Acute pancreatitis
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Acute pancreatitis

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Gastroenterology

Gastroenterology

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Acute pancreatitis Acute pancreatitis Presentation Transcript

  • Acute Pancreatitis
  • Acute Pancreatitis
    • Sudden onset of unrelenting upper abdominal pain resulting from inflammation of the pancreas
    • Patients commonly present to ER due to severe abdominal pain
    • Requires admission to the hospital for medical management
  • Pathophysiology
    • Release of kallikrein and chymotrypsin results in increased capillary membrane permeability, leading to leakage of fluid into the interstitium and development of edema and relative hypovolemia
    • Elastase is the most harmful in terms of direct cell damage, it causes dissolution of the elastic fibers of blood vessels and cuts, leading to hemorrhage
    • Phospholipase A destroys phosholipids of cell membranes causing severe pancreatic and adipose tissue necrosis
    • Lipase flows into damaged tissue and is absorbed into systemic circulation, resulting in fat necrosis of the pancreas and surrounding tissues
  • Acute Pancreatitis
    • Inflammation of the pancreas that produces exocrine and endocrine dysfunction
    • Results from premature activation of pancreatic exocrine enzymes (trypsin, phospholipase A, and elastase)
  • Edematous (Interstitial) Pancreatitis
    • Usually mild
    • Resolves in about 7 days
    • Results in fluid accumulation and swelling
  • Severe or Necrotizing Pancreatitis
    • Associated with a high degree of complications and mortality
    • Caused by the release of cytokines and other proinflammatory mediators that produce a hyperinflammatory reaction, resulting in cell death and tissue damage
  • Causes of Acute Pancreatitis
    • Ethanol abuse
    • Biliary diseases
      • Gallstones
      • Choledocholithiasis
      • Biliary sludge
      • Microlithiasis
    • Mechanical/structural injury
      • Sphincter of Oddi dysfunction
      • Pancreas divisum
      • Trauma
      • Postendoscopic retrograde cholangiopancreatography
      • Pancreatic malignancy
      • PUD
      • IBD
    • Medications
      • Azathiprine/6-mercaptopurine
      • Dideoxyinosine
      • Pentamidine
      • Sulfonamides
      • Thiazide diuretics
      • ACEI
    • Metabolic
      • Hypertriglyceridemia
      • Hypercalcemia
    • Infectious
      • Viral
      • Bacterial
      • Parasitic
    • Vascular
      • Vasculitis
    • Genetic predisposition
    • idiopathic
  • Acute Pancreatitis: Damage and Destruction
    • Inflammation is caused by premature activation of enzymes which leads to tissue damage
    • If pancreatitis damages the islets of Langerhans, diabetes mellitus may result
    • Severe sudden pancreatitis causes massive hemorrhage and total destruction of the pancreas, manifested as diabetic acidosis, shock and coma
  • Clinical Presentation
    • Upper abdominal pain rapidly increasing in severity, often within 60 minutes
    • Epigastric pain
    • Right-sided pain
    • Diffuse abdominal pain with radiation to back
    • Pain rarely only in left upper quadrant
    • Restless
    • Prefer to sit and lean
    • N/V
    • Fever
    • Tachycardia
  • Abdominal Examination
    • Decreased or absent bowel sounds
    • Abdominal tenderness
    • Guarding
    • Palpable mass in epigastric area
    • Biliary colic
    • Jaundice if there’s obstruction of the bile duct
    • Cullen’s sign
    • Grey Turner’s Sign
  • Clinical Manifestations
    • Abdominal distention
    • Abdominal guarding
    • Abdominal tympany
    • Hypoactive bowel sounds
    • Severe disease: peritoneal signs, ascites, jaundice, palpable abdominal mass, Grey Turner’s sign, Cullen’s sign, and signs of hypovolemic shock
  • Diagnostic Evaluation
    • Patient’s history
    • Physical examination
    • Diagnostic findings
      • Serum amylase levels greater than three times the upper limit
      • Serum amylase levels may be normal in patients with pancreatitis related to alcohol abuse or hypertriglyceridemia
      • Levels greater than five times the top normal value should be expected in patients with renal failure because amylase is cleared by the kidneys
  • Imaging Modalities
    • Plain abdominal x-rays for visualizing gallstones or a gas-filled transverse colon ending at the area of pancreatic inflammation
      • colon cut-off sign
    • Abdominal ultrasound
      • Cholelithiasis, biliary sludge, bile duct dilation, and pseudocysts
    • CT of abdomen
    • MRCP (magnetic resonance cholangiopancreatography)
  • Ranson’s Criteria
    • The severity of acute pancreatitis is determined by the existence of certain criteria, called Ranson’s criteria
    • The more criteria met by the patient, the more severe the episode of pancreatitis
    • 1% mortality: fewer than three
    • 16%: three or four criteria
    • 40% with five or six criteria
    • 100%: seven or eight criteria
  • Ranson’s Criteria
    • On admission
      • Patient older than 55
      • WBC > 16,000
      • Serum glucose >200
      • Serum lactate dehydrogenase >350
      • Aspartate aminotransferase > 250
    • During initial 48 hours after admission
      • 10% decrease in Hct
      • BUN increase > 5
      • Serum calcium < 8
      • Base deficit > 4
      • PaO2 < 60
      • Estimated fluid sequestration > 6 liters
  • Common Complications of Acute Pancreatitis
    • Pulmonary
      • Atelactasis
      • Pleural effusions
      • ARDS
    • Cardiovascular
      • Cardiogenic shock
    • Neurologic
      • Pancreatic encephalopathy
    • Metabolic
      • Metabolic acidosis
      • Hypocalcemia
      • Altered glucose metabolism
    • Hematologic
      • DIC
      • GI bleeding
    • Renal
      • Prerenal failure
  • Management
    • Fluid Management
    • Nutritional support
      • Rest gut
      • TPN
    • Pain management
    • Supporting other organ systems
  • Treatment
    • IV replacement of fluids, proteins, and electrolytes
    • Fluid volume replacement and blood transfusions
    • Withholding food and fluids to rest the pancreas
    • NG tube suctioning
    • Drugs
    • Peritoneal lavage
    • Surgical drainage
    • Laparotomy to remove obstruction