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Acute
PancreatitisAcute, reversible inflammatory process
of the pancreas
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Case Study
A 55-year-old man presents to the emergency
department complaining of severe mid-
epigastric abdominal pain that radiates to the
back. The pain improves when the patient leansforwards and worsens with lying supine and
movement.
He also complains of nausea, vomiting, and
anorexia, and had a history of heavy alcoholic
intake this past week.
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On examination, he is tachycardic, tachypnoeic,
and febrile with hypotension.
Abdominal distension, epigastric tenderness
with abdominal guarding
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PRESENTATION
WBC : 19.1, Platelet: 289, Hematocrit: 41% (40-54)
Serum Lipase: 2211 (0160 U/L)
Serum Amylase: 804 (40140 U/L)
ALT:10 (
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Acute Pancreatitis: Pathophysiology
INFLAMMATIONOF THE PANCREAS Inappropriate activation of pancreatic enzymes
Intraparenchymal and extraparenchymal extravasation
of enzymes cause auto-digestion of pancreatic
parenchyma and damage to peri-pancreatic tissues andvascular network
Pancreatic enzymes cause extensive local damage as well as
activation of complement and cytokine systems
Inflammatory response causes further damageFluid sequestration, fat necrosis, vasculitis, leading to
occlusions and thrombosis, hemorrhageSIRS ( Shock, ARDS,DIC,
Renal failure)
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Aetiology
I- Idiopathic
G- Gallstones
E- Ethanol (Alcohol)
T- Trauma
S- Steroids
M- Mumps
A- Autoimmune S- Scorpion venom
H- Hyperlipidemia, Hypercalcemia
E- ERCP and emboli
D- Drugs
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Clinical features
Abdominal pain (usually epigastric/diffuse upper quadrant)
- May radiate to the back, relieved by leaning forward
Nausea
Vomiting
Anorexia
Low grade fever
Less common signs:
Cullens sign (Peri-umbilical blue discoloration)
Grey Turner sign (Bilateral flank blue discoloration indicating
haemorrhagic pancreatitis)
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Physical Examination
General (Distressed, anxious, ill-looking)
Vital signs (Fever/tachycardia/tachypnoea/hypotension)
Sclera: Mild jaundice (biliary obstruction)
Abdomen: Tenderness, guarding, distension
Diminished/absent bowel sound
Mass maybe palpable (pseudocyst)
Pleural effusion (10-20%)
Signs of hypocalcemia may present:
- Chvostekssign (Facial muscle spasm when facial nerve is tapped)
- Trousseaus sign (Carpopedal spasm when blood pressure cuff is
applied)
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Differential diagnosis
Differential diagnosis Characteristics
Peptic Ulcer Disease Longstanding epigastric pain, which does not
generally radiate to the back; reflux; heartburn; and
anorexia. Identifiable causes such as non-steroidal
anti-inflammatory drug (NSAID) use, Helicobacter
pylori may present.
Intestinal Obstruction -History of abdominal surgeries (especially colon
resection, caesarean sections, and aortic
procedures).
-Hernias in the physical examination.
-Presents with abdominal distension (depends onthe level of obstruction), tympanism, decreased
bowel sounds, anorexia, emesis (quality depends on
location of obstruction), or constipation.
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Differential diagnosis Characteristics
Cholangitis Charcot's triad (jaundice, right upper quadrant
pain, and fever) present in 70% of patients, altered
mental status, and hypotension indicate biliary
sepsis.
Choledocholithiasis Severe right upper quadrant pain of sudden onset,
jaundice, and hx of cholelithiasis. May occlude the
common bile duct and cause pancreatitis.
Viral Gasteroenteritis Generalised non-specific abdominal pain,
anorexia, nausea, emesis, diarrhoea, and
dehydration.
Hepatitis Jaundice, right upper quadrant pain, anorexia, and
general malaise.
Examination: tenderness to palpation over the right
upper quadrant and enlarged liver.
