Acute Pancreatitis Flashcards
Definition: Acute Pancreatitis
An acute degenerative inflammatory disease of the pancreas, which is based on the autolysis of its own gland tissue activated by enzymes followed by the addition of microbial and aseptic inflammation.
Causes of acute pancreatitis:
A) Factors contributing to the development of acute pancreatitis:
a) diseases of the gallbladder and extrahepatic ducts (calculous cholecystitis, choledochal lithiasis, stenosis of the major duodenal papilla);
b) abuse of alcohol, fatty foods;
c) abdominal trauma with damage to the pancreas;
d) poor blood circulation in the pancreas;
e) allergic conditions.
B) The factors causing the development of acute pancreatitis:
a) mechanical ( biliopancreatic, reflux from duodenum to choledoch, intraductal hypertension);
b) neurohumoral (stress, druginduced pancreatitis);
c) toxicallergic (allergies, immunobiological disorders).
Pathological forms of acute pancreatitis:
- edematous form of acute pancreatitis;
- necrotizing form of acute pancreatitis:
- fatty pancreatic necrosis;
- hemorrhagic pancreatic necrosis;
- combination of fatty and hemorrhagic pancreatic necrosis;
• complicated form of acute pancreatitis.
A) Edematous form of acute pancreatitis:
- visually pale gland tissue, tight, edematous, there is swelling of the tissues around the gland;
- microscopically edema of the internal and interlobular connective tissue, scattered foci of the gland cells, dystrophy and necrobiosis of pancreas.
B) Necrotic form of acute pancreatitis:
a) fatty pancreatic necrosis:
- visually the gland is increased in volume, has a variegated appearance due to areas of necrosis, which contain caseous masses;
- possible areas of steatonecrosis in parapancreatic tissues;
- microscopically: in areas of necrosis cells can be found in a state of dystrophy, necrosis and decay;
b) hemorrhagic necrotizing pancreatitis:
- visually the gland is increased in volume, purplish-black, soft, easily splits, haemorrhagic imbibition of parapancreatic tissues determined;
- microscopically: against the background of degeneration and necrosis of the pancreas, tissue changes are observed. Unlimited distribution of hemorrhagic exudate is characteristic;
c) mixed (fatty and hemorrhagic) pancreatic necrosis.
C) It is a complicated form of acute pancreatitis:
a) complications of abdominal and retroperitoneal space:
- acute liquid formation of in the lesser omentum cavity;
- enzymatic aseptic peritonitis;
- infected peritonitis;
- abdominal abscesses, pancreatic abscess and phlegmon of the retroperitoneal space (parapancreatitis, paracolitis);
- arrosive bleeding;
- pancreatic and intestinal fistulas;
b) complications in the pleural cavity:
- reactive pleurisy;
- pleural empyema.
Clinical course of acute pancreatitis according severity and disease development periods:
A) Mild form (up to 75-80% of patients) hospitalization to the surgical department;
B) Severe form (up to 20-25% of patients), hospitalization to the intensive care unit:
a) period of hemodynamic shock and pancreatogenic toxemia:
(lasts from several hours to 2- 3 days and manifests with hemodynamic and microcirculatory disturbances);
b) period of pancreatogenic toxemia and multiorgan failure:
(lasts from 2-3 to 7-10 days and is characterized by dysfunction of vital organs);
c) period of dystrophic and suppurative complications:
(starts from 10-14 days after the disease onset and is characterized by the development of purulent process in the pancreas and parapancreatic tissues).
Clinical signs of acute pancreatitis
(correspond with the severity of acute pancreatitis):
A) The complaints of the patient with acute pancreatitis:
a) pain, which is localized in the epigastric region, above the navel, or has a belt-like character
- sudden onset;
- has a continous or progressive character;
- radiating to the left side of the chest, left shoulder girdle;
- pain intensity depends on the severity of pancreatitis;
b) nausea;
c) repeated vomiting, which does not bring relief;
d) hiccups;
e) severe weakness;
f) retention of gas.
B) Medical history:
a) acute onset;
b) the presence of provoking factors (alcohol, excessive consumption of protein and fatty foods, the pathology of the gallbladder and extrahepatic ducts).
C) Objective evidence of disease:
a) common clinical signs of acute pancreatitis depends on the period of the disease in which the patient is examined by doctor:
• period of hemodynamic disorders and pancreatogenic shock there are signs of hemodynamic and hypovolemic disorders of varying severity:
- decrease in blood pressure;
- change of skin color (a disturbance of microcirculation, the appearance of pathognomonic symptoms of color);
- dysfunction of the central nervous system;
• period pancreatogenic toxemia and multiple organ failure:
- severe nonspecific response of the body, which is manifested by failure of two or more functional systems due to the action on the tissues of vital organs of aggressive mediators and metabolic products;
• period of dystrophic and suppurative complications:
- purulent resorptive fever;
- severe intoxication;
b) local clinical signs of acute pancreatitis depends on the nature of the changes in the pancreas and the presence of complications:
• Inspection of the abdomen:
- abdomen symmetrically swollen;
- abdominal wall is behind in the act of breathing.
• Positive microcirculatory pathognomonic symptoms:
- Grunwald sign - the appearance of bluish discoloration of the skin and petechial rash around the navel and on the buttocks.
- Cullen’s sign - the presence of bluegreen or jaundiced skin pigmentation in the navel.
- Lagerlof’s sign - cyanosis of the face.
- Mondor’s sign - purple spots on the face and trunk
. - Gray-Turner’s sign - cyanosis of the flanks.
• Palpation of the abdominal wall:
- at superficial palpation moderate muscle tension in the epigastric region , above the navel;
- at deep palpation pain in the projection of the pancreas, the presence of infiltrate in
projected tissue.
• Positive pathognomonic abdominal symptoms:
- Kerte’s sign - a painful abdominal wall resistance in the form of section 57 cm above the navel,
depending on the localization of the process the painful area can be shifted to the left or right. - Gobiet sign (radiograph) - isolated distension transverse colon without Kloiber’s cups.
• Positive pathognomonic pain symptoms:
- Blyth symptom - girdle pain at the level of the navel.
- Voscresensky’s symptom - lack of pulsations of the abdominal aorta in the epigastric region.
- Mayo-Robson’s sign - pain while pressing in the left costovertebral angle.
- Chukhrienko’s sign - increased epigastric pain at the push of the anterior abdominal wall under the
navel towards the xiphoid process of the sternum.
• Percussion of the abdominal wall:
- tympanitis in epigastric and mesogastric regions (paresis of the colon);
- dull sound in sloping areas of the abdominal cavity (fluid in the abdomen).
• Auscultation of the abdomen: pronounced inhibition of peristalsis.
Formation of the preliminary diagnosis is based on clinical data.
(acute pancreatitis)
Preliminary diagnosis is formed on the basis of the patient’s complaints , anamnesis and objective manifestations , confirmed by physical methods of research.
To confirm or clarify the diagnosis the diagnostic program is formed, which includes laboratory and instrumental methods of investigation aimed at clarifying the severity of the disease and the identification of areas of pancreatic necrosis .
Diagnostic program in patients with suspected acute pancreatitis:
A) Laboratory tests:
a) complete blood count (leukocytosis with a shift to the left, lymphopenia, eosinopenia);
b) biochemical blood tests (bilirubin increase, activation of hepatic enzymes: alanine transaminase ALT , aspartic transaminase AST, alkaline phosphatase AP, decreased calcium);
c) clinical analysis of urine (presence of protein, erythrocyte, casts), increased urine diastase;
d) blood glucose (increase);
e) serum amylase (increase).
N.B.! Adverse prognostic features: leukocytosis with a shift to the left, lymphopenia, decreased eosinophils, calcium, increase in blood glucose.
B) Additional instrumental methods of investigation:
a) ultrasound (to assess the condition of the pancreas and parapancreatic fiber, the presence of fluid in the abdominal cavity, the state of the gallbladder and extra-hepatic bile ducts);
b) computed tomography (to clarify the presence and extent of necrosis of changes in the pancreas);
c) Plain X-ray of abdomen to determine the indirect signs of acute pancreatitis (distension of the transverse colon) and effusion in the left pleural cavity;
d) diagnostic laparoscopy (can be used to confirm the diagnosis, and at the presence of abdominal effusion turns into a medical procedure and the drainage of the abdominal cavity is performed).
Differential diagnosis
acute pancreatitis
(conducted depending on the period of pathological processes: shock, multiple organ failure or septic complications):
A) The period of hemodynamic disorders and pancreatogenic shock:
a) differential diagnosis with urgent surgical diseases of the abdominal cavity:
- acute cholecystitis;
- stomach or duodenal ulcer complicated by perforation;
- thrombosis of mesenteric vessels;
- acute appendicitis.
B) Period of multiple organ failure:
- peritonitis.
C) The period of suppurative complications:
- abdominal abscess;
- sepsis.
Complications of acute pancreatitis
(due to late referral to a doctor, severity and extent of the pathological process in the tissue, errors in diagnosis and the volume of medical care):
A) Acute fluid formation in the projection of the pancreas (with adequate treatment there is possibility of spontaneous regression).
B) Enzymatic peritonitis.
C) purulent peritonitis.
D) Subdiaphragmatic abscess.
E) Reactive pleurisy.
F) Purulent pleurisy.
G) Intestinal fistula.
H) Pancreatic fistula.
I) Arrosive bleeding
Therapeutic tactics in patients with acute pancreatitis
Involves intensive pathogenetic therapy with surgery when complications arise
A) The pathogenetic therapy in hemodynamic violation and pancreatogenic shock:
- pain relief (prolonged epidural blockade, blockade by Roman-Stoliarov, analgesics, antispasmodics);
- gastric lavage with cold water through the double-lumen tube (cooling of the pancreas);
- inhibition of the secretion of the pancreas and stomach (fasting after the first 3-4 days of the appearance of pain, aspiration of gastric contents, pharmacological blockade of gastric (proton pump blockers) and pancreas (sandostatin) secretion;
- correction of volemic disorders (deficit of blood circulation volume);
- inactivation of pancreatic enzymes in the bloodstream (antifermental drugs (gordox, contrycal);
- detoxification therapy (stimulation of diuresis or forced diuresis after recovery blood circulation volume deficit).
B) Pathogenic therapy between endogenous intoxication and failure of parenchymatous organs:
- intensive therapy aimed at correcting of vital organs disorders along with the continuation of pathogenetic therapy;
- to pathogenetic therapy added:
• antimicrobial therapy;
• partial or total parenteral nutrition;
• if possible enteral tube feeding;
• influence on the motility of small and large intestines.
C) Indications for surgery in the first and second periods of acute pancreatitis:
a) enzymatic peritonitis;
b) biliary pancreatitis (acute pancreatitis, which is combined with choledocholithiasis, acute cholecystitis);
D) Indications for surgery in the third period of acute pancreatitis:
a) purulent process in the retroperitoneal space;
b) purulent peritonitis;
c) pancreatic abscess.
Anesthesia in surgical treatment of acute pancreatitis
general anesthesia with artificially ventilated lung
Surgical treatment of acute pancreatitis:
A) Early operations mostly minimally invasive treatment:
- laparoscopic drainage of the abdominal cavity (in presence of effusion in the abdominal cavity);
- video-laparoscopic cholecystectomy, external drainage of the common bile duct (in biliary pancreatitis cases);
- endoscopic papillotomy (in presence of choledocholithiasis).
B) Laparotomy surgery:
- resection of pancreatic tissue;
- pancreatectomy;
- drainage of abdominal and retroperitoneal.
Clinico-statistical classification of acute pancreatitis:
K85 Acute pancreatitis
Layout clinical diagnosis: Acute pancreatitis {TX form}, {XX}, {in FX}, {complicated with OX}
Degree of severity:
T1 mild
T2 severe
Nature of course:
X1 abortive course
X2 slowly progressive pancreatitis
X3 rapidly progressive necrotizing pancreatitis
Period of the disease:
F1 the period of hemodynamic disorders and pancreatogenic shock
F2 the period of functional insufficiency of parenchymal organs {MOF QX severity}
Clinical manifestations:
Q1 multiorgan failure 1st stage
Q2 multiorgan failure 2nd stage
Q3 multiorgan failure 3rd stage
Q4 multiorgan failure 4th stage
F3 period of dystrophic and suppurative complications {QX}
Clinical manifestations:
Q1 pancreatic abscess
Q2 parapancreatitis
Q3 sepsis
Complications: O1 acute formation of fluid in the projection of the lower omentum O2 fermentative peritonitis O3 purulent peritonitis O4 jaundice O5 subdiaphragmatic abscess O6 intestinal fistula O7 arrosive bleeding O8 pleurisy O9 empyema O10 pancreatic fistula
Examination of disability and rehabilitation of patients:
acute pancreatitis
A) Length of hospital treatment is determined individually, depending on the severity of the disease, the nature of its course, the presence of complications and operations if they are carried out.
B) The recommended duration of outpatient treatment and conduction of drug rehabilitation therapy and limited physical activity is 8-12 weeks.
C) In the case of necrotizing pancreatitis complicated forms there is a possibility of permanent loss of working capacity
