acute pancreatitis ukm

8/10/2019 Acute Pancreatitis UKM

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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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