Ch. 17 Severe Epigastric Pain with Nausea and Vomiting Flashcards
How do you diagnose acute pancreatitis?
Acute pancreatitis is considered a clinical dx. Two of the following three required:
- Sudden, severe, persistent epigastric pain radiating to the back
- Elevated lipase or amylase to 3x greater than the upper limit of normal
- Characteristic findings on imaging (i.e., enlarged pancreas, sentinel loops, colon cutoff sign, etc…)
What is the significance of bruising around the umbilicus and flank?
Grey Turner’s Sign refers to a blue-black discoloration in the flanks. It is considered a sign of retroperitoneal hemorrhage due to acute pancreatitis.
Cullen’s Sign is a blue-red discoloration at the umbilicus, and the appearance is a result of digested blood products in the retroperitoneum, forming methemalbumin, that then travel towards the anterior abdominal wall.
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Retroperitoneal organs
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Most common cause of acute pancreatitis vs. chronic pancreatitis
Radiologic differences
Acute: Gallstone (40%), alcohol (30%)
- Dilated loops of bowel near pancreas (sentinel loop)
Chronic: Alcohol (90%), anatomic defects (pancreas divisum)
- Pancreatic calcifications
How many phases are there in acute pancreatitis?
- Premature activation of trypsin within the pancreatic acinar cells
- Intrapancreatic inflammation
- Extrapancreatic inflammation (affecting multiple organ systems)
What is the mechanism for hypotension in pancreatitis?
Inflammation and cytokine storm –> endothelial injury and increased permeability in the peripancreatic vasculature –> fluid leaking into retroperitoneal space
Cytokine storm –> massive vasodilation (which along with a shrunken intravascular volume –> severe hypotension)
What is the diagnostic imaging of choice on admission for acute pancreatitis?
RUQ U/S since the most common cause of acute pancreatitis is gallstones (this is the first etiology that should be ruled out)
Mgmt:
What is the initial treatment for acute pancreatitis?
Supportive –> managed conservatively with vigorous IV fluid hydration, NPO, analgesics, nasogastric decompression only if vomiting
Majority of pt’s symptoms resolve within 3-5 days with this mgmt
- What should you suspect if a patient with severe acute pancreatitis, develops a fever and leukocytosis 3 weeks into hospitalization?
- What should you suspect if a patient with a recent hospitalization for pancreatitis comes in 4 weeks later with persistent abdominal pain, a palpable epigastric mass, and persistently elevated serum amylase?
-
Pancreatic abscess
- Order a CT scan with contrast looking for necrotic tissue (areas that do not enhance) or a pancreatic abscess
-
Pancreatic pseudocyst
- Order a CT scan
- Majority of pts: resolves spontaneously in 6 weeks with supportive tx only
What kind of nutritional support is necessary?
ENTERAL (not parenteral) is preferred –> feeding tube placed past the ligament of Treitz to avoid activation of the pancreas