32. Acute pancreatitis Flashcards
WHAT IS THE DEFINTION OF acute pancreatitis
premature activation of the exocrine proteolytic enzymes in the pancrease causing inflammation =
udden onset
REVERSIBLE INFLAMMATION
what is the etiology of acute pancreatitis ?
get smashed
gallstones ethanol trauma steroids / sulfonamides / furosemide mumps autoimmune sphincter of oddi dysfunction hypercalecmia from hyperparathyroidims ERCP surgery and procedures
strict diet followed by rapid intro of fattty food
god , sat , meha
what is the classification of acute pancreatitis ?
severity = revised ATLANTA CRITERIA
1)mild acute
interstitial edema no organ failure
no local complication
sponatneous resolution in 1 week
2) moderately severe acute -
can haveor not have local complication ,
with transient organ failure up to 48 hrs
2) severe acute - pancreatitis - causing multiorgan failure persisting more than 48 hours
and local complication - peripancreatic fluid collection and necrosis
what is the pathophysiology leading to pancreatic necrosis and multiorgan failure and HYPOCALCEMIA ?
activation of zymogens
autlysisi and digestion of pancreatic parenchyma
inflammatory cells attracted and release cytokines
the cytokines and vascular damage = vasodilation and increased vascular perm
fluid goes from intravascular to interstitial
giving hypotension and tachycadia
uncorrected hypotension = decreased organ perfuson = multiorgan failure and pancreatic necrosis
lipases released break down mesenteric and peripancreatc fat
increase in free fatty acis
which bonds to calcium = hypocalcemia
what are the clinical signs and symptoms
SUDDENONSET OF PAIN - IN THE LEFT UPPER QUADRANT , PERIUMBILICAL
CAN RADIATE TO WHOLE ABDOMEN , MID BACK AND CHEST
PATTERN = CONSTANT
wrost after eating and drinking and when supine
vomitting without sens of relief
dark brown urine - increase bile in urine
steatorrhea - clay coloured stool
jaundice
fever
syncope and fatigue
tachycardia , hypotension , tachypnea , diaphoresis
ecchymosisi of the umbilicus
what is the diagnosisi of acute pancreatitis ?
2 of 3
pain suggestive of pancreatitis
elevated serum lipase above 3 x ULN (amylase is also rised but non specific)
charecteristic findings on imaging
abdominal US - gallbladder stones and biliary obstruction
CONTRAST ENHANCED CT -
when necrotic pancreatitis suspected
72 hrs after onset of attack
MRI
MRCP , ERCP
blood test ncreased crp wbc hyperglycemia and glucosurea , protein urea , increased creatinin , increased urea hct high
gallstone pancreatitis - cholestatsic parameters
do ECG = = 30 percent changes in S-T segmnet
diffuse t wave inversion and ST elevation
what are some of the local complications ?
peripancreatic fluid
peripancreatic necrosis
what are some systemic complication
BAD PROGNOSISIIF THIS DEVELOPS
SIRS - systemic inflammtory response
inflammatory activity
followed by compensatory anti inflammatory activity - infectious spread through immunosuprresion
prescnce of 2 or more than in this criteria
fever more than 38 or less than 36 degrees
pulse more than 90
resp rate more than 20 /min
wbc less than 4,000 or more than 12,000 mm3 and more than 10 percent bands
what are the assesment criteria for severity and prognosis
apache 2 MORE THAN 8 = severe acute pancreatitis 12 physiological parameters + age + comorbidities ----------- ranson score >3 = severe pancreatitis 5 parameters at time of presentation 6 during first 48 hours --------- WITHIN 48 HOURS
modified glasgow score age over 55 wbc over 15 000mm3 glucose more than 10mmol/l urea more than 16 mmol/l albumin less than 32g/l Pa02 less than 60mmhg calcium less than 2 mmol/l AST/ALT > 100 iu/l LDH > 600iu/ml
3 or more = severe course
what is the treatment ?
early and aggressive hydration 4-6 l / daily to get a 0.5ml/k/h with urine output and decreased urea level
enteric feeding
low fat liquid and go to low fat regular diet
severe pancreatitis = naso jejunal tube enetral feeding
analgesics - fentanyl and metamizole
imipenem in patients with necrotising pancreatitis = reduce infection
Severe pancreatitis with infected necrosis or persistent fluid collections should be treated with percutaneous US or CT-guided aspiration/ drainage
o surgical detriment
gall stone affected pancreatitis = laproscopic cholescystectomy
ERCP and spincterotomy = acute galstone with acute cholangitis
or unresolved billary obstruction
dd for acute pancreatitis ?
cholecystitis
complications of acute pancreatitis ?
abdominal compartment syndrome
pancreatic abcess
ascitis
pleural effusion to left