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Assessment of severity
Severity of acute pancreatitisis commonly assessed using :
1. RansonsCriteria
5 clinical signs at presentation on admission and at 48hrs
3 associated with severe course (systemic complications
and/or pancreatic necrosis)
2. Glasgow Criteria
3. APACHE II
12 routine physiologic measurement, age and previous
health status
8 associated with severe course
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RansonsCriteria
At Admission
Age >55 yrs
WBC >15 x 109
Blood Glucose > 10 mmol/L Serum LDH >600 IU/L
AST >200 IU/L
Initial 48 Hours
Hematocrit decrease >10%
BUN elevation >10 mmol/L
Serum Ca 6L
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Glasgow Criteria
PaO2Oxygen < 60mmHg or 7.9kPa
Age > 55
Neutrophilia ,White blood cells > 15
Calcium < 2 mmol/L
Renal Urea > 16 mmol/L
Enzymes: Lactate dehydrogenase (LDH) > 600 IU/L Aspartate
transaminase (AST) > 200 IU/L
Albumin < 32 g/L
Sugar Glucose > 10 mmol/L
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Investigation
Serum Amylase (40-140 U/L)
- elevated 2-12 hrs following onset of symptoms
- 2-3 x upper limit
Serum Calcium
- Fall as a result of complexing w/ fatty acids
Serum Lipase (0-160 U/L)
- More specific for pancreatic disease
- 2x normal range
Urinary Amylase (24-400 U/L)- >5000 IU/ 24 hrs
FBC, Renal Profile, LFT, Fasting lipid
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Role of Radiology in Acute Pancreatitis
Rule out other intraabdominal conditions as cause of
abdominal pain or other symptoms
Bowel obstruction, infarction or perforation; acute
cholecystitis; appendicitis
Confirm diagnosis and Identify causes(e.g. gallstones)
Evaluate and stage local pancreatic morphology
Identify and manage complications
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Imaging
Plain Abdominal x-ray
Screen for/exclude separate or accompanying abdominal
process
- Signs of peritonitis or bowel ischemia
Free air- Bowel Obstruction
Abdominal ultrasound
Excellent for identifying gallbladder pathology, and gallstones(Most common cause of pancreatitis!)
Evaluate bileduct dilation
May visualize masses and follow up of pseudocyst
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CT Scan
Aid in diagnosis and staging of pancreatitis
Depict, quantify pancreatic parenchymal injury
Ability to assess the presence or absence of:Edema (focal or diffuse)
Peripancreatic fluid and inflammation
Fluid collections
PseudocystsNecrosis
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Management
Fluid resuscitation and correction of electrolyte
imbalance
Analgesia
Bowel rest (Keep Nil By Mouth)
Stress ulcer prophylaxis (PPI)
Treat underlying cause : eg. Cholecystectomy, avoidance
of alcohol intake
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Mild pancreatitis in 80-90% of cases
Most resolve in 5-7 days on average
Gallstone induced pancreatitis may benefit from
ERCP and stone removal
Severe Pancreatitis in remaining 10-20%
(clinical indicators suggestive of severe disease
include peritonitis, shock, respiratory distress)
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Severe Acute Pancreatitis
Admission to ICU
- Nasogastric drainage
- Oxygen supplementation
- Fluid resuscitation
- Close monitoring of vital signs, CVP, urine output, ABG,
hematological and biochemical parameters
- Analgesia
- Nutritional support
- CT scan
- Immediate ERCP : Gallstone pancreatitis/sign of cholangitis
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Complications
Acute Pancreatic Fluid Collection
Pancreatic Necrosis
Pancreatic Pseudocyst
Pancreatic Abscess
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References
H. George Burkitt, Essential Surgery, 4thEd. Churchill
Livingstone
Acute Pancreatitis, British Medical Journal
Balthazar, E J, Acute Pancreatitis: Assessment of Severity with
Clinical and CT Evaluation. Radiology 2002; 223:603613
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