechanisms for pancreatic acinar cell injury some of the most common causes are duct obstruction which can be secondary to cholelithiasis which results in an amperi obstruction at the level of ampulla of batter it could also be secondary to chronic alcoholism because of ductile concrescence both of these result in interstitial edema of the cell which results in impede blood flow and ischemia the other cause is a senora cell injury which can occur secondary to alcohol certain drugs like Dido Nelson valproic acid pentamidine tetracycline group of drugs and sulphur containing drugs like sulfonamides diuretics the other causes include trauma ischemia certain viruses predominantly the mumps virus which all result in release of intracellular pro enzymes and lysosomal hydrolysis which results in activation of these enzymes eventually all of these lead to a cenar cell injury the less common modality is a deep active intracellular transport now whenever there is metabolic injury or when there is alcohol consumption in excess or if there is duct obstruction all of these lead to defective delivery of Pro enzymes - the lysosomal compartment for hydrolysis as a result there is intracellular activation of enzymes and results in a cenar cell injury when there is a cenar cell injury it results in activation of the enzymes which results in interstitial inflammation and edema along with proteolysis along with fat necrosis secondary to lipases and phospholipase --is and there can also be hemorrhage because of the release of last aces all of these factors contribute to its development of acute pancreatitis let's go ahead and talk a little bit about the signs and symptoms in a patient to help diagnose acute pancreatitis some of the signs and symptoms to help diagnose acute pancreatitis in a patient include severe epigastric abdominal pain associated with radiation to the back approximately 90% of patients usually have nausea and vomiting pain is often worsened when the patient is supine and improves with sitting or resuming the fetal position and it's an important point to be noted in some patients the pain may be in the right upper quadrant or rarely confined to the left side most patients have fever and tachycardia as well as severe abdominal pain which is reproducible on examination patients with severe acute pancreatitis may have this Nia did diaphragmatic inflammation secondary to pancreatitis pleural effusions or adult respiratory distress syndrome some of the other signs would include a cone sign a colon sign is a bluish discoloration around the umbilicus resulting from hemoperitoneum there's another sign called great Turner sign which is blueish red discoloration along the flanks in serious cases of acute pancreatitis the patient may develop hypocalcemia a RDS which is adult respiratory distress syndrome and hemodynamic instability let's go ahead and look at some of the microscopic findings in mild forms this interstitial edema and focal areas of fat necrosis in the pancreas and peri pancreatic fat fat necrosis results from enzymatic destruction of the fat cells the released fatty acids combined with calcium to form insoluble salts that precipitate in sea-doo now let's go ahead and take a look at the gross findings microscopically the pancreas exhibit red-black hemorrhagic areas interspersed with foci of yellow white chalky fat necrosis now how is it to be diagnosed a kid pancreatitis can be diagnosed by serum levels of pancreatic enzymes and products early in the course of acute pancreatitis there's a breakdown in the synthesis secretion coupling of pancreatic digestive enzymes whereas synthesis continues while there is a blockage of secretion as a result digestive enzymes leak out of the S&R cells through the basolateral membrane to the interstitial space and then enter the systemic circulation therefore there will be increase in serum lipase which is most specific and then there are also be increased in serum amylase and decreased levels of calcium calcium levels decrease because calcium precipitates as calcium fatty acid soaps that are deposited into the pancreas now let's talk about the various imaging modalities that are helpful in diagnosing acute pancreatitis several features may be seen on image in patients with acute pancreatitis abdominal and chest radiographs the radiographic findings in acute pancreatitis range from unremarkable in mild disease to localized alias of a segment of small intestine which is termed as the sentinel loop or the colon cutoff sign in more severe disease on abdominal ultrasound in patients with acute pancreatitis the pancreas appear diffusely enlarged and hypoechoic gall stones may be visualized in the gallbladder or the bile duct ultrasound of the gallbladder shows posterior acoustic shadowing produced by a stone in the lumen of the gallbladder there is no gallbladder wall thickening a finding that may be seen with acute cholecystitis abdominal computed tomography contrast enhance abdominal CT scan findings of acute interstitial atom addis pancreatitis include focal or diffuse enlargement of the pancreas with heterogeneous enhancement with intravenous contrast CT scan of the cute industrial edematous pancreatitis the CT scan in a certifier old man with acute interstitial pancreatitis reveals heterogeneous appearance of the pancreas as indicated by the yellow arrows and peri pancreatic fat stranding as shown by the arrow head acute pancreatitis should be suspected in a patient with acute onset of a persistent severe epigastric pain with tenderness on palpation on physical the diagnosis of acute pancreatitis requires the presence of two of the following criteria acute onset of persistent severe epigastric pain that is often radiating to the back elevation in serum lipase or amylase 2-3 times or greater than the upper limit of normal characteristic findings of acute pancreatitis on imaging which is a CT or an MRI or a trance abdominal electro sonography now let's discuss a little bit about the treatment options the initial management of a patient with acute pancreatitis consists of supportive care with fluid resuscitation pain control and nutritional support in the initial stages which is within the first 12 to 24 hours of acute pancreatitis fluid replacement has been associated with the reduction in morbidity and mortality supportive care unless patient has very severe disease is required in my pancreatitis / oral intake can be resumed as tolerated that is when the patient no longer experiences any postprandial pain in more severe pancreatitis antral and nutrition should be initiated in the first 24 to 48 hours no food or fluids to be consumed orally which is NPO IV fluids and pain control until abdominal pain begins to resolve this is often referred to as pancreatic rest if the cause of pancreatitis is found to be a gallstone the patient should undergo closest ectomy abdominal pain is often the predominant symptom in patients with acute pancreatitis adequate pain control requires the use of intravenous opiates such as morphine or fentanyl usually in the form of a patient controlled analgesia pump now what are the secretly that can be expected multi-system organ failure like di c ER d s serious cyst formation necrotizing pancreatitis or some of the secretly that can be expected now the take-home point from this video is that acute pancreatitis can be severe requiring ICU care and even intubation