Thread by @Burayda_carnivl

موضوعنا اليوم من أهم مواضيع الجهاز الهضمي
#pancreatitis acute

التهاب البنكرياس الحاد تعالوا نعرف تفاصيل المرض في هذا الثريد 👌⬇️

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عناوين الثريد
1- ايش هو الـ Acute pancreatitis
والـ pathophysiology للمرض
2- Causes أسباب المرض❗️
3- Risk factor ايش العوامل المؤثرة
4-complication مضاعفات المرض
5- sign and symptoms 👁
6- diagnosis التشخيص
7- Goal of therapy 🎯
ايش الهدف من العلاج
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8- non pharmacological and pharmacological treatment ?
الخطة العلاجية للمريض

9-managment in pregnancy?🤰🏻

10- Evaluation of therapeutic outcomes ?
المتابعة مع المريض 👨🏻‍⚕️

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🔴 Acute pancreatitis
ايش هو الـ
Is pancreatic parenchymal inflammation that is characterized by sudden onset of constant epigastric or left upper quadrant pain

هو حالةٌ خطيرةٌ، يُصاب فيها البنكرياسُ بالالتهاب لفترةٍ قصيرة. وهو عضوٌ صغيرٌ يتوضَّعُ خلفَ المعدة وتحت القفص الصدري

Pathophysiology الـ
AP is initiated by premature activation of trypsinogen to trypsin within the pancreas, leading to activation of other digestive enzymes and autodigestion of the gland.
Activated pancreatic enzymes within the pancreas and surrounding tissues produce damage(1)

………………………………………………………………
& necrosis to pancreatic tissue, fat, vascular endothelium, and adjacent structures.
Lipase damages fat cells, producing noxious substances that cause further pancreatic and peripancreatic injury(2)

يتبع

Release of cytokines by acinar cells injures those cells and enhances the inflammatory response. 🧬
Injured acinar cells liberate chemoattractants that attract neutrophils, macrophages, and other cells to the area of inflammation(3)

causing systemic inflammatory response syndrome(SIRS)
Vascular damage and ischemia cause release of (kinins) which make capillary walls permeable and promote tissue edema
Pancreatic infection may result from increased intestinal permeability & translocation of colonic bacteria🦠

Causes الأسباب❗️
The most common causes are
☑️Cholelithiasis or (gallstones).
☑️Alcohol abuse 🍺
☑️Hypertriglyceridemia over 1000mg/dL
☑️Metabolic disorders causing chronic hypercalcemia
☑️complication after endoscopic retrograde
☑️cholangiopancreatography (ERCP)

……………

🟥Rare causes include the following:
 
• Drug-induced such (multiple oral hypoglycemic agents, diuretics, oral contraceptives, statins ,valproic acid, HAART and at least 120 others) ( thiopurines)
• Pancreatic tumor.
• Pancreatic infection
Scorpion sting ( لسعة عقرب 🦂)

4- Risk factor العوامل المؤثرة :
• Age and sex
• Race : 2 to 3 fold higher among the black population than whites 🙎🏾‍♂️>🙎🏻‍♂️
• Lifestyle
• Diet 🥗
• Obesity
• Diabetes

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Complications المضاعفات

🔴Local complications:
fluid collection, pancreatic necrosis, infection, abscess, pseudocyst formation, pancreatic ascites
🔴Systemic complications:
Multi-organ failure (respiratory, cardiovascular, and renal),metabolic hemorrhagic, CNS abnormalities

Clinical Presentation (Sign&symptoms)👁

💢Severe epigastric pain, often radiating to the back.
💢Epigastric tenderness with rebound and guarding
💢Nausea & vomiting
💢Hypotension, tachycardia, and pyrexia
💢Dyspnea and tachypnea (respiratory complications)
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Diagnosis التشخيص

اختصرنا التشخيص بصورة واحده👇🏻

Goal of treatment اهدافنا من علاج المريض 🎯
☑️Replacing fluids
☑️Relieving abdominal pain and nausea.
☑️ Correcting electrolytes, glucose, and lipid abnormalities.
☑️ Minimizing systemic complications.
☑️ Managing pancreatic necrosis and infection
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🔴Non pharmacological العلاج اللادوائي :

Nutritional support so important in AP

1/
Patients with mild AP ➡️ oral feeding when pain is decreasing & inflammatory markers are improving
المرضى مع الالتھاب الخفیف نبدأ معھم بالتغذیة عن طریق الفم إذا خّف الألم وتحسن الالتھاب

Nutritional support should begin when oral nutrition will be withheld for longer than 1 week.
یُنصح بالتغذیة الوریدیة (المغذي) إذا لن یستطیع المریض الأكل خلال أسبوع واحد أو أكثر
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Enteral feeding via nasogastric or nasojejunal tube is preferred ☑️ over parenteral nutrition (PN) in severe AP (if it can be tolerated). If not PN should be implemented before protein and calorie depletion become advanced عشان نمنع نقص البروتين والسعرات الحرارية

