ACUTE  PANCREATITIS

 

Pancreatitis is an inflammation of pancreas that ranges from mild edema to necrosis.

Etiology:

  1. Toxins: ETOH, Meds (BCP, diuretics, sulfa,  etc.),
     
  2. Obstructive: Biliary stones, Biliary  or Pancreatic CA
     
  3. Trauma:  Trauma, Post-OP , ERCP,  perforating PUD,
     
  4. Metabolic:  Uremia, hypercalcemia, Hypertriglyceremia,
     
  5. Infectious: Viral, Sepsis.
     
  6. Miscellaneous: Pregnancy, Collagen disease,

S & S:

  1. Epigastric pain radiating to the back.
     
  2. N/V, Tachycardia.
     
  3. ¯Breath sounds 2ry to atelectasis, ¯ Bowel sounds 2ry to ileus.
     
  4. Cullen's and Grey-Turner's sign (rare).

DX:

  1. ­Amylase. This occasionally lags behind ( elevation starts 3-6hrs after the clinical picture) and in 20%  of alcoholics may be normal or routinely elevated. It is  95% sensitive and 88% specific. No correlation  between  rate or level of rise and the clinical severity, but when amylase is  three times above the normal limit specificity of amylase increases. Amylase plateaus in 20-30 hrs. and returns to normal in 48-72 hrs.
     
  2. ­Lipase. Sensitivity 80% and Specificity 99%.  May remain elevated  10-14 days after the return to normal  of amylase.
     
  3. Both Amylase and Lipase may be increased in CRF patients without having pancreatitis. It  would be helpful to know pt's baseline of  these markers since they often have abdominal pain and are also prone to develop uremic pancreatitis.
     
  4. ­WBC, ­ HCT (initially), ­ BUN (dehydration), ­ Serum glucose, ­ LDH, ¯ Ca, ¯ in pO2 on ABG,  ­ ALT more than 3 times normal points to gallstone pancreatitis.
     
  5. Xray  may show "sentinel loop", atelectasis, pleural effusion.
     
  6. US is useful to R/O "surgical" causes of pancreatitis, for example if  this is 2ry  to choledocolithiasis pt should have surgical  floor admission (although this statement may be challenged by those advocating  ERCP for stone removal and then medical floor admission is acceptable). US is also useful  to R/O pseudocyst.
     
  7. CT is  superior to US in dx of pancreatitis but generally not for diagnosis.

Treatment:

  1. Mostly supportive; NPO, IVF
     
  2. NGT. While may provide comfort for N/V  it does  not alter the outcome.
     
  3. IVF. In acute pancreatitis fluid sequestration occurs commonly making the IVF a mainstay  of the  treatment. The therapeutic goal is guided by U/O.
     
  4. Correction of electrolyte abnormalities
     
  5. N/V controlled with Prochlorperazine (Compazine).
     
  6. Pain controlled with Opioides
     
  7. Surgical treatment is indicated if pancreatitis is 2ry to GB stone, perforated PUD, or complications of acute pancreatitis such as pseudocyst or development of abscess.
     
  8. If pancreatitis is 2ry to sepsis, stone , or abscess, cover with broad spectrum antbx
     
  9. Pancreatic Ascites may occur 2ry to pseudocyst or trauma. Paracentesis will reveal  ­ amylase and lipase. Surgical intervention  may be indicated.
  10. Hypocalcemia must be corrected with Ca Gluconate.
     
  11. ERCP with spincterotomy should, in acute stage, be reserved for severe cases of acute biliary pancreatitis.

     

             On Admission

                48 H Later

    Age > 55

    ¯ in Hct by 10 %

    BS > 200 mg/dL

    > in BUN 5 mg/dL

    WBC > 16000

    Ca <8 mg/dL

    SGOT > 250 IU

    pO2 < 60mmHg

    LDH > 350 IU

    >6L fluid sequestration
     

    base deficit >4mEq/L
    The Ranson's criteria: 
     









    Complications:
        1.  Local: necrosis, pseudocyst, abscess, hemorrhage
        2.  Systemic: shock, hyperglycemia, hypocalcemia, DIC, respiratory and renal failure.
        3.  Mortality:
    • 0-3 signs ® mortality 1%.
    • 3-6 signs ® mortality 15-40%.
    • >7 signs ® mortality  100%.

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