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Diagnosis of Acute Pancreatitis

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Diagnosis of Acute Pancreatitis

  1. 1. Compiled and edited by AJ
  2. 2. ①HISTORY • Abdominal pain – Site: upper abdomen – Acute onset – Gradually intensifies in severity – Duration: varies – Radiates to the back – Worsening when drinking alcohol or eating heavy meal – Relieve sometimes by sitting upright or leaning forward – Associated with nausea, vomiting, anorexia, fever
  3. 3. Don’t forget to ask.. • History of previous biliary colic • History of alcohol consumption • Any recent operative or other invasive procedures (e.g. ERCP) • Any intake of certain medications • Any viral infection • Family history of hypertriglyceridemia
  4. 4. ②EXAMINATION General examination • Pale • Diaphoretic • Listless • Jaundice (minority of patients) Vital signs • Fever • Tachycardia • Hypotension • Tachypnea
  5. 5. Abdominal examination • Abdominal tenderness • Muscular guarding (guarding tends to be more pronounced in the upper abdomen) and distention. • Bowel sounds are often diminished or absent because of gastric and transverse colonic ileus.
  6. 6. Uncommon physical findings • Cullen’s sign: bluish discoloration around the umbilicus resulting from hemoperitoneum • Grey-Turner’s sign : reddish- brown discoloration along the flanks resulting from retroperitoneal blood dissecting along tissue planes. • Erythematous skin nodules : focal subcutaneous fat necrosis(size not more than 1 cm, and the site is on extensor skin surfaces) • Polyarthritis
  7. 7. ③INVESTIGATIONS LABORATORY • CBC – Anemia(hgic), leukocytosis (inflammation, infection) • Liver enzymes – ALT if increases more that 150 U/L probably dto gallstones • Serum electrolytes, BUN, creatinine – Low Ca2+ • Blood glucose, cholesterol, triglycerides – Blood glucose high dto B-cell injury • ABG – respiratory distress
  8. 8. Laboratory studies Serum amylase Serum lipase C- reactive protein Other markers
  9. 9. • Pancreatic enzymes (serum amylase and lipase) – Serum amylase sensitivity of 81-95% but not specific for pancreatitis – Serum lipase more preferred dto its improved sensitivity esp in alcohol-induced pancreatitis, and its prolonged elevation – Rise 2-4 times the upper limit of normal is recommended for dx – Neither is useful in monitoring or predicting the severity the episode of acute pancreatitis
  10. 10. • Serum C-Reactive Protein: best marker for severity • Trypsinogen and elastase have no significant advantage over amylase or lipase
  11. 11. IMAGING IN ACUTE PANCREATITIS Role: • To clarify the diagnosis when the clinical picture is confusing • Help in determine the possible causes • Assess severity (Balthazar score) • Determine prognosis • Detecting complications
  12. 12. 1. Abdominal Ultrasound • Indicated early in acute pancreatitis – Pros • Inexpensive • Excellent for identifying gallbladder pathology • Technique of choice of detecting gallstones (Most common cause of pancreatitis!) • Evaluate bile‐duct dilation • May visualize masses and follow up of pseudocyst – Cons • Not optimal for pancreas; retroperitoneal location easily obscured by bowel gas distension • Less sensitive for stones in distal CBD • Limited in early assessment of pancreatitis
  13. 13. 2. Abdominal X-ray • Limited role in acute pancreatitis • Poor visualization of the pancreas and retroperitoneum • Most common radiologic signs associated with acute pancreatitis include: – Free air in the abdomen, indicating a perforated viscus – The colon cut-off sign, and sentinel loop sign, both indicating inflammatory process damaging peripancreatic structures
  14. 14. COLON CUT-OFF SIGN •Markedly distended transverse colon with air •Absence of gas distal to splenic flexure
  15. 15. SENTINEL LOOP SIGN Mildly dilated, gas-filled segment of small bowel with or without air fluid level
  16. 16. 3. Contrast-Enhanced CT • Standard imaging of choice – Pros • Aid in diagnosis and staging of pancreatitis • Evaluate complications • Evaluate common bile duct for stones or other obstructions • Assess severity of acute pancreatitis (CT Severity Index) – Cons • limited in patients who are allergic to intravenous (IV) contrast or have renal insufficiency.
  17. 17. CTSI
  18. 18. 3. MRI • Increasingly used in diagnosis and management of acute pancreatitis – Pros • alternative in situations in which CECT is contraindicated • Non‐invasive and no use of IV contrast • Ability to delineate pancreatic and bile ducts (detect choledocholithiasis missed on U/S ) • Greater sensitivity than CT in detecting mild pancreatitis – Cons • Expensive • Less readily available in non‐tertiary medical centers

Editor's Notes

  • Point 3… until it reaches constant ache
    Point 4 … usually lasts more than a day
    Point 6.. ‘fatty dyspepsia’

    All of these obtain from complaint & its analysis
  • In severe acute pancreatitis, often the patient is pale, diaphoretic and listless
    Tachypnea occur in ARDS

  • These findings are associated with severe necrotizing pancreatitis
  • Routine ix
  • Ix for the organs affected.. Serum amylase, lipase, n so on
  • CT severity index (CTSI) based on findings from a CT scan with intravenous contrast to assess the degree of pancreatic inflammation, necrosis and complications in patients with acute pancreatitis. The severity of computed tomography findings correlated with clinical prognosis. CTSI includes grading of pancreatitis (A-E) and the extent of pancreatic necrosis. The CTSI was added to the traditional balthazar score in the 1990 by the same author.


    CTSI
    The CTSI is determined on the basis of the sum of the scores obtained in balthazar score and those obtained in the evaluation of glandular necrosis percent.  
    0-3: AP mild
    4-6: AP moderate
    7-10: AP severe

    CTSI
    Grading of pancreatitis
    A: normal pancreas: 0
    B: enlargement of pancreas: 1
    C: inflammatory changes in pancreas and peripancreatic fat: 2
    D: ill defined single fluid collection: 3
    E: two or more poorly defined fluid collections: 4
    Pancreatic necrosis 
    none: 0
    less than/equal to 30%: 2
    >30-50%: 4
    >50%: 6
    The maximum score that can be obtained is 10.
  • Rise within hours of pancreatic injury. A threshold 2-4 times the upper limit of normal
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