Acute Pancreatitis I.

Definition/General Considerations * Acute pancreatitis: Acute pancreatic inflammation characterized by severe abdominal pain, N/V, electrolyte and acidbase abnormalities, and occasionally hemorrhage, sepsis, and respiratory failure. - ancreatic enzymes autodigest pancreas hemorrhagic fat necrosis, !a deposition and sometimes formation of pseudocyst "cysts not lined #ith ductal epithelium$ * !auses: % &A' ()*+ % &iliary ",&$, Alcohol, 'rugs, (ypercalcemia/hyperlipidemia, )diopathic, *rauma, +corpions A$ ,allstones "-./$ &$ Alcohol "-./$: )ncreased pancreatic ductal pressure or ethanol-induced increased ductal permeability !$ 0ther "1./$ 2$ 'rugs: dd), dd!, d-*, sulfonamides, tetracycline, thiazides, pentamidine, estrogen 1$ (ypercalcemia/(yperlipidemia "*, 3 2...$ 4$ )diopathic -$ *rauma 5$ +corpions * 6ortality is 2.-25/, pseudocysts develop in 1--/ and -./ resolve on o#n * !omplications: ')!, hemorrhage, sepsis, A7'+, renal failure, pleural effusion II. Clinical Findings * +igns/+ymptoms A$ Abdominal ain: 8pigastric pain radiating to bac9 &$ N/V/: from inflammation or infection !$ 'ehydration: (ypovolemia tachycardia, hypotension, and shoc9 '$ 'iffuse abdominal tenderness and/or epigastric mass "pseudocyst, abscess, phlegmon$ 8$ 'ullness over ; lo#er lung pleural effusion or pseudocyst :$ (emorrhagic pancreatitis 2$ ,rey *urner<s sign: 8cchymotic discoloration of flan9 from pancreatic hemorrhage 1$ !ullen<s sign: 8cchymosis of the periumbilical area from pancreatic hemorrhage ,$ :etal position: 0pens up retroperitoneal space and gives more room to pancrease III-IV. Workup/Laboratory Findings * )nitially A$ !&!: ;eu9ocytosis &$ Amylase "more sensitive$ or lipase "more specific$: &oth increased !$ !hem-=, !a: (yperglycemia, hypocalcemia '$ ;:*s 8$ ;'(, *,: )ncreased, increased 3 2... :$ */ ** ,$ !>7: &asilar atelectasis, indicative of pleural effusion ($ Abdominal >-rays 2$ !olon cutoff sign or sentinel loop: 'ilated +& or transverse colon ne?t to pancreas due to peripancreatic inflammation 1$ )leus 4$ ancreatic calcification chronic )$ Abdominal !*: 0nly do if no clinical improvement is present b/c may be: 2$ ancreatic edema 1$ Abscess/Necrosis 4$ hlegmon -$ ancreatic calcification 5$ seduocysts * *o follo#: A$ !&!, !a, &@N, a01, and base deficit from arterial blood gas &$ Assess prognosis #ith 7anson !riteria of: 2$ )nitial evaluation: Age 3 55, A&! 3 2BC, A+* 3 15., ;'( 3 45., ,lucose 3 1.., base deficit 3 1$ !hanges in first -D hours: (ct E 3 2./, &@N rises 3 5, !a F D, a01 F B., fluid seGuestration 3 B; 4$ 6ortality % 1/ #ith .-1 criteria, 1./ if 4--, -./ #ith 5-B criteria, and nearly 2../ #ith 3 = criteria

V. Differential Diagnosis A$ 7uptured AAA: alpable periumbilical mass, shoc9, obstruct ureters and duodenum - >-ray, @/+, !*, and aortography sho#ing aneurysm &$ erforated peptic ulcer: 8pigastric pain relieved by eating or using antacidsH presents #ith sudden upper abdominal pain, shoulder pain, and ,) bleed - 8,' of upper ,) series !$ Acute appendicitis: 7;I tenderness starting as epigastric and going to 6c&urney<s pointHfeverHtenderness - ;eu9ocytosis, fecalith on ?-ray or !* '$ Acute cholecystitis: 7@I pain, fever, 6urphy<s sign "inspiratory arrest upon deep palpation of 7@I$ - ;eu9ocytosis, @/+, increased bilirubin and ;:*s 8$ 6): ;@I pain, chest pain, nausea, diaphoresis, +0& - 8C,, troponins, !C-6& :$ 6esenteric ischemia: 2$ Acute: At. loss, postprandial pain, and abdominal bruits % triadH due to atherosclerosis - Aortogram 1$ !hronic: 7apid onset of pain out of proportion, vomiting, diarrheaH history of heart condition predisposing to emboliH due to clots ,$ +&0: !rampy ab pain, N/V, lac9 of flatus, ab. tenderness, ad. distension and hyperactivity, high-pitched &+ - Ab series % 'istended loops of bo#el pro?imal - @pright film % air-fluid levels of free air beneath diaphragm on A ($ Nephrolithiasis )$ yelonephritis: ;;I pain, high fever, rigors, !VA tenderness, @*) h? - yuria and J urine culture K$ (epatitis: 7@I pain/tenderness, fever, Laundice - )ncreased ;:*s, bilirubin, leu9ocytosis, and serology - @/+ to rule out other causes VI. Treat ent A$ Non-operative 2$ N 0 N, if patient has emesis * 6 if 3 =-2. days 1$ )V fluid and electrolyte repletion "similar dehydration as burn victim$ a$ Normal saline for resuscitation b$ 6aintenance #ith '5 M normal saline 4$ ain control: 6erperidine 3 morphine to reduce spasms of sphincter of 0ddi -$ 7espiratory monitor and support 7N 5$ Alcohol #ithdra#al pp? B$ Aatch for pseudocyst, abscess, sepsis, and A7'+ =$ &road-spectrum ab? if necrotic pancreatic issue or someone really ill "imipinem or cefuro?ime$ &$ 0perative 2$ +urgical debridement of pancreatic necrosis 1$ 0perative drainage of noninfected pseudocysts internally or infected e?ternally 4$ 0perative hemostasis in cases of pancreatic hemorrhage -$ 'iagnostic laparotomy in cases of uncertain deterioration 5$ 87! and sphincterotomy #ith stone e?traction, the intervl cholecystectomy for gallstone pancreatitis after pain has resolved