acute pancreatitis

Acute PancreatitisAcute Pancreatitis

Otic, Rafael Jr. Otic, Rafael Jr.

Puache, Marco Teodoro F.Puache, Marco Teodoro F.

Racadio, Ma. Perpetua A.Racadio, Ma. Perpetua A.

Medical HistoryMedical History

Identifying Data:Identifying Data:

This is a case of L.P. 42-year This is a case of L.P. 42-year old female from Dasmarinas, old female from Dasmarinas, married, admitted for the first married, admitted for the first time in the institution.time in the institution.

Chief Complaint:Chief Complaint:

Abdominal PainAbdominal Pain


History of Present IllnessHistory of Present Illness

3 hours prior to consult, the 3 hours prior to consult, the patient experienced epigastric pain patient experienced epigastric pain described as heavy without radiation described as heavy without radiation and 10/10 in severity. and 10/10 in severity.

She vomited once of She vomited once of postprandial vomitus. She took postprandial vomitus. She took Buscopan which afforded temporary Buscopan which afforded temporary relief. No consult was done.relief. No consult was done.


Cont…Cont…

2 hours prior to consult, the 2 hours prior to consult, the patient had recurrence of patient had recurrence of epigastric pain, 10/10 in epigastric pain, 10/10 in severity, intermittent and colicky, severity, intermittent and colicky, no radiation. Still no consult.no radiation. Still no consult.


Cont…Cont…

Few hours prior to consult, Few hours prior to consult, due to persistence of pain, the due to persistence of pain, the patient sought consult in the patient sought consult in the institution.institution.


Past Medical HistoryPast Medical History Unremarkable, no previous Unremarkable, no previous

surgical history. No allergies to surgical history. No allergies to food and drugs.food and drugs.

Personal and Social HistoryPersonal and Social History Unremarkable, the patient does Unremarkable, the patient does

not smoke and drink alcoholic not smoke and drink alcoholic beverages.beverages.


Family HistoryFamily History Unremarkable. No history of Unremarkable. No history of

hypertension, heart disease, DM, hypertension, heart disease, DM, asthma, and cancer.asthma, and cancer.

PhysicalPhysical ExaminationExamination

General: The patient is conscious, General: The patient is conscious, coherent, ambulatory and not in coherent, ambulatory and not in cardio-respiratory distress.cardio-respiratory distress.


Vital Signs:Vital Signs: BP: 170/100 mmHgBP: 170/100 mmHg RR: 24/minRR: 24/min HR: 72/minHR: 72/min Temperature: 36.5 CTemperature: 36.5 C

HEENT:HEENT: AS, PPC, no nasoaural AS, PPC, no nasoaural discharged, (-) CLAD, no discharged, (-) CLAD, no tonsillopharyngeal congestion.tonsillopharyngeal congestion.


Chest/Lungs:Chest/Lungs: SCE, no SCE, no retractions, no adventitious retractions, no adventitious sounds.sounds.

Heart:Heart: Adynamic precordium, Adynamic precordium, normal rate, regular rhythm, no normal rate, regular rhythm, no murmurs.murmurs.


Abdomen:Abdomen: Protuberant, globular Protuberant, globular abdomen, soft in palpation. No abdomen, soft in palpation. No scars. scars. (+) epigastric tenderness(+) epigastric tenderness

(-) bowel sound(-) bowel sound

Extremities:Extremities: no gross deformities, no gross deformities, full and equal pulses, no edema, full and equal pulses, no edema, no cyanosis.no cyanosis.


Laboratory Studies:Laboratory Studies: AmylaseAmylase – 1,300 – 1,300 (high)(high) LipaseLipase – 2,168 – 2,168 (high)(high) Chest x-ray (PA)Chest x-ray (PA) – Normal Chest – Normal Chest

findingfinding 12 Lead ECG12 Lead ECG – normal sinus – normal sinus

rhythm, non specific ST T waverhythm, non specific ST T wave


CBCCBC – WBC 10,700 – WBC 10,700 (high)(high), Hb 10.9 , Hb 10.9 (low)(low), Hc 34.0 , Hc 34.0 (low)(low), Seg 75% , Seg 75% (high)(high), , lym 20% lym 20% (low)(low), Mono 04% , Mono 04% (low)(low), Plt –, Plt –adequate.adequate.

