197448
Acute pancreatitis
- Epidemiology
- Incidence -
100-400 cases per
1 million population
- Incidence -
100-400 cases per
1 million population
- Pathology
- Autodigestion by
activated
pancreatic
enzymes
- 4 stage process
- 1. oedema and fluid shift, which can
cause shock. Vomiting compounds this.
Fluid and enzymes into the peritoneal
cavity, causing fat necrosis in the
peritoneal cavity.
- 2. Autodigestion of blood
vessels - haemorrhage into
extraperitoneal space. Blood
staining causing bruising in
flanks (Grey-Turners) and
umbilical (Cullen's).
- 3. Inflammation
proceeds to
necrosis, which can
become infected.
- 1. oedema and fluid shift, which can
cause shock. Vomiting compounds this.
Fluid and enzymes into the peritoneal
cavity, causing fat necrosis in the
peritoneal cavity.
- 4 stage process
- Autodigestion by
activated
pancreatic
enzymes
- Causes
- Gallstones -
60% cases,
ethanol is
second.
- GET SMASH'N
- Gallstones, ethanol,
Trauma, steroids (other drugs
AZT), mumps (other viral
infections e.g. coxsackie), AI
e.g. SLE, scorpion bites,
hyperlipidaemia (hyperPTH,
hypothermia), neoplasia
- Gallstones, ethanol,
Trauma, steroids (other drugs
AZT), mumps (other viral
infections e.g. coxsackie), AI
e.g. SLE, scorpion bites,
hyperlipidaemia (hyperPTH,
hypothermia), neoplasia
- Gallstones -
60% cases,
ethanol is
second.
- Clinical features
- Sudden onset, severe,
epigastric pain, radiating
to the back.
- ±N and V, may
include the whole
abdomen and lead
to shock
- Diffusely tender abdomen with
normal bowel sounds. But can
resemble peritonitis in severe
cases - px still, rigid abdomen,
guarding, absent bowel
sounds.
- Diffusely tender abdomen with
normal bowel sounds. But can
resemble peritonitis in severe
cases - px still, rigid abdomen,
guarding, absent bowel
sounds.
- ±N and V, may
include the whole
abdomen and lead
to shock
- Sudden onset, severe,
epigastric pain, radiating
to the back.
- Investigations
to diagnose
- Serum AMY > 3 x ULN
- Urine AMY or lipase
can be used if clinical
suspicion but normal
sAMY.
Nota:
- uAMY elevated for 24-48 hours longer. Degree of elevation not related to the severity of the condition.
- CT can show
necrosis or
tumour of the
pancreas if
given a few
days.
- Urine AMY or lipase
can be used if clinical
suspicion but normal
sAMY.
- Serum AMY > 3 x ULN
- Severity
- Significance
- Closer monitoring,
prophylactic abx,
consider for urgent ERCP
and endoscopic
sphincterotomy.
- Most patients get better
but severe acute cases -
MOF sometimes. If they
overcome acute phase
then infected necrosis is
possibility. CT aspiration confirms the diagnosis.
Nota:
- Infected necrosis most common cause of death in acute pancreatitis.
- Infected necrosis - high
WCC, low density
changes, positive blood
culture.
- Open necrosectomy + cavity
irrigation, retroperitoneal
endoscopic necrosectomy using
a modified nephroscope,
transgastric endoscopic
necrosectomy.
- Open necrosectomy + cavity
irrigation, retroperitoneal
endoscopic necrosectomy using
a modified nephroscope,
transgastric endoscopic
necrosectomy.
- Pseudocyst
can develop -
lesser
peritoneal sac.
- Most patients get better
but severe acute cases -
MOF sometimes. If they
overcome acute phase
then infected necrosis is
possibility. CT aspiration confirms the diagnosis.
- Closer monitoring,
prophylactic abx,
consider for urgent ERCP
and endoscopic
sphincterotomy.
- Systems
- Serial CRP measurements
- Ransons, Glasgow or APACHE II
- One point per item, >3 is severe
- At admission: >55 years,
glucose >11, LDH>500, AST
>200, WCC >16
- 48 hours later: HCT
dropped >10%, urea
>16, calcium <2,
arterial pO2 < 8kPa,
base deficit <
4mmol/L
- At admission: >55 years,
glucose >11, LDH>500, AST
>200, WCC >16
- One point per item, >3 is severe
- Serial CRP measurements
- Significance
- Management
- ABC
- ABGs, IVs + fluid, catheter
- UO maintained >
30ml/hour, analgesia, fluid
balance chart.
- NGT, NBM and
antiemetics if V. May
required antiemetics
because opioids are going
to be used.
- PPIs or H2R
antagonists in first
week
- NGT, NBM and
antiemetics if V. May
required antiemetics
because opioids are going
to be used.
- ABGs, IVs + fluid, catheter
- UO maintained >
30ml/hour, analgesia, fluid
balance chart.
- Poorer
prognosis if
AKI or ARDS
develops.
- Prophylactic abx if
predicted severe - for 7
days, BS e.g. meropenem,
ciprofloxacin
- Aetiology
- Gallstones - USS
and
cholecystectomy to
prevent further
attacks
- Urgent sphincterotomy
if biliary disease and
severe acute
pancreatitis.
- Urgent sphincterotomy
if biliary disease and
severe acute
pancreatitis.
- Gallstones - USS
and
cholecystectomy to
prevent further
attacks
- ABC
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