Pancreatitis (inflammatory disease of pancreas) Signs and Symptoms Diagnostic Tests

Pancreatic Diseases

Pancreatitis is inflammatory disease of pan­creas

Various presentations of Pancreatitis :

• · Hypertriglyceridemia
• · Vitamin B₁₂ malsorption
• · Hypercalcemia
• · Hypocalcemia
• · Hyperglycemia
• · Ascites
• · Pleural effusion
• · Chronic abdominal pain.

Pancreatitis Prognosis:

• Several techniques are used to determine how well (or how poorly) patients with pancreatitis will progress during their illness and whether they may benefit from intensive care.
• The best of these is the APACHE II system; it grades patients with pancreatitis on the basis of 14 measurable physiological parameters, including the patient’s

Pancreatitis Classic presentation

• Pancreatitis Signs and Symptoms
• Pancreatitis History

• •Similar to an acute abdomen of any cause
• •Acute pancreatitis:
  • Alcohol use
  • Past history of gallstones
  • Family history of gallstones
  • Medication use
  • Abdominal trauma
  • Recent weight loss
• •Chronic pancreatitis:
  • Alcohol use
  • Signs of steatorrhea
  • Signs of hyperglycemia
• · Severe constant epigastric pain radiating to back.
• · Elevated serum amylase.

Pancreatitis Etiology

• · Unknown
• · Alcohol abuse
• · Biliary tract disease
•  Drugs
• · Trauma
• · Viral infections
• · Metabolic and connective tissue disorders.

Pancreatitis Diagnostic Tests and Interpretation—

Lab

• •No test is 100% sensitive or specific
• •Acute pancreatitis:
  • Elevated serum amylase (amylase P)
  • Elevated serum lipase
  • Liver function tests (LFTs): Hyperbilirubinemia and elevated (mild) ALT, AST, and/or alkaline phosphatase when associated with alcoholic hepatitis or choledocholithiasis
  • Glucose increased in severe disease
  • Calcium decreased in severe disease
  • White blood cells (WBCs): 10,000–25,000/µL

Other Tests

• Serum Amylase: In patients with acute abdominal or back pain, estimation of serum amylase is done.
• If serum amylase is more than 65 units/litre, acute pancreatitis is a possibility.
• If serum amylase is more than 130 units per li­ter, the diagnosis is pancreatitis.
• In acute pancreatitis, serum amylase is increased from 24 hours to 3 days and returns to normal in 5 days.
• In acute pancreatitis, sometimes serum amylase may not be increased as in :
• 1. Late sample – after 5 days
• 2. In chronic pancreatitis
• 3. Hypertriglyceridemia.
• False elevation of serum amylase is seen in carcinoma lung, oesophagus, breast, ovary.
• Urinary amylase is not sensitive or specific. Elevation of pleural fluid and ascitic amylase occurs in other conditions also.
• Serum amylase more than 3 times normal is best test and highly specific for pancreatitis.
• Serum trypsinogen is elevated and is very specific for pancreas, but less sensitive.
• Normal is 28 to 58 ng/ml. Less than 20 ng/ml means> pancreatic steatorrhea.
• Trypsinogen levels are increased in pancreatitis as well as renal failure.
• Single best enzyme test for acute pancreatitis is li­pase estimation.

Tests for Pancreatic Structure X-ray: shows

• 1. Localized ileus in jejunum (sentinel loop)
• 2. Generalized ileus with air fluid levels
• 3. Colon cut-off sign (isolated distension of trans-
• verse colon)
• 4. Duodenal distension with air fluid levels
• 5. Massive pseudocyst
• 6. In chronic pancreatitis – pancreatic calcification on and around second lumbar vertebra.

Ultrasound: shows

• · Edema
• · Inflammation
• · Calcification
• · Pseudocyst
• · Mass lesions
• · Gall stones.
• In acute pancreatfti~ pancreas is enlarged. Pancreatic pseudocyst – echo-free smooth round fluid collection.
• In pancreatic carcinoma – distortion of normal struc­tures.
• If more than 3 cm localized echo-free solid lesion seen, it is usually carcinoma.
• In obesity and gas in large bowel, pancreas difficult· to see.

CT is best for:

• · Chronic pancreatitis and complications.
• · Pancreatic tumors
• · Pancreatic pseudocyst
• · Abscess
• · Calcium deposition.
• Dynamic CT using rapid IV contrast is for pancreatic necrosis to predict mortality and morbidity.
• Spiral CT is very good.

Endoscopic ultrasonography (EUS)

•  is done to see pancreatic parenchyma and pancreatic duct, common bile duct stones, pseudo cyst.
• Endoscopic ultrasound (EUS) is better than Endoscopic retrograde cholepancreatography (ERCP).
• EUS is also for:
• Biopsy
• Nerve blocks through EUS Dilatation of main pancreatic duct.

Magnetic Resonance Cholepancreatography (MRCP)

• To see –
• Pancreatic duct Bile duct
• It is useful in elderly as it is a dure.
• Selective catheterization –
  • of celiac and superior mesenteric arteries, and hepatic, splenic, and gas­trgduodenal arteries for angiography.
  • Percutaneous aspiration biopsy of pancreatic mass is done to differentiate between inflammatory swelli’ng and neoplasm.
• Exocrine pancreatic function
  • 1. Direct stimulation of pancreas by IV infusion of secretin, or secretin plus CCK (cholecystokinin), then measurement of duodenal contents.
  • 2. Study of digestion products from lumen like un­digested meat fibers, stool fat, fecal nitrogen.
  • 3. Measurement of pancreatic enzymes like elastase.