Acute Pancreatitis Otic, Rafael Jr.  Puache, Marco Teodoro F. Racadio, Ma. Perpetua A.
Medical History <ul><li>Identifying Data: </li></ul><ul><li>This is a case of L.P. 42-year old female from Dasmarinas, mar...
Medical History <ul><li>History of Present Illness </li></ul><ul><li>3 hours prior to consult, the patient experienced epi...
Medical History <ul><li>Cont… </li></ul><ul><li>2 hours prior to consult, the patient had recurrence of epigastric pain, 1...
Medical History <ul><li>Cont… </li></ul><ul><li>Few hours prior to consult, due to persistence of pain, the patient sought...
Medical History <ul><li>Past Medical History </li></ul><ul><ul><li>Unremarkable, no previous surgical history. No allergie...
Medical History <ul><li>Family History </li></ul><ul><ul><li>Unremarkable. No history of hypertension, heart disease, DM, ...
Medical History <ul><li>Vital Signs:   </li></ul><ul><ul><ul><li>BP: 170/100 mmHg </li></ul></ul></ul><ul><ul><ul><li>RR: ...
Medical History <ul><li>Chest/Lungs:  SCE, no retractions, no adventitious sounds. </li></ul><ul><li>Heart:  Adynamic prec...
Medical History <ul><li>Abdomen:  Protuberant, globular abdomen, soft in palpation. No scars.  (+) epigastric tenderness <...
Medical History <ul><li>Laboratory Studies: </li></ul><ul><ul><li>Amylase  – 1,300  (high) </li></ul></ul><ul><ul><li>Lipa...
Medical History <ul><ul><li>CBC  – WBC 10,700  (high) , Hb 10.9  (low) , Hc 34.0  (low) , Seg 75%  (high) , lym 20%  (low)...
Diagnosis <ul><li>Acute Pancreatitis (mild)  </li></ul>
Acute Pancreatitis <ul><li>Auto-digestion of the pancreas by its own enzymes </li></ul><ul><li>Non bacterial inflammation ...
Possible Etiology <ul><li>Most common cause:  cholelithiasis and alcohol. </li></ul><ul><li>Other causes: </li></ul><ul><l...
Possible Etiology <ul><li>Other causes cont… </li></ul><ul><li>metabolic (hypertriglyceride, hypercalcemia, renal failure)...
Possible Etiology <ul><li>Other causes cont… </li></ul><ul><li>Medications </li></ul><ul><li>connective tissue diseases/ v...
Clinical Features <ul><li>can vary from mild abdominal pain to shock. </li></ul><ul><li>Common symptoms: </li></ul><ul><li...
P.E. Findings <ul><li>Low grade fever, tachycardia, hypotension </li></ul><ul><li>erythematous skin nodules due to subcuta...
P.E. Findings <ul><li>Abdominal tenderness and rigidity, diminished bowel sounds, palpable upper abdominal mass </li></ul>...
Laboratory Findings <ul><li>Serum amylase:  elevated >3x normal (if salivary gland dse/intestinal perforation or infarctio...
Laboratory Findings <ul><li>Serum lipase level:  increases in parallel with amylase level and measurement of both tests in...
Laboratory Findings <ul><li>Hyperglycemia is common. </li></ul><ul><li>Serum bilirubin, alkaline phosphatase and aspartame...
Imaging <ul><li>Abdominal Radiographs  are abnormal in 30-50% of pts but are not specific for pancreatitis.  </li></ul><ul...
Imaging <ul><li>Ultrasound  often fails to visualize the pancreas because of overlying intestinal gas but may detect galls...
Imaging <ul><li>CT SCAN  can confirm diagnosis of pancreatitis (edematous pancreas) and is useful for predicting and ident...
Treatment <ul><li>most (90%) cases subside over a period of 3-7 days. </li></ul><ul><li>Conventional measures: </li></ul><...
Treatment <ul><li>Treatment of hypocalcemia, if symptomatic </li></ul><ul><li>Limitation of oral intake (with dietary fat ...
THANK YOU END
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Acute pancreatitis

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Acute pancreatitis

  1. 1. Acute Pancreatitis Otic, Rafael Jr. Puache, Marco Teodoro F. Racadio, Ma. Perpetua A.