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وهذي اخر معلومه عن التغذية في حالة AP
👇🏻

🔴pharmacological treatment ايش العلاج للمريض؟
1- Pt with AP ➡️ IV antiemetics for nausea.
2- Patients requiring ICU admission should treated with antisecretory agents if they are at risk of stress-related mucosal bleeding.
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3.Vasodilation from the
inflammatory response, vomiting and nasogastric suction يؤدي الى👇🏼
hypovolemia& electrolyte abnormality ➡️need replacement

Pt should take fluid replacement to ⬇️ risk of persistent SIRS ,organ failure
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Different guidelines recommend goal-directed IV fluid with either lactated Ringer’s at an initial rate of 5 to 10 mL/kg/hour or crystalloids at a rate of 250 to 500 mL/hour

4. Parenteral opioid analgesics ➡️used to control abdominal pain (Parenteral morphine is often used)☑️
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5. Prophylactic antibiotics not recommended with AP without signs/symptoms of infection, including those with necrosis. But empiric antimicrobial therapy considered in pt with necrosis who deteriorate or fail to improve within 7 to 10 days

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6. Selective digestive tract decontamination using minimally-absorbed antibiotics (eg, polymyxin E, tobramycin, amphotericin B) to eradicate intestinal flora may reduce the risk of pancreatic infection, but more studies are needed

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7-Broad spectrum antibiotic➡️
in sever AP complicated by necrosis
🔴imipenem-cilastatin
🔴fluoroquinolone with metronidazole for penicillin-allergic patients

8-There are insufficient data to support use of octreotide for AP
H2 antagonist or PPI ➡️not improve pt with AP
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Management of Acute Pancreatitis in Pregnancy:🤰🏻

Resting the digestive tract by
☑️not eating
☑️pain control
☑️ aggressive fluids given through an IV line are essential.
🔴Typically, if the reason is gallstone pancreatitis یتم تأجیل إزالة المرارة إلى ما بعد الحمل

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a #stent placed into the bile duct can be placed to temporize the situation until operative is needed
یمكن وضع الدعامة في القناة الصفراویة لكسب الوقت حتى تكون ھناك حاجة إلى استئصال جراحي
if waiting until the end of pregnancy is not possible
الإجراء الجراحي ممكن یتنفذ بشكل آمن☑️👌

🔴if the cause of AP is due to TG , medications & dietary modifications can be used to help prevent recurrent attacks

🔴if the attack occurs late in the third trimester, delivery is usually advocated this will cause an immediate decrease in the TG level اول ما تولد راح ينخفض

Management should consider both maternal and fetal risks contingent on the treatment:
🔴irradiation during endoscopic retrograde cholangiopancreatography (ERCP)
🔴biliary endoscopic sphincterotomy
🔴general anesthesia and laparoscopy
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📛Evaluation of Therapeutic Outcomes📛
👨🏻‍⚕️المتابعة مع المريض

In pt with mild AP, assess pain control, fluid
electrolyte status, and nutrition periodically depending on the degree of abdominal pain and fluid loss.
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🚑Transfer patients with severe AP to an intensive care unit for close monitoring of vital signs
fluid and electrolyte status
WBC count, blood glucose, lactate dehydrogenase,
aspartate aminotransferase, serum albumin, hematocrit, blood urea nitrogen, serum creatinine, and INR.

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Monitor for signs of infection, relief of abdominal pain, and adequate nutritional status.
Severity of disease and pt response should be assessed using an evidence-based method
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من لا يشكر الناس لا يشكر الله حابين نقدم شكر لأعضاء فريق جرعة ترياق ككل وشكر خاص لكتابة المحتوى:

Wed Al-Masaary
@pharmdwed
-Banan Aleid @Banan_alEid
Asmaa Alamri @soma14116am
Asalah Alshamrani @a9oolah
Raad alqarni @phRaad1
Khuld Aloufi
Danah Bukhowah
@MoreThanDana
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والاشراف على المحتوى العلمي وتخطيطه:
بقيادة
@DrAntisaad د.سعد
ونائبيه :
@morooj_3 د.مروج
@heroxide د.خزنه سعد

والتصميم :
امل احمد
@AmalHKO

وفريق دار تجهيز الثريد
بقيادة بدور @ibodor_
اعضائها:
ساره @saraaal9_
محمد @mbashammakh96
وبأشراف :
د.رنا الشمري @rana_alshlagy
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وشكرا لكم جميعا ونتمنى لكم قرائه مفيدة 🙏🏻❤️