PANCREATITIS

This is a review lecture for final year students attached to the University unit &
students preparing for exams. This is not meant for initial study.
Prepared by Dr Dale Maharaj, Lecturer, UWI
Definition: Pancreatitis is an inflammatory process in which there is autodigestion of the
gland by pancreatic enzymes.
Acute pancreatitis: acute inflammation that resolves both clinically and histologically.
Chronic pancreatitis: characterized by persistent histologic changes (loss of endo and
exocrine function) even after the cause has been removed.
Anatomy & Pathophysiology:
Retroperitoneal organ
Acapsular
Acute edematous pancreatitis: parenchymal edema with peripancreatic fat necrosis
Hemorrhagic/necrotizing pancreatitis: parenchymal necrosis with hemorrhage
Pseudocyst: enzymatic fluid walled off by granulation tissue, omentum. (Not lined by epithelium)
Pancreatic abscesses: bacterial seeding of pancreatic or peripancreatic tissue
Systemic effects include:
Cytokines vasodilation, increased vascular permeability, pain, shock
Fat necrosis may cause hypocalcemia.
Pancreatic B cell injury hyperglycemia.
Diaphragmatic splinting, pleural effusion, atelectasis respiratory compromise
Etiology:
1. Alcohol consumption (>100g/dy for several years)
2. Biliary stones
3. Blunt or penetrating trauma to the abdomen
4. Drugs: azathioprine, corticosteroids, thiazides, NSAIDs, mercaptopurine, methyldopa
5. Abdominal surgery
6. ERCP
7. Hypertriglyceridemia
8. Hypercalcemia
9. Bacterial infections eg mycoplasma & Viral infections: mumps, Coxsackievirus B
10. Parasitic infections eg ascaris
11. Scorpion bite (titius trinitatus), Snake bites
Clinical Features:
1. Epigastric pain or right upper quadrant pain radiating to the back
2. Pain alleviated on sitting up and leaning forward
3. Nausea and/or profuse vomiting
4. Difficulty breating
5. History aimed at cause- alcohol, gallstones, hypercholesterolemia

Examination:
1. Shock
2. Respiratory distress : tachypnea, use of accessory muscles of respiration, basal
creps, stony dullness
3. Mild jaundice
4. Acute Abdomen: abdominal tenderness, distension, guarding, and rigidity, Grey
Turner sign, Cullens sign, Foxs Sign
5. Hypocalcemia (carpo-pedal spasm, Chovsteks sign, Trousseaus sign)
Investigations: (can be diagnostic or supportive)
1. Hb
2. WBC : (WBC >12000)
3. Group and cross match blood
4. RBS
5. Cr and electrolytes third spacing, vomiting
6. Serum amylase (amylase p-isomer more specific for pancreatitis). Can be normal
in hypertriglyceridemia
7. Lipase: Remains elevated longer than amylase. More useful in chronic
pancreatitis
8. LFTs
9. ABG
10. Erect CXR
11. Supine abdomen- calcified pancreas (chronic), colon cut off sign and sentinel
loop(acute)
12. Abdominal Ultrasound
13. CT scan: Balthazar Grades A-E, visualization of biliary tree
14. Para-aminobenzoic acid test (ie, bentiromide [Chymex] test) for chronic
pancreatitis
Treatment
Fluid resuscitation- crystalloids. Use blood in hemorrhagic pancreatits
Input/output charting
Keep NPO
NGT
Catheterize
TPN
Analgesics avoid morphine (sphincter of Oddi)
Antibiotics especially in cases of sepsis and gallstones (third generation cephalosporins)
Pulse oximetry and correction of acidosis
Intubation and ventilation in cases of respiratory failure (ARDS)
Patient should ideally nursed in an ICU or step-down facility.

Indications for surgical intervention:

Inability to distinguish acute pancreatitis from a surgical emergency
ERCP or sphincterotomy for common duct stone removal.
Debridement of necrotic pancreatic tissue
Abscess drainage
Control of hemorrhage
Prognosis:
The use of Ransons criteria:
Present on admission
Older than 55 years
WBC higher than 16,000
Blood glucose higher than 200 mg/dL
Serum lactate dehydrogenase (LDH) more than 350 IU/L
SGOT greater than 250 IU/L
Developing during the first 48 hours
Hematocrit fall more than 10%
BUN increase more than 8 mg/dL
Serum calcium less than 8 mg/dL
Arterial oxygen saturation less than 60 mm Hg
Base deficit higher than 4 mEq/L
Estimated fluid sequestration higher than 600 mL
Score 0-2: minimal mortality rate.
Score 3-5: 10%-20% mortality rate.
Score >5: mortality rate > 50%
Differential diagnosis:
Perforated gastric or duodenal ulcer
Mesenteric infarction
Strangulating intestinal obstruction
Ectopic pregnancy
Dissecting aneurysm
Biliary colic
Appendicitis
Diverticulitis
Inferior wall MI