Acute pancreatitis

BYPROF GOUDA ELLABBAN

Case Report Jassim, 36 years-old, Saudi male, a

known case of HTN. Came to ER with nausea, vomiting,

& sudden epigastric abdominal pain for 12 hours, radiating to the back, releaved by leaning forward, and worsening by eating a meal with high fat content, or by lying supine.

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Definition

AP: is inflammation of the pancreas due to autodigestion of the pancreas by its activated

enzyme.

Causes Gallstones: pancreatic duct

obstruction (AMPULLA of VATER) by small gallstones.

Alcohol abuse. Viral infection (MUMP). Peptic ulcer disease. Trauma to the abdomen or back.

Pathophysiology

By the premature activation of digestive enzymes within the acinar cells.

Ordinarily (in normal individuals), pancreatic proenzymes become activated upon release within the duodenum.

Pathophysiology

Pancreatitis

early activation of pancreatic enzymes

cycle of inflammation and necrosis

autodigestion of the pancreas and surrounding tissues

Signs and Symptoms Sudden pain in the epigastric area, which is:

Steadily increases in severity. Radiates through to the back. Made worse by:

Lying flat on the back. After eating or drinking,

especially a high fat content foods and alcohol drinking. Relived by leaning forward.

Abdominal distention and Tenderness. Nausea. Vomiting.

Signs and Symptoms Grey turner’s sign: left flank Discoloration in sever

case Dehydration. Hypotension. Shock. Rapid pulse. Fever. Sweating. Slight jaundice.

Differential diagnoses Biliary System Disease:

Biliary Colic. Cholangitis. Cholecystitis. Cholelithiasis.

Chronic Pancreatitis. Acute Gastritis.

Differential diagnoses Duodenal Ulcers. Intestinal Perforation. Myocardial Infarction. Omental Torsion. Mesenteric Artery Thrombosis. Intra-abdominal Sepsis.

Investigations

Investigations

Laboratory

Tests

Imaging

Studies

Routine Specific

Investigations Laboratory Tests:

Routine: CBC:

May show leucocytosis. LFT:

Elevated alanine aminotransferase in gallstone AP. RFT. Glucose Test:

Elevated level indicating pancreatic endocrine disorder.

Laboratory Tests

Investigations Specific:

Serum amylase. “Not specific” Urine amylase. Serum lipase. Note:

Serum amylase and lipase levels are typically elevated in AP. Serum lipase is More reliable, has higher specificity than

amylase. Urine amylase increases secondary to an increase in the

renal clearance of amylase. Serum calcium: may be decreased. C – reactive protein:

CRP value determine the severity of AP.

Laboratory Tests

Investigations Imaging Studies:

Abdominal CT scan.i. Confirms the laboratory tests.ii. Indicated in patients with severe AP.iii. Is the imaging study of choice for assessing AP

complications. Abdominal Ultrasound.

The imaging study of choice for gallstone AP.

Abdominal MRI. Abdominal X-ray. (its benefit here is just to

exclude other acute abdomen causes)

Imaging Studies

Investigations Imaging Studies

Management First confirm the diagnosis ( serum amylase &

CT scan) Determine the severity of the attack. Mortality rate in severe cases is over 25%; so

severe cases should be managed in ICU where pulmonary, renal & abdominal complication can be diagnosed & treated.

First confirm the diagnosis ( serum amylase & CT scan)

Determine the severity of the attack. Mortality rate in severe cases is over 25%; so

severe cases should be managed in ICU where pulmonary, renal & abdominal complication can be diagnosed & treated.

How to determine the severity of AP attacks?

According to Ranson Criteria…

>3 = Severe

Ranson Criteria for Predicting Mortality in Acute Pancreatitis

At Admission During Initial 48 Hours

Age >55 yrs Hematocrit falls by >10 mg/dl

WBC >16,000/cc BUN increases by >5 mg/dl

LDH >350 IU/L Calcium <8 mg/dL

AST >250IU/L PaO2 <60 mmHg

Glucose >200 mg/dL Base deficit >4 mg/dl

   Fluid sequestration >6 L

WBC = white blood cell; BUN = blood urea nitrogen;LDH = lactate dehydrogenase; AST = aspartate aminotransferase;

PaO2 = partial pressure of carbon dioxide, arterial.

Supportive treatment Analgesia:

Relive of pain, traditionally with pethidine not morphine to avoid spasm of sphincter.

Fluid replacement: With colloid or blood transfusion, to treat shock &

establish diuresis. In less severe cases, water & electrolyte is enough.

Resting of pancreas: NPO. Nasogastric tube: in case of vomiting.

Nutrition: total parenteral nutrition (TPN)

Supportive treatment Antibiotics:

Recommended in severe cases & gallstone pancreatitis.

Prophylaxis aginst gastric erosion: With sucralfate or H2-antagonist (e.g. ranitidine).

Endoscpic sphinctrotomy: Useful in gall stone pancreatitis especially severe

cases. Dilated common bile duct.

Endoscopic sphinctrotomy

Surgery Emergency surgery is not indicated in mild acute

pancreatitis.

Some surgical procedures such as resection of necrotic tissue (necrosectomy) and peritoneal lavage may have a role in select patients with severe, progressive necrotizing pancreatitis or pancreatic abscess.

Cholecystectomy has been demonstrated to be effective in patients with recurrent acute pancreatitis and microlithiasis

operative drainage of pseudocyst may also be required.

Complication

Complication

Local Systemic

Systemic Complication Pulmonary Complications: such as pulmonary

edema and adult respiratory distress syndrome. Renal dysfunction. Gastrointestinal bleeding. Colitis. Splenic vein thrombosis

Local Complication Fluid Collections

Fluid collections are common in patients with acute pancreatitis. Simple fluid collections resolve spontaneously in most patients, so therapy is not usually required. The presence of gas within a fluid collection suggests underlying

infection and mandates therapy.

Local Complication Pseudocysts

The most common complication of acute pancreatitis (occurring in approximately 25% of patients).

Pseudocyst is a collection of pancreatic juice enclosed in a wall of fibrous or granulation tissue.

Formation of psudocyst require 4 weeks or more from the onset of acute pancreatitis.

The most common complication of acute pancreatitis (occurring in approximately 25% of patients).

Local Complication Pancreatic necrosis:

Pancreatic necrosis is a significant complication of acute pancreatitis, and may result in mortality rates as high as 15%. Whatever the mechanism of acute pancreatitis, in necrotizing pancreatitis, there is obstruction of the pancreatic microcirculation

Local Complication Abscess formation Pancretic effusion Pancreatic ascitis

Prognosis Among patients with mild acute

pancreatitis episodes, the mortality rate is 1%.

Severe attack associated with 20-25% mortality rate.

Infected necrosis associated with mortality rate up to 50%.

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