ACUTE PANCREATITISGERARD P. PERLAS MDFPCP,FPSG,FPSDEMCU FDTMF HOSPITAL

ETIOLOGYAlcoholBiliary Tract Dse. - GallstonesDrugs Sulfonamides, diureticsInfections Mumps, Viral HepatitisMetabolic- inc. triglycerides, inc. Ca.

Pathogenesis (enzymes elaborated)TrypsinogenChymotrypsinogensProelastasePhospholipase A

Active enzymes

proteolysis edema hemorrhage Vascular injury

coagulation, fat & cell necrosis

Bradykinin, Histamine

vasodilatation inc. vascular permeability edema

Clinical Features Acute onset of Upper abdominal pain lesser by knee-chest position, w/ radiation to the backvomiting

Physical examinationDistressed, anxiousTachycardiaFeverShock may be presentJaundiceAbdominal tenderness, rigidityCullens signGrey Turners sign

Laboratory Tests:Amylase85-100% sensitivity3 fold rise is diagnosticGoes down in 48-72 hrs.

Other causes of HyperamylassemiaMumpsGut perforationBiliary tract dseRuptured viscusPeritonitisRuptured ectopic pregnancyPancreatic psudocystDiabetic ketoacidosis

Serum LipaseMore specific for acute pancreatitisEqually as sensitive as AmylaseElevated on first day of illnessElevated longer than amylase

Laboratory TestsLeukocytosisHyperglycemiaHypocalcemiaHyperbilirubinemiaHypoalbuminemiaHigh LDHhypoxemia

Radiologic StudiesPlain abdominal Xrayslocalized ileus, usually involving the jejunum ("sentinel loop");generalized ileus the "colon cutoff sign," which results from isolated distention of the transverse colon; duodenal distention with air-fluid levels; a mass, which is frequently a pseudocyst.

Upper GI seriesDisplacement of the stomach by a retroperitoneal massWidening of the duodenal C-loop

Ultrasound of PancreasEnlarged pancreasPseudocystTo rule out mass lesion Pancreatic CA

CT scanMost sensitive testPancreatic necrosis

Differential Diagnosesperforated viscus; peptic ulceracute cholecystitis and biliary colicacute intestinal obstructionmesenteric vascular occlusionrenal colicmyocardial infarctiondissecting aortic aneurysmconnective tissue disorders with vasculitisPneumoniadiabetic ketoacidosis

Factors that Adversely Affect Survival in Acute PancreatitisRansons criteriaAcute Physiology and chronic health evaluation (APACHE) score > 12Obesity

Key indicators of Organ FailureHypotension BP < 90 mmHg or CAR > 130 beats/minPO2 < 60 mmHgOliguria> creatinine

Metabolic IndicatorsSerum Calcium < 8.0 mg/dlSerum albumin < 32 g/L

Criteria for Severe Acute Pancreatitis Organ FailureShockPulmonary insufficiency PO2 < 60 mmHgRenal Failure : creatinine > 2mg/dlGI bleeding > 500 ml/ 24 hrs And/or Local ComplicationsNecrosisAbscessPseudocyst

Unfavorable Early Prognostic SignsEqual or > 3 Ransons signsEqual or > 8 APACHE II points

Mild Pancreatitis or Acute Interstitial PancreatitisTreatmentNPOFluid resuscitationMeperidine 50 100 mg iv q 3-4 hrsPrognosis is Excellent

Severe or Necrotizing Pancreatitis+ Fluid resuscutationO2 inhalation for hypoxemiaInotropics for ShockCorrect electrolytesAntibiotics ImipenemCT ScanParenteral Nutrition10% Mortality rate

SurgeryPancreatic PseudocystAbscess