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Acute Pancreatitis

Acute Pancreatitis is an inflammatory process of variable severity; most episodes of acute pancreatitis are self-limiting and associated with mild transitory symptoms that remit with in 3 to 5 days.

What is the Etiology of acute pancreatitis?

1. Gall stone
2. Alcoholism
3. Drugs induces (Isoniazid, estrogen, thiazide, furosemide)
4. Hypertriglyceridemia
5. Hypercalcemia
6. Infections (mumps, orchitis, Coxsackie’s virus B, E-B virus, Hepatitis A and B)
7. Tumors
8. Trauma

What is the Pathogenesis of Acute Pancreatitis?

The exact Mechanism is still unclear. However, the chain of events beings and pancreatic acinar cell injury. Afflicted acinar cells locally release activated pancreatic digestive enzymes that result in parenchymal autodigestion along with the recruitment of inflammatory cell mediators, eventually leading to a systemic inflammatory response.

What Pathological changes in Acute Pancreatitis?

The pathologic changes of acute pancreatitis include parenchymal and peripancreatic fat necrosis and an associated inflammatory reaction.

What are the sings and symptoms of acute pancreatitis?

  1. Severe epigastric pain radiate straight though to the mid-central back. Pain is relived by leaning forward or lying on the side with the knees drawn upward.
  2. Persistent Nausea and vomiting after the stomach has been emptized.
  3. Black stool or vomit of blood.
  4. Looking ill and anxious.
  5. Hyperthermia
  6. Tachycardia, tachypenia
  7. Hypotension
  8. Hypovolemia
  9. Collapsed neck vein
  10. Tenderness or rebound tenderness
  11. Flank ecchymoses (Gray-turner sign) and periumbilical ecchymoses (Cullen sign)

How to diagnosed acute pancreatitis?

Diagnosis relies on patient history, physical examination, laboratory studies and radiological imaging.

Laboratory studies include:

  • Serum amylase level, it is the most useful test which rises with in 2 to 12 hours of symptoms.
  • Serum Lipase level, it rises in acute pancreatitis.
  • Trypin-activated peptide (TAP); urine TAP is elevated in acute pancreatitis.
  • C-reactive protein (CRP) is elevated in acute pancreatitis.
  • Serum calcium level decrease.

Radiologic Imaging includes:

  • Ultrasound: Ultrasound has the specificity and sensitivity 62% and 95% respectively.
  • Computed tomography (CT): has sensitivity and specificity of 90% and 100% respectively.
  • MRI has same sensitivity and specificity as CT.
  • ERCP

What are the complications of acute pancreatitis?

  • Necrotizing pancreatitis
  • Infected pancreatitis necrosis
  • Acute pseudocyst
  • Visceral pseudoaneurysm

What are the Differential diagnoses of acute pancreatitis?

  • Bowel obstruction
  • Cholecystitis or cholangitis
  • Perforated hollow viscous
  • Acute appendicitis

How to managed acute pancreatitis?

Supportive care

  • Volume resuscitation with isotonic fluid is crucial.
  • Gastric rest and nutritional support with Nasogastric decompression.
  • Analgesic; pethidine or morphine is required.
  • Antibiotic are recommend is some patients for prophylaxis.
  • Somatostatin to inhibit pancreatic enzyme.
  • Respiratory monitoring
  • ERCP is done in less then 48 hours after the onset of symptoms to extract stone.

Surgical treatment is needed for the small percentage of patients who continue to deteriorate despite aggressive supportive therapy, but there is not a clear indication for surgical intervention.

Surgical procedure includes:

  1. Percutaneous drainage
  2. Wide debridement of necrotic tissue (necrosectomy)
  3. Pancreatic resection
  4. Open or laparoscopic cholecystectomy is recommended for gallstone induced pancreatitis.

What is the prognosis of acute pancreatitis?

Prognosis depends upon Ranson criteria;

Ranson’s criteria are useful in assessing prognosis in early acute pancreatitis. The more of the criteria are met the higher the mortality. Ranson’s criteria are assessed both at admission and at 48 hours.

Ranson criteria include:

Admission Risk Factors

  1. Age : >55 years
  2. White blood count : >16 000/mm
  3. Blood glucose level : >11.0 mmol/l
  4. Lactate dehydrogenase (LDH) : >350 IU/l
  5. Aspartate aminotransferase (AST) : >250 U/l

At 48 hours Risk Factors

  1. Packed cell volume: decrease >10% from admission
  2. Blood urea nitrogen (BUN) : increase >1.8 mmol/l from admission
  3. Calcium: <2 mmol/l
  4. Oxygen partial pressure : <60 mm Hg
  5. Base deficit : >4 mmol/l
  6. Fluid sequestration: > 6 l

Prognosis

  • Risk factors <3: 1% mortality
  • Risk factors 3-4: 15% mortality
  • Risk factors 5-6: 40% mortality
  • .Risk factors >7: 100% mortality

References:

  • Sabiston textbook of surgery 18th edition
  • Bailey and love, surgery 25th edition
  • www.sciencedirect.com
  • radiopaedia.org
  • The Washington manual of surgery, 5th edition.

 

From: Emedicinezone.com

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