Acute Pancreatitis Flashcards
Acute pancreatitis
Acute pancreatitis isa condition where the pancreas becomes inflamed (swollen) over a short period of time.
Etiology Idiopathic (25%) Gallstones (biliary pancreatitis, 40% of cases, biliary pancreatitis) Ethanol (25%) Trauma Steroids Mumps Autoimmune (sjorens) Scorpion Stings Hypertriglyceridemia and Hypercalcemia ERCP (Endoscopic retrograde cholangiopancreatography) Drugs (loop and thiazide diuretics, sulfonamides, protease inhibitors, NRTIs)
Clinical features
Severe, constant epigastric pain. radiating towards the back (worse after meals and supine, improves when leaning forward)
Nausea, vomiting and fever.
Signs of shock: oliguria/anuria, hypotension, tachycardia. juandice in patients in patients with biliary pancreatitis
Abdominal examination:
Tenderness, distention and guarding.
Ileus (reduced bowel sounds and typanny on precusion)
Ascites
skin changes:
Cullen sign (periumbilical ecchymosis).
Grey Turner sign (flank ecchymosis with discolouration)
Fox sign (ecchymosis over inguinal canal)
If pulmonary complications are present:chest pain,dyspnea, pleural signs and ARDS may be present
Diagnosis
Two of the three following criteria should be met for a diagnosis of acutepancreatitisto be made.
Characteristic abdominalpain
↑ Serumpancreatic enzymes:lipaseoramylase≥ 3×ULN
Characteristic findings of acutepancreatitisoncross-sectional imaging(e.g.,contrast-enhanced CTabdomen)
Diagnosis extra.
All patients
Performlaboratory studiesto:
Establish the diagnosis: serumlipaseand/oramylaselevels
Determine severity:CBC,BMP,ABG,LDH,inflammatory markers, serumcalcium
Evaluate for the underlying etiology:liver chemistries, serum or plasmatriglyceridelevels
Obtainultrasoundabdomen.
Diagnostic uncertainty: Performcontrast-enhanced CT(CECT) abdomen.
Confirmed diagnosis
Perform further diagnostics as needed to determine the etiology (e.g.,MRCPfor suspectedbiliary pancreatitis).
Calculate severity scores of acutepancreatitisto estimate severity and prognosis.
In patients withsevere pancreatitis, considerCECTabdomen5–7 daysafter the onset of symptoms to assess fornecrotizing pancreatitis.
Ultrasound
Indications:first-line imaging modality for all patients
Supportive findings
Features of acutepancreatitis(visible in 20% of cases).
Enlargedhypoechoicpancreas(pancreaticedema)
Peripancreatic fluid and/orascites
Features ofbiliary pancreatitis
Cholelithiasisand/orgallbladdersludge
Dilated biliary tree
Evidence of complications:pancreatic pseudocysts,walled-off necrosis(typically> 4 weeksfrom symptom onset)
CT abdomen andpelviswith IV contrast
Indications
Diagnostic uncertainty (e.g., typical clinical features in a patient with moderately elevatedpancreatic enzymes)
Severe pancreatitis: optimally performed> 5–7 daysafter symptom onset
Lack of improvement (after> 7 days) or sudden acute deterioration
To evaluate for underlying aetiology if routine diagnostic studies are negative
Findings
Features of acutepancreatitis
Enlargement of thepancreaticparenchymawithedema
Indistinctpancreaticmargins with surroundingfat stranding
Peripancreatic free fluid
Evidence of complications
Necrotizing pancreatitis: non-enhancing areas ofpancreaticparenchyma
Acutenecroticcollections: ill-defined, heterogeneous appearance with varying densities
Walled-off necrosis: an encapsulated collection ofnecroticmaterial, usually occurring> 4 weeksafter the onset ofnecrotizing pancreatitis
Infection: air within thepancreaticor peripancreatic tissue or fluid collections
Other imaging techniques
X ray: sentinel loop, colon cutoff.
MRI abdomen
combination with MRCP in cases of chloedochlithiasis.
Magnetic resonance cholangiopancreatography: diagnostic, less risk than with ERCP (endoscopic retrograde cholangiopancreatography) with perforation and haemorrhage. Chloedocholithiasis and pancreatic duct abnormalities.
Severity grading and prognostic scores
Revised Atlanta grading of severity:
Mild acute pancreatitis: no organ failure and no local or systemic complications
Moderate acute pancreatitis: transient organ failure (< 48 hours) and/or local or systemic complications
Severe acute pancreatitis: persistent organ failure (> 48 hours)
Modified Marshall score system determines organ failure. (respiratory, renal and cardiovascular)
Ranson criteria
GALAW CHOBBS
One of the oldest predictive models used toestimate severity and prognosis of biliary and nonbiliarypancreatitis, butfull assessment is only possible after48 hours
Glucose 200
AST 250
LDH 350
AGE 55
WBC 16000
Calcium less than 8
Hematocrit decrease 10%
pO2 60mmhg
base deficit 4
BUN increase 5
Fluid sequestration 6l
Acute stabilisation
ABCDE survey,
hemodynamic and respiratory support and maintain NPO status till cause of acute abdomen can be ruled out. O2 therapy
GOAL Directed IV fluid therapy.
crystalloids such as normal saline. 5-10ml/kg/hour. Hemodynamically unstable patient. Rapid fluid bolus (1L in 10-30mins)
Repeated monitoring (o2, vitals) lab values, and physical for abdominal compartment syndrome.
Perform electrolyte therapy as needed.
Goal objectives: Heart rate less than 120bpm, MAP 65-85
Urine output 0.5-1ml/kg/hour
CVP 8-12mmhg, hemocrit
Analgesics: NSAIDS and Opioids
Antiemetics
antibiotics are only given if there is evidence of infection.
Monitor vitals, O2 saturation every few hours. Takes bloods (BMP,CBC, HCT) every 6-12 hours.
Nutrition
Early oral feeding: begin as soon as tolerated by the patient.
(Enteral tube preferred over parenteral nutrition)
Parental nutrition used only in patients who cannot tolerate feeds.
Management of underlying cause.
Bilary pancreatitis therapeutic ERCP: bilary pancreatitis with cholangitis (urgent) or persistent bile duct obstruction. cholecystectomy: all patient with biliary pancreatitis to prevent recurrence.
Hypertriglyceridemia induced pancreatitis insulin therapy, plasmapheresis and hemofiltration. Longterm therapy fibrates.
Hypercalcemia induced pancreatitis loop diuretics and fluid terapy , calcitonin and biphosphates.
Necrotizing pancreatitis complications
necrosis of pancreatic and peri pancreatic tissue. fever, persistent tachycardia, insufficient symptomatic improvement over days. CECT Sterile necrotising pancreatitis, can be managed conservatively. Encourage enteral feeding. Provide nutritional support as needed.
Infected necrotising pancreatitis
bacterial superinfection or necrotising pancreatic parenchyma similar to those of necrotising pancreatitis. lab studies persistent or worseningleukocytosis,bacteremia, and increasinginflammatory markers. CECT: gas within thepancreasand/or peripancreatic tissue or fluid collections. Supportive care: fluid therapy, analgesic, nutritional support Broad spectrum antibiotics; meropenem (good tissue perfusion 4 weeks) Drainage of infected material if there is a clinical detonation. Pancreatic debridement. (Necrostomy) 4 weeks Image-guided percutaneous drainage (2-4 weeks) High mortality rate (30%)
Walled off necrosis
an encapsulated collection of sterile necrotic material. 4 weeks after the onset of necrotising pancreatitis. Percutaneous drainage or endoscopic necrostomy.
