Acute pancreatitis
Introduction
-Acute pancreatitis is an acute inflammatory disorder of the pancreas that involves the pancreas and peripancreatic tissues.
-It can vary in presentation from mild to severe.
-It is the most common inpatient gastrointestinal diagnosis in the United States.
-The most common causes of acute pancreatitis in the United States are gallstones and alcohol abuse.
-Other causes: infections, ischemia, hypercalcemia, hypertriglyceridemia, neoplasms, toxins, drugs, trauma
Symptoms & Signs
Abdominal pain: Acute onset of a severe constant epigastric pain that radiates through to the mid back; often made worse by walking and lying supine and better by sitting and leaning forward; nausea, vomiting, fever, tachycardia, tachypnea, Cullen sign (periumbilical ecchymoses), Grey Turner sign (flank ecchymoses), tetany as a result of hypocalcemia
Memory Aid: CUllen Sing: PeriUmbilical
Diagnosis
Labs: Elevated serum amylase and lipase; leukocytosis, elevated serum creatinine, BUN, elevated C-reactive protein; Elevated immunoreactive trypsinogen more sensitive in infants; In hypertriglyceridemia-induced pancreatitis, serum amylase is spuriously normal
Imaging
Plain radiographs: may show a “sentinel loop” (a segment of air-filled small intestine most commonly in the left upper quadrant), the “colon cutoff sign” (a gas-filled segment of transverse colon abruptly ending at the area of pancreatic inflammation); calcified gallstones
Contrast-enhanced CT is the most common currently available imaging technique for staging the severity of pancreatitis
Treatment
-The most important first step in the evaluation is to identify risk of progression to severe pancreatitis
-All patients with suspected acute pancreatitis should be admitted to hospital.
-The severity is assessed using scoring systems: Ranson criteria, SOFA score, APACHE II score, BISAP score
-Treatment depends on the severity of symptoms
Mild disease: Fluid resuscitation, pain control, resume intake of fluid and foods when the patient is pain free; clear liquids, low-fat diet; mild disease subsides spontaneously within several days.
Severe disease: Admission to ICU; IV fluids; Bowel and pancreatic rest; calcium gluconate if there is hypocalcemia with tetany; treat coagulopathy; Enteral nutrition; antibiotics for infected pancreatitis; Surgical consultation
Prognosis
Mortality rate 25% with infected necrosis; 30% with multiorgan failure
Complications: acute tubular necrosis, ARDS, pancreatic abscess, pseudocyst, chronic pancreatitis, pericardial effusion, peptic ulcer disease, hyperglycemia, psychosis