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Acute Pancreatitis

HAROL IZQUIERDO SALAZAR


MEDICINA-FARMACOLOGIA

Normal Anatomy & Physiology



neutralize chyme digestive enzymes hormones

Exocrine Function
common bile duct
HEAD BODY

TAIL

ampulla

pancreatic duct

pancreatic enzymes

Enzyme Secretion
acinus

pancreatic duct microscopic view of pancreatic acini duodenum

Enzyme Secretion
Neural
acetylcholine VIP GRP

Hormonal
CCK gastrin

Secretin (hormonal)
H2O bicarbonate

Acute Pancreatitis
Pathogenesis
acinar cell injury

premature enzyme activation

failed protective mechanisms

Acute Pancreatitis
Pathogenesis
premature enzyme activation

autodigestion of pancreatic tissue

local vascular insufficiency


local complications

activation of white blood cells

release of enzymes into the circulation


distant organ failure

Acute Pancreatitis
Pathogenesis
SEVERITY Mild

STAGE 1: Pancreatic Injury


- Edema - Inflammation

STAGE 2: Local Effects


- Retroperitoneal edema - Ileus

STAGE 3: Systemic Complications


Severe

- Hypotension/shock - Metabolic disturbances - Sepsis/organ failure

Signs & Symptoms


Severe epigastric abdominal pain - abrupt
onset (may radiate to back)

Nausea & Vomiting Weakness Tachