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.
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
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.
Investigations
to diagnose
Serum AMY > 3 x ULN
Urine AMY or lipase
can be used if clinical
suspicion but normal
sAMY.
Annotations:
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.
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.
Annotations:
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.
Pseudocyst
can develop -
lesser
peritoneal sac.
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