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.

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.
• X–ray
• Ultrasound
• CT – scan
• Radio–nuclide 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%.