Definition:
Acute inflammation of the pancreas, which leads
to destruction of the gland’s parenchyma, these leads in turn to release of
pancreas digesting enzymes leading to self-digestion, necrosis, water lost, and
maybe to superinfection.
Symptoms:
- The typical Bild of acute pancreatitis, is the
acute onset (within 10-20 minutes) of upper abdominal pain, at mid epigastrium
or right upper abdomen, with band-like radiation to the back
- The pain lasts for days, and relives by bending
forward
- Nausea and vomiting by about 90% of the
patients.
- Grey-turner’s sign: ecchymotic discoloration of
the flanks due to retroperitoneal bleeding by necrosis. Is rare 1%
- Cullen’s sign: periumbilical discoloration is
rare 1%
Diagnosis:
Physical examination:
- Abdomen may be distended with tender and
guarding.
- Fever
- Tachycardia
- Be severe cases shock and coma
- Cullen’s sign or Grey-turner’s sign 1%.
- Findings suggesting the causes such as
hepatomegaly by alcohol, xanthomas bei hyperlipidemia and parotid swelling be
mumps
Laboratory tests:
- Serum amylase: raises 6-12 hours of onset and
lasts for 10 hours in blood. Usually still elevated 3-5
days. Sensitivity and specificity are low.
- Urine amylase: amylase/creatinine-clearance ACCR
= 3%. By macroamylasemia doesn’t raise.
- Lipase: raises earlier and lasts longer, more
specific and sensitive 85-100% than amylase.
NOTE: combination of the enzymes
doesn’t improve diagnostic accuracy, daily measurement of the enzymes doesn’t
asses the progress, and the level of the elevation of the enzymes doesn’t
correlate with the severity of the disease !
Abdominal ultrasound: Ideal to image the gallbladder and biliary tree,
may reveal enlargement with hypoechoic pancreas
Chest film: may reveal pleura effusion (lift sided or bilateral), ARDS
Abdomen- CT: INDICATED WENN patients with pancreatitis don’t improve
under conservative therapy (after 48-72 hours) to assess the complications such
as necrosis, pseudocysts
Abdomen-MRT: advantages over the CT is in the fewer
nephrotoxicity, better distinguish between fluids due to Abscess, necrosis,
hemorrhage or pseudocysts, and imaging the pile tree with MRCP.
Causes of acute pancreatitis:
1- Gallstones: 35-40% of the cases.
2- Biliary sludge should be suspected in the absence of other causes
3- Alcohol 30% of cases
Hypertriglyceridemia, > 1000 mg/dl, 1-3.5 %: Poorly controlled
diabetes, alcoholism, obesity, pregnancy, prior pancreatitis, and a personal or
family history of hyperlipidemia should suggest the diagnosis of HTGP
4- Medicaments 03-1.4%.
5- Post-ERCP pancreatitis, 3-5% of pat. undergoing
ERCP. 25% of pat. undergoning Ampulla manometry
6- Genetic mutations: Inherited forms of pancreatitis may present as
recurrent acute pancreatitis: PRSS1, CFTR, CTRC ect…
7- Infections and toxins: the routine search for an
infectious etiology in idiopathic pancreatitis is not recommended
- Viruses: Mumps, coxsackievirus, hepatitis B, cytomegalovirus,
varicella-zoster, herpes simplex, HIV
- Bacteria – Mycoplasma, Legionella, Leptospira, Salmonella
- Fungi – Aspergillus
- Parasites – Toxoplasma, Cryptosporidium, Ascaris
8- Trauma
9- Autoimmune pancreatitis: can cause acute pancreatitis, but it
usually mimic a pancreatic tumor: weight los , jaundice, and pancreatic
enlargement: consider IgG4/ANA
10- Tumors of the ampulla/
periampullary tumors. Intraductal tumors (IPMN)
11- Rare causes: Pancreas
Divisum, sphincter oddi dysfunction.
12- 30% idiopathic: the
chance of recurrence is little, thus intensive search for the cause in the
first attack of idiopathic pancreatitis is not necessary.
Therapy:
First step: asses disease severity, acute pancreatitis has
two wide groups:
According to revised Atlanta classification:
1- Acute edematous pancreatitis
2- Acute necrotizing pancreatitis
The severity of acute pancreatitis can be:
1- Mild: no local or systemic complications
2- Moderate: local or systemic complications that last < 48 hours
3- Severe: systemic complications that last > 48 hours
Local complications are such: fluid collection,
pseudocysts, necrosis
Systemic complications are organ failure:
respiratory, cardiovascular, renal.
Some scores to predict the severity of acute
pancreatitis such Ranson, APACHI II und BISAP, Ranson and BISAP scores are
shown below:
Step two:
Therapy of mild acute pancreatitis:
- supportive care including pain control
- intravenous fluids
- and correction of electrolyte and metabolic abnormalities.
- Nutrition: oral feeding can be started as the pain get
better, that would happen in 24-48 hours.
The majority of patients require no further
therapy and recover and eat within three to seven days.
Therapy of severe acute pancreatitis:
- intensive
care unit monitoring
- fluid
replacement: After initial resuscitation with 20 cc/kg of intravenous
fluid given over 60 to 90 minutes, approximately 250 to 300 cc of intravenous
fluids per hour are typically required for 48 hours if the cardiac status
permits.
- Hypocalcemia
should be corrected if ionized calcium is low or symptomatic. Low magnesium
levels should be corrected.
- Serum
glucose levels should be carefully monitored.
- Pain
control: Hydromorphone, Fentanyl
- Nutritional support (parenteral or nasojujenal tube)
should be provided to those who are unlikely to resume oral intake for more
than five to seven days. Oral feeding can be started as the local complications
start getting better
- Infection-Prophylaxis: imipenem 500 mgx3 day/
meropenem 1g x3 day. by patients with CT-proven necrosis, for no
more that 14 days unless infection is proven.
Necrosectomy: indicated by:
- Infected pancreatic necrosis
- sterile pancreatic necrosis with abdominal pain
preventing oral intake.
Therapy of special conditions
Gallstones pancreatitis:
- ERCP should be done within 72 hours
- Cholecystectomy within 7 days after recovering,
and 3 weeks after recovery by necrotizing pancreatitis
- Biliary sludge is indication to cholecystectomy
by pat. With pancreatitis.
Hypercalcemia:
1- Apheresis (2c): indicated by severe pancreatitis with TG levels
> 1000 mg/dl
After one cycle if TG < 500 mg/dl, apheresis should be stoped,
if not, further cycles are needed.
2- Intravenous Insulin (2c) (normal insulin) with Glucose 5% as
infusion at a rate of 0.1-0.3 IE Insulin/Kg/hours until TG level of < 500
mg/dl be reached
Control TG every 24 hours, glucose every 4 hours (keep Glucose
level between 150-200)
Indication: - Apheresis not available or not to be
tolerated - Serum glucose > 500 mg/dl.
3- Antihyperlipidemic agents: - Gemfibrozil 600 mg x2 a day (2c)
4- Dietary therapy: fat restriction
Splenic vein thrombosis:
19% in cases: treatment of the cause, anticoagulation
by extend of the thrombosis to the V. portae or. V. mesenterica superiora
Autoimmune pancreatitis:
One of the criteria to establish its diagnosis is the HISORt Criteria:
Histology
Imaging on computed tomography: diffuse
enlargement, featureless borders, delayed enhancement
Serologic testing: Elevated serum IgG4 levels
Other organ involvement: bile duct strictures,
autoimmune thyroiditis, interstitial nephritis, Sjogren syndrome.
Response to glucocorticoid therapy
Therapy:
glucocorticoid 40mg/day for 4-6 weeks then taper at 5 mg/week
control with CT/MRT after 4-6 weeks of glucocorticoid therapy
to confirm response, otherwise another causes of AP should be considered.
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