Acute Pancreatitis: Causes, Symptoms, and Management - Prof. Sharma, Exercises of Medicine

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Acute pancreatitis is a discrete episode of

inflammation resulting from intrapancreatic

activation of digestive enzymes.

It is a disease with a wide spectrum of

severity, complications, and outcome.

Acute edematous or interstitial

pancreatitis.

• In this stage, the pancreatic inflammation

and disease is mild and self-limited in most

patients.

• The inflammation results in interstitial

edema.

• The parenchymal damage is minimal, and

the organ recovers its function after

resolution of the inflammation.

Hemorrhagic or necrotizing pancreatitis.

• Here the inflammation may be extensive and progress to coagulation necrosis of the gland and the surrounding tissues, leading to hemorrhagic or necrotizing pancreatitis.
• The mass of inflamed pancreas containing necrotic tissue is referred to as a phlegmon.

ETIOLOGY

Alcoholism and biliary tract disease.

The two most common etiologic factors

associated with pancreatitis are alcoholism

and biliary tract disease (gallstones).

These two factors account for 75% to 85% of

all cases.

Mortality of Alcoholic pancreatitis lower than

gall stone pancreatitis.

ETIOLOGY

Postoperative pancreatitis

• It is infrequent but has a high mortality.
• It occurs after cardiopulmonary bypass, thoracic, and abdominal surgical procedures.
• Operations on and near the pancreas such as gastrectomy, biliary tract surgery, and splenectomy are involved in most of the cases.

ETIOLOGY

Endoscopic retrograde pancreatography.

Pancreatitis may occur in less than 1% of

cases after endoscopic retrograde

pancreatography

ETIOLOGY

Blunt abdominal trauma

It is the most common cause of pancreatitis in children and young adults.

ETIOLOGY

Metabolic disorders

Hypertriglyceridemia Hypercalcemia

ETIOLOGY

Organ transplantation

• Pancreatitis may complicate renal and liver transplantation.

ETIOLOGY

Pregnancy

• Women in whom acute fatty liver of pregnancy develops in the third trimester may also develop acute pancreatitis.
• However, 90% of instances of pancreatitis during pregnancy are associated with gallstones.

ETIOLOGY

Infections.

• Viral agents,
• Bacteria.
• Opportunistic protozoa

ETIOLOGY

Connective tissue diseases.

Drugs

Anatomic abnormalities.

Hereditary pancreatitis

Clinical presentation

Abdominal pain is the most common complaint in acute pancreatitis.

It is usually located in the epigastrium, left upper quadrant, or periumbilical area, and often radiates to the back, chest, flanks, and lower abdomen.

Clinical presentation

• The pain is steady, dull, and boring in character.
• It is usually more intense when the patient is supine and may lessen in the sitting position with

the trunk flexed forward and the knees drawn up.

• Patients also complain of nausea, vomiting, and abdominal distention secondary to ileus.

• Patients with acute pancreatitis present

with fever, tachycardia, and hypotension.

• Shock is common in severe instances due to

hypovolemia caused by third-space fluid

sequestration (in retroperitoneal and other

spaces).

• Jaundice may occur.

• Abdominal tenderness and rigidity may be

present.

• Bowel sounds are diminished or absent.

• The presence of a bluish discoloration

around the umbilicus (Cullen's sign) and at

the flanks (Turner's sign) suggests

hemoperitoneum and results from

hemorrhagic necrotizing pancreatitis.

• pleural effusion (especially on the left side),

• pneumonitis

• subcutaneous fat necrosis resembling

erythema nodosum may be present.

• Tetany due to hypocalcemia is a rare finding.

DIAGNOSTIC STUDIES Laboratory studies

Serum amylase

Even though there is no definite

correlation between the severity of

pancreatitis and the degree of serum amylase elevation, serum amylase elevation is commonly equated to the presence of pancreatitis.

DIAGNOSTIC STUDIES Laboratory studies

Serum amylase

• In 75% of the patients with acute pancreatitis, the serum amylase is elevated.
• Hyperamylasemia is noted within the first 24 hours and persists for 3 to 5 days.
• Amylase levels normalize unless there is extensive pancreatic necrosis, ductal obstruction, or pseudocyst formation.

DIAGNOSTIC STUDIES Serum lipase

• levels are elevated in approximately 70% of patients
• When both serum amylase and serum lipase are determined, elevation of both is more diagnostic.

DIAGNOSTIC STUDIES

• Urine amylase is increased in acute pancreatitis and may remain elevated for 7 to 10 days after serum levels have returned to normal.
• Leukocytosis
• Hyperglycemia
• LFT

RADIOLOGIC STUDIES

Ultrasonography

CT scan

Plain x-ray

ERCP

RANSON PROGNOSTIC CRITERIA

On Admission Age>55 y WBC>16,000/ÂμL Blood glucose>200 mg/dL (no diabetic history) Serum LDH>350 IU/L (normal up to 225) SGOT>250 Sigma Frankel units/L (normal up to 40)

RANSON PROGNOSTIC CRITERIA

Within 48 h Age>55 y WBC>15,000/ÂμL Blood glucose>180 mg/dL (no diabetic history) Serum urea>16 mmol/L (no response to IV fluids) BUN rise>5 mg/dL Pao 2 >60 mm Hg Serum calcium>8.0 mg/dL Hematocrit fall>10% Base deficit>4 mEq/L Fluid sequestration>6 L Serum albumin>3.2 gm/dL Serum LDH>600 units/L (normal up to 255 units/L) AST or ALT>200 units/L (normal up to 40 units/L)

Treatment

• In most patients (85%-90%) with acute pancreatitis, the disease is self-limited and resolves spontaneously.
• These patients are medically treated with supportive care with special attention given to

1. analgesia, 2.maintenance of normal intravascular volume,
2. frequent monitoring of vital signs, 4.and treatment of possible complications of the disease.