  2. 2. Medical History <ul><li>Identifying Data: </li></ul><ul><li>This is a case of L.P. 42-year old female from Dasmarinas, married, admitted for the first time in the institution. </li></ul><ul><li>Chief Complaint: </li></ul><ul><li>Abdominal Pain </li></ul>
  3. 3. Medical History <ul><li>History of Present Illness </li></ul><ul><li>3 hours prior to consult, the patient experienced epigastric pain described as heavy without radiation and 10/10 in severity. </li></ul><ul><li>She vomited once of postprandial vomitus. She took Buscopan which afforded temporary relief. No consult was done. </li></ul>
  4. 4. Medical History <ul><li>Cont… </li></ul><ul><li>2 hours prior to consult, the patient had recurrence of epigastric pain, 10/10 in severity, intermittent and colicky, no radiation. Still no consult. </li></ul>
  5. 5. Medical History <ul><li>Cont… </li></ul><ul><li>Few hours prior to consult, due to persistence of pain, the patient sought consult in the institution. </li></ul>
  6. 6. Medical History <ul><li>Past Medical History </li></ul><ul><ul><li>Unremarkable, no previous surgical history. No allergies to food and drugs. </li></ul></ul><ul><li>Personal and Social History </li></ul><ul><ul><li>Unremarkable, the patient does not smoke and drink alcoholic beverages. </li></ul></ul>
  7. 7. Medical History <ul><li>Family History </li></ul><ul><ul><li>Unremarkable. No history of hypertension, heart disease, DM, asthma, and cancer. </li></ul></ul><ul><li>Physical Examination </li></ul><ul><li>General: The patient is conscious, coherent, ambulatory and not in cardio-respiratory distress. </li></ul>
  8. 8. Medical History <ul><li>Vital Signs: </li></ul><ul><ul><ul><li>BP: 170/100 mmHg </li></ul></ul></ul><ul><ul><ul><li>RR: 24/min </li></ul></ul></ul><ul><ul><ul><li>HR: 72/min </li></ul></ul></ul><ul><ul><ul><li>Temperature: 36.5 C </li></ul></ul></ul><ul><li>HEENT: AS, PPC, no nasoaural discharged, (-) CLAD, no tonsillopharyngeal congestion. </li></ul>
  9. 9. Medical History <ul><li>Chest/Lungs: SCE, no retractions, no adventitious sounds. </li></ul><ul><li>Heart: Adynamic precordium, normal rate, regular rhythm, no murmurs. </li></ul>
  10. 10. Medical History <ul><li>Abdomen: Protuberant, globular abdomen, soft in palpation. No scars. (+) epigastric tenderness </li></ul><ul><li> (-) bowel sound </li></ul><ul><li>Extremities: no gross deformities, full and equal pulses, no edema, no cyanosis. </li></ul>
  11. 11. Medical History <ul><li>Laboratory Studies: </li></ul><ul><ul><li>Amylase – 1,300 (high) </li></ul></ul><ul><ul><li>Lipase – 2,168 (high) </li></ul></ul><ul><ul><li>Chest x-ray (PA) – Normal Chest finding </li></ul></ul><ul><ul><li>12 Lead ECG – normal sinus rhythm, non specific ST T wave </li></ul></ul>
  12. 12. Medical History <ul><ul><li>CBC – WBC 10,700 (high) , Hb 10.9 (low) , Hc 34.0 (low) , Seg 75% (high) , lym 20% (low) , Mono 04% (low) , Plt –adequate. </li></ul></ul><ul><ul><li>LDH – 414.00, Calcium – 1.72 (low) , SGOT/AST-16.5, Potassium – 3.65 </li></ul></ul><ul><ul><li>Abdominal UTZ – normal ultrasound of the liver, gallbladder, pancreas, spleen, kidneys urinary bladder and uterus. (-) adnexal mass. </li></ul></ul>
  13. 13. Diagnosis <ul><li>Acute Pancreatitis (mild) </li></ul>
  14. 14. Acute Pancreatitis <ul><li>Auto-digestion of the pancreas by its own enzymes </li></ul><ul><li>Non bacterial inflammation </li></ul>
  15. 15. Possible Etiology <ul><li>Most common cause: cholelithiasis and alcohol. </li></ul><ul><li>Other causes: </li></ul><ul><li>Abdominal trauma </li></ul><ul><li>Postoperative or postendoscopic retrograde cholangiopancreatography (ERCP) </li></ul>
  16. 16. Possible Etiology <ul><li>Other causes cont… </li></ul><ul><li>metabolic (hypertriglyceride, hypercalcemia, renal failure) </li></ul><ul><li>hereditary pancreatitis </li></ul><ul><li>Infection (mumps, viral hepatitis, coxsackievirus, ascariasis, mycoplasma) </li></ul><ul><li>oppurtunistic infections (CMV, Cryptococcus, Candida, TB) </li></ul>
  17. 17. Possible Etiology <ul><li>Other causes cont… </li></ul><ul><li>Medications </li></ul><ul><li>connective tissue diseases/ vasculitits (SLE, thrombotic thrombocytopenic purpura) </li></ul><ul><li>penetrating ulcer </li></ul><ul><li>obstruction of the ampulla of Vater (regional enteritis) </li></ul>
  18. 18. Clinical Features <ul><li>can vary from mild abdominal pain to shock. </li></ul><ul><li>Common symptoms: </li></ul><ul><li>steady, boring midepigastric pain radiating to the back that is frequently increased in the supine position </li></ul><ul><li>Nausea/vomiting </li></ul>
  19. 19. P.E. Findings <ul><li>Low grade fever, tachycardia, hypotension </li></ul><ul><li>erythematous skin nodules due to subcutaneous fat necrosis </li></ul><ul><li>basilar rales, pleural effusion (often at the left) </li></ul><ul><li>Abdominal tenderness and rigidity, diminished bowel sounds, palpable upper abdominal mass </li></ul>
  20. 20. P.E. Findings <ul><li>Abdominal tenderness and rigidity, diminished bowel sounds, palpable upper abdominal mass </li></ul><ul><li>Cullen's sign: blue discoloration in the periumbilical area due to hemoperitoneum </li></ul><ul><li>Turner’s sign: blue-red-purple or green-brown discoloration of the flanks due to tissue catabolism of hemoglobin. </li></ul>
  21. 21. Laboratory Findings <ul><li>Serum amylase: elevated >3x normal (if salivary gland dse/intestinal perforation or infarction is excluded. </li></ul><ul><ul><li>normal serum level does not exclude diagnosis of pancreatitis. </li></ul></ul><ul><ul><li>degree of elevation does not predict severity of pancreatitis </li></ul></ul><ul><ul><li>Amylase levels typically return to normal in 48-72 hours. </li></ul></ul><ul><li>Urinary amylase-creatinine clearance ratio: no more sensitive or specific than blood amylase levels. </li></ul>
  22. 22. Laboratory Findings <ul><li>Serum lipase level: increases in parallel with amylase level and measurement of both tests increases the diagnostic yield. </li></ul><ul><li>Other test: </li></ul><ul><ul><li>Hypocalcemia - occurs in approx. 25% of patients. </li></ul></ul><ul><ul><li>Leukocytosis - (15,000-20,000/ul) occurs frequently. </li></ul></ul><ul><ul><li>Hypertriglyceridemia - occurs in 15-20% of cases and can cause a spuriously normal serum amylase level. </li></ul></ul>
  23. 23. Laboratory Findings <ul><li>Hyperglycemia is common. </li></ul><ul><li>Serum bilirubin, alkaline phosphatase and aspartame aminotransferase can be transiently elevated. </li></ul><ul><li>Hypoalbuminemia and marked elevations of serum lactic dehydrogenase (LDH) are associated with a increase mortality rate. </li></ul><ul><li>Hypoxemia is present in 25% of patients. Arterial pH <7.32 may spuriously elevate serum amylase. </li></ul>
  24. 24. Imaging <ul><li>Abdominal Radiographs are abnormal in 30-50% of pts but are not specific for pancreatitis. </li></ul><ul><ul><li>Common findings include total or partial ileus (sentinel loop) and the colon cut-off sign, which results form isolated distention of the transverse colon. Useful for excluding diagnoses such as intestinal perforation with free air. </li></ul></ul>
  25. 25. Imaging <ul><li>Ultrasound often fails to visualize the pancreas because of overlying intestinal gas but may detect gallstones, pseudocysts, mass lesions, or edema or enlargement of the pancreas. </li></ul>
  26. 26. Imaging <ul><li>CT SCAN can confirm diagnosis of pancreatitis (edematous pancreas) and is useful for predicting and identifying late complications. </li></ul><ul><li>Contrast-enhanced dynamic CT is indicated for clinical deterioration, the presence of risk factors that adversely affect survival or other features of serious illness </li></ul>
  27. 27. Treatment <ul><li>most (90%) cases subside over a period of 3-7 days. </li></ul><ul><li>Conventional measures: </li></ul><ul><li>Provision of pain relief. The preferred analgesic is morphine for acute pancreatitis </li></ul><ul><li>Restoration of fluid and electrolyte balance </li></ul>
  28. 28. Treatment <ul><li>Treatment of hypocalcemia, if symptomatic </li></ul><ul><li>Limitation of oral intake (with dietary fat restriction) to avoid secretory stimulation of the pancreas. </li></ul><ul><li>May require: </li></ul><ul><ul><li>Supplementation O2 by mask </li></ul></ul><ul><ul><li>Endotracheal intubation and mechanical ventilation </li></ul></ul>
  29. 29. THANK YOU END
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