ACUTE PANCREATITIS Symptoms Diagnosis and Treatment

ACUTE PANCREATITIS Symptoms Diagnosis and Treatment

ACUTE PANCREATITIS

  • acute inflammatory process of the pancreas. It is usually associated with severe acute upper abdominal pain and elevated blood levels of pancreatic enzymes
  • The pancreas secretes 1500 to 3000 ml of pancreatic fluid with about 20 enzymes.
  • The disease may be relatively mild, resolving in 3 or 4 days, or severe enough to cause multiple organ system failure, shock, and death (in about 5% of patients).
  • pH is more than 8.
  • Pancreatic enzymes are involved in major digestion process.
  • Regulation of pancreatic secretion – Secretin is re­leased by stimulus of gastric acid, which stimulates secretion of pancreatic juice. Release of CCK (chole­cystokinin) from the duodenum and jejunum occurs.’
  • The parasympathetic nervous system i.e. vagus nerve stimulates release of pancreatic juice.
  • Nitric oxide is also a neuro-transmitter for pancreatic exocrine secretion.

ACUTE PANCREATITIS

ACUTE PANCREATITIS Symptoms Diagnosis and Treatment


Water and electrolyte secretion

  • Bicarbonate is the chief ion in pancreatic secretion and helps to neutralize gastric acid.

Enzyme secretion

  • The pancreas secretes amylolytic, lipolytic and pro­teolytic enzymes which are amylase, lipase, phospho­lipase A, cholesterol esterase; Endopeptidase-trypsin and chymotrypsin; Exopeptidases – Carboxypepti­dases, Aminopeptidases, Ribonucleases, Enteroki­nase.
  • Acetylcholine and peptides are neurotransmitters. Vasoactive intestinal peptide (VIP) causes the release of acetyl choline. •
  • Autodigestion of Pancreas is prevented by pres­ence of proteases in precursor form only (inactive form).
  • Exocrine – Endocrine function
    • Insulin stimulates secretion of CCK and secretin re­sulting in exocrine secretion.

ACUTE PANCREATITIS

  • The severity of acute pancreatitis varies from edema­tous pancreatitis to necrotizing pancreatitis.
  • Haemarrhagic pancreatitis can be found in pancre­atic trauma, carcinoma, congestive heart failure, pan­creatitis

ACUTE PANCREATITIS Etiology

  • · Gall stones
  • · Alcohol
  • · Hypertriglyceridemia
  • · Trauma
  • · Post operative
  • · Drugs – Azathioprine, sulphonamides, estrogens, tetracyclines, valproic acid, anti HIV, 6 mercap­topurine
  • · Sphincter of Oddi dysfunction
  • · Vasculitis
  • · Connective tissue disorder
  • · Thrombotic thrombocytopenic purpura
  • · Cancer
  • · Hypercalcemia
  • · Hereditary pancreatitis
  • · Cystic fibrosis
  • · Renal failure
  • · Infection – Mumps, parasites
  • · Autoimmune – Sjogren’s syndrome
  • · Biliary tract disease.

ACUTE PANCREATITIS Clinical Features Symptoms –

  • · Abdominal pain – may be mild to severe, con­stant and agonizing.
  • · Pain is located in epigastrium, periumbilical re­gion, radiating to back, chest, flanks, lower ab­domen.
  • · Pain is more in supine position; patients feel re­lieved with trunk flexed, knees drawn up.
  • · Nausea, vomiting, abdominal distension- due to gastric and intestinal hypomotility.

ACUTE PANCREATITIS Physical examination

  • · Patient is anxious
  • · There is low grade fever
  • · Tachycardia and Hypotension are usually present.
  • · There is shock due to :
  • – Hypovofemia due to exudation of blood and proteins into retroperitoneum (retroperitoneal burn)
  • – Vasodilatation and increased vascular permeability
  • – Systemic response
  • · Jaundice
  • · Erythema
  • · Pulmonary crepts, collapse, pleural effusion (left
  • sided)
  • · Abdominal tenderness
  • · Muscle rigidity
  • · Decreased bowel sounds
  • · Pancreatic pseudo-cyst palpable
  • · Cullen’s sign – blue discoloration around umbili­cus
  • · Turner’s sign – blue or brown discoloration of flanks.

ACUTE PANCREATITIS Lab Diagnosis

  • · Serum amylase increased 3 times.
  • · After 2 – 3 days serum amylase value may re­turn to normal.
  • · Patients with acidemia, arterial pH less than 7.3
  • may have false elevation of serum amylase.
  • · Serum lipase increased in acute pancreatitis.
  • · Leucocytosis more than 15,000/ I-lI
  • · Hematocrit more than 50%
  • · Hyperglycemia
  • · Hypocalcemia
  • · Hyperbilirubinemia (>4 mg / dl)
  • Serum bilirubin returns to normal in one week
  • · Serum alkaline phosphatase is increased
  • · LDH is increased
  • · Serum albumin is decreased
  • · Hypertriglyceridemia
  • ·Hypoxemia – specially with ARDS. ECG – ST-T abnormalities.
  • Xray
  • Ultrasound
  • CT scan
  • Radionuclide scan

Diagnosis

  • Patient with acute pain in abdomen or back with nau­sea, fever, tachycardia, leucocytosis hypocalcemia, hyperglycemia increased serum amylase suggests pancreatitis.

ACUTE PANCREATITIS Differential diagnosis

  • Perforation – peptic ulcer – diagnosed by free intrap­eritoneal air.
  • Acute cholecystitis – Right sided pain.
  • Biliary colic – Ileus absent, stone seen on sonography. Acute intestinal obstruction – colicky pain, physical examination and X-ray are suggestive.
  • Mesenteric vascular occlusion – bloody diarrhoea, arteriography for diagnosis.
  • Renal colic – typical pain of renal colic.
  • Myocardial infarction – typical findings – ECG, elevated troponin.
  • Dissecting aortic aneurysm – hypertension and chest pain.
  • Vasculitis and Pneumonia.
  • Diabetic ketoacidosis – Serum lipase and amylase not elevated.

ACUTE PANCREATITIS Complications

  • High risk patients are elderly, age more than 70 years, patients with hypotension, tachycardia, CO2 < 60 mmHg, oliguria «50 ml/hour), GI bleeding, obesity, hematocrit >44%, CRP > 150 mg / I.
  • Complications are
  • · Necrosis
  • · Ascites
  • · Pancreatic abscess
  • · Pseudo cyst – rupture, haemorrhage, infection
  • · Intestinal obstruction
  • · Bowel infarction
  • · Obstructive jaundice
  • · Pleural effusion
  • · Atelectasis
  • · Pneumonia
  • · Mediastinal abscess
  • · ARDS (Acute respiratory distress syndrome)
  • · Hypotension
  • · Shock
  • · Sudden death
  • · Pericardial effusion
  • · DIC (Disseminated intravascular coagulation)
  • · Gastrointestinal haemorrhage
  • · Peptic ulcer
  • · Portal vein thrombosis
  • · Esophageal varices
  • · Renal failure
  • · Acute tubular necrosis
  • · Encephalopathy
  • · Blindness – Purtscher’s retinopathy
  • · Fat emboli.
  • Pancreatitis is more common in patients of AIDS due to infection’ with cytomegalovirus, mycobacterium avium, use of drugs like pentamidine and trimethoprim sulphamethoxazole.

ACUTE PANCREATITIS Treatment

  • Usually self-limiting in 7 days Analgesics for pain
  • IV fluids and colloids
  • Nil orally
  • Nasogastric suction to prevent gastric contents entering duodenum
  • Antibiotics – Imipenem – cilastatin 500 mg T03 for 2 weeks
  • Glucocorticoids, calcitonin, NSAIDs, somatosta­tin, octreotide
  • Fungicides for Candida infection
  • CT scans help to decide severity and prognosis IV fluids – liquid diets
  • Supportive care
  • Surgical pancreatic debridement- necrosectomy Laparotomy with drainage and removal of ne­crotic tissue.
  • For hypertriglyceridemia – weight loss, fat free diet, exercise, avoid alcohol and drugs like estrogen, vita­min A, thiazides and beta blockers, control of diabe­tes.

Infected Pancreatic Necrosis, Abscess and Pseudocyst

  • It may occur from 2 – 4 wks after pancreatitis
  • There is secondary infection
  • Diagnosed by CT – guided needle aspiration Pseudocyt should be aspirated
  • For nectrotic pancreas management as above

Pseudocyst of pancreas

  • are collection of tissue, fluid, pancreatic enzyme and blood in 1 to 4 wks after acute pancreatitis. There is no epithelial lining there­fore it is called pseudocyst. There may be ascites, abdominal pain, palpable tender mass in middle or left upper abdomen, increased serum amylase.
  • In X-ray, pseudocyst displaces a part of GIT In ultrasound it can be seen.
  • It may resolve spontaneously
  • Complication of psudocyst – pain, rupture, haemorrhage, abscess, shock, death
  • Surgery may be required
  • Pseudoaneurysm may occur in 10%.
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