LDHLDH – 414.00, Calcium – 1.72 – 414.00, Calcium – 1.72 (low)(low), , SGOT/AST-16.5, Potassium – 3.65SGOT/AST-16.5, Potassium – 3.65

Abdominal UTZAbdominal UTZ – normal ultrasound – normal ultrasound of the liver, gallbladder, pancreas, of the liver, gallbladder, pancreas, spleen, kidneys urinary bladder and spleen, kidneys urinary bladder and uterus. (-) adnexal mass.uterus. (-) adnexal mass.

DiagnosisDiagnosis

Acute Pancreatitis Acute Pancreatitis (mild) (mild)

Acute PancreatitisAcute Pancreatitis

Auto-digestion of the pancreas Auto-digestion of the pancreas by its own enzymesby its own enzymes

Non bacterial inflammationNon bacterial inflammation

Possible EtiologyPossible Etiology

Most common cause:Most common cause: cholelithiasis and alcohol.cholelithiasis and alcohol.

Other causes:Other causes: Abdominal traumaAbdominal trauma Postoperative or Postoperative or

postendoscopic retrograde postendoscopic retrograde cholangiopancreatography cholangiopancreatography (ERCP)(ERCP)


Other causes cont…Other causes cont… metabolic (hypertriglyceride, metabolic (hypertriglyceride,

hypercalcemia, renal failure)hypercalcemia, renal failure) hereditary pancreatitishereditary pancreatitis Infection (mumps, viral Infection (mumps, viral

hepatitis, coxsackievirus, hepatitis, coxsackievirus, ascariasis, mycoplasma)ascariasis, mycoplasma)

oppurtunistic infections (CMV, oppurtunistic infections (CMV, Cryptococcus, Candida, TB)Cryptococcus, Candida, TB)


Other causes cont…Other causes cont… MedicationsMedications connective tissue diseases/ connective tissue diseases/

vasculitits (SLE, thrombotic vasculitits (SLE, thrombotic thrombocytopenic purpura)thrombocytopenic purpura)

penetrating ulcerpenetrating ulcer obstruction of the ampulla of obstruction of the ampulla of

Vater (regional enteritis)Vater (regional enteritis)

Clinical FeaturesClinical Features

can vary from mild abdominal can vary from mild abdominal pain to shock.pain to shock.

Common symptoms:Common symptoms: steady, boring midepigastric steady, boring midepigastric

pain radiating to the back that is pain radiating to the back that is frequently increased in the frequently increased in the supine positionsupine position

Nausea/vomitingNausea/vomiting

P.E. FindingsP.E. Findings

Low grade fever, tachycardia, Low grade fever, tachycardia, hypotensionhypotension

erythematous skin nodules due to erythematous skin nodules due to subcutaneous fat necrosissubcutaneous fat necrosis

basilar rales, pleural effusion (often at basilar rales, pleural effusion (often at the left)the left)

Abdominal tenderness and rigidity, Abdominal tenderness and rigidity, diminished bowel sounds, palpable diminished bowel sounds, palpable upper abdominal massupper abdominal mass

P.E. FindingsP.E. Findings

Abdominal tenderness and rigidity, Abdominal tenderness and rigidity, diminished bowel sounds, palpable diminished bowel sounds, palpable upper abdominal massupper abdominal mass

Cullen's sign: blue discoloration in the Cullen's sign: blue discoloration in the periumbilical area due to periumbilical area due to hemoperitoneumhemoperitoneum

Turner’s sign: blue-red-purple or green-Turner’s sign: blue-red-purple or green-brown discoloration of the flanks due to brown discoloration of the flanks due to tissue catabolism of hemoglobin.tissue catabolism of hemoglobin.

Laboratory FindingsLaboratory Findings

Serum amylase:Serum amylase: elevated >3x normal (if elevated >3x normal (if salivary gland dse/intestinal perforation or salivary gland dse/intestinal perforation or infarction is excluded.infarction is excluded.

normal serum level does not exclude diagnosis normal serum level does not exclude diagnosis of pancreatitis.of pancreatitis.

degree of elevation does not predict severity of degree of elevation does not predict severity of pancreatitispancreatitis

Amylase levels typically return to normal in 48-Amylase levels typically return to normal in 48-72 hours.72 hours.

Urinary amylase-creatinine clearance Urinary amylase-creatinine clearance ratio:ratio: no more sensitive or specific than no more sensitive or specific than blood amylase levels.blood amylase levels.


Serum lipase level:Serum lipase level: increases in increases in parallel with amylase level and parallel with amylase level and measurement of both tests increases measurement of both tests increases the diagnostic yield.the diagnostic yield.

Other test:Other test: HypocalcemiaHypocalcemia - occurs in approx. 25% - occurs in approx. 25%

of patients.of patients. LeukocytosisLeukocytosis - (15,000-20,000/ul) - (15,000-20,000/ul)

occurs frequently. occurs frequently. HypertriglyceridemiaHypertriglyceridemia- occurs in 15-- occurs in 15-

20% of cases and can cause a 20% of cases and can cause a spuriously normal serum amylase level. spuriously normal serum amylase level.


Hyperglycemia is common.Hyperglycemia is common.

Serum bilirubin, alkaline phosphatase and Serum bilirubin, alkaline phosphatase and aspartame aminotransferase can be aspartame aminotransferase can be transiently elevated.transiently elevated.

Hypoalbuminemia and marked elevations Hypoalbuminemia and marked elevations of serum lactic dehydrogenase (LDH) are of serum lactic dehydrogenase (LDH) are associated with a increase mortality rate.associated with a increase mortality rate.

Hypoxemia is present in 25% of patients. Hypoxemia is present in 25% of patients. Arterial pH <7.32 may spuriously elevate Arterial pH <7.32 may spuriously elevate serum amylase.serum amylase.

ImagingImaging

Abdominal RadiographsAbdominal Radiographs are are abnormal in 30-50% of pts but abnormal in 30-50% of pts but are not specific for pancreatitis. are not specific for pancreatitis. Common findings include total or Common findings include total or

partial ileus (sentinel loop) and the partial ileus (sentinel loop) and the colon cut-off sign, which results colon cut-off sign, which results form isolated distention of the form isolated distention of the transverse colon. Useful for transverse colon. Useful for excluding diagnoses such as excluding diagnoses such as intestinal perforation with free air.intestinal perforation with free air.

ImagingImaging

UltrasoundUltrasound often fails to often fails to visualize the pancreas because visualize the pancreas because of overlying intestinal gas but of overlying intestinal gas but may detect gallstones, may detect gallstones, pseudocysts, mass lesions, or pseudocysts, mass lesions, or edema or enlargement of the edema or enlargement of the pancreas.pancreas.

ImagingImaging

CT SCANCT SCAN can confirm diagnosis of can confirm diagnosis of pancreatitis (edematous pancreas) pancreatitis (edematous pancreas) and is useful for predicting and and is useful for predicting and identifying late complications. identifying late complications.

Contrast-enhanced dynamic CTContrast-enhanced dynamic CT is is indicated for clinical deterioration, indicated for clinical deterioration, the presence of risk factors that the presence of risk factors that adversely affect survival or other adversely affect survival or other features of serious illnessfeatures of serious illness

TreatmentTreatment

most (90%) cases subside over most (90%) cases subside over a period of 3-7 days.a period of 3-7 days.

Conventional measures:Conventional measures: Provision of pain relief. The Provision of pain relief. The

preferred analgesic is morphine preferred analgesic is morphine for acute pancreatitisfor acute pancreatitis

Restoration of fluid and Restoration of fluid and electrolyte balanceelectrolyte balance

TreatmentTreatment

Treatment of hypocalcemia, if Treatment of hypocalcemia, if symptomaticsymptomatic

Limitation of oral intake (with Limitation of oral intake (with dietary fat restriction) to avoid dietary fat restriction) to avoid secretory stimulation of the secretory stimulation of the pancreas.pancreas.

May require:May require: Supplementation O2 by maskSupplementation O2 by mask Endotracheal intubation and Endotracheal intubation and

mechanical ventilationmechanical ventilation

THANK YOUTHANK YOU

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acute pancreatitis

Health & Medicine

medical history cont

medical history unremarkable

medical history abdomen

medical history chestlungs

history of hypertension

medical history vital

medical history cbc

social history unremarkable