pancreatitis - the university of tennessee graduate school of
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Pancreatitis
Objectives
Define acute and chronic pancreatitisEtiologySigns and symptomsDiagnosisTreatmentsComplications
Acute Pancreatitis
Diffuse inflammationEnzymatic destructionInterstitial edema and inflammationHemorrhage and necrosis
Etiology Acute Pancreatitis
AlcoholBiliary tract diseaseHyperlipidemiaHereditaryHypercalcemiaTraumaIschemia, infections, venom
Etiology
Azathioprine, estrogens, isoniazid, metronidazole, tetracycline, valproicacid, trimethoprim-sulfamethoxazole
Clinical Presentation
Noncrampy, epigastric abdominal pain“knifing” or “boring through” to the backNausea and vomitingTachycardia, tachypnea, hypotension, hyperthermia Voluntary and involuntary guarding
What is this? Why?
Cullen’s Sign
Hemorrhagic pancreatitisBlood dissects up the falciformligament
What is this? Why?
Grey Turner’s Sign
Hemorrhagic pancreatitisBlood dissect into the posterior retroperitoneal soft tissue in the flank
Fox’s Sign
Rare findingBluish discoloration below the inguinal ligament or at the base of the penis.
Tests
labs- amylase and lipaseCT scan CXR-elevation of left diaphragmAXR- sentinal loop sign
-colon cutoff sign
Early Prognostic Signs
Ranson’s prognostic signs of pancreatitisCriteria for acute gallstone pancreatitis
Ranson’s
At admission: Age >55yWBC >16,000/mm3Blood glucose >200 mg/dlLDH >350 IU/LAST >250 U/dl
Ranson’s
Initial 48 hoursHct fall >10%BUN elevation> 5 mg/dlSerum Calcium<8 mg/dlPao2< 60 mmHgBase deficit >4 mEq/lFluid sequestration > 6 L
Acute Gallstone Pancreatitis
At admission:Age > 70yWBC >18,000Blood glucose > 220LDH > 400AST >250
Acute Gallstone Pancreatitis
Initial 48 hHCT fall > 10%BUN elevation > 2Calcium < 8Base deficit > 5Fluid sequestration > 4 L
Prognosis
Mortality zero; less than 2 criteriaMortality 10% to 20%; 3 to 5 criteriaMortality > 50%; more than 7
Treatment Mild Pancreatitis
Supportive Restriction of oral intakeNGTH2 blockersPain control
When Resume Diet?
After ABD pain has decreasedAmylase returns to normalDiet: low-fat and low-protein
Severe Pancreatits
NPOSupportive care in the ICUAggressive fluid resus.TPN
Complications
Paralytic ileusHyperglycemiaHypocalcemiaRenal failureHemorrhage-erosion into a major vessel
Complications
NecrosisInfected necrosisAbscessPseudocystThrombosis of splenic vein- sinistralportal hypertension and gastric varices
Chronic Pancreatitis
Chronic inflammatory conditionFibrosis, duct ectasis and acinaratrophy Irreversible destruction of tissue
Etiology of Chronic Pancreatitis
Alcohol 70%IdiopathicHerditary hyperparathyroidismHypertriglyceridemiaAutoimmune Obstruction , traumaPancreas divisum
Presentation
Chronic pain- epigastric radiates to backAnorexiaWeight lossIDDMSteatorrhea
Diagnosis
Pancreatic calcificationsChain of lakes
Treatment
Control painSmall-volume, frequent, low-fat, high-protein, high-carbohydrate meals.OctreotideLipase and trypsinERCP with stents, sphincterotomy, stone extraction
Treatment Operative
SphincteroplastyPeustow- side-to-side longitudinal pancreasticojejunostomyCeliac plexus neurolysis with alcolholinjectionThoracoscopic splanchnicectomy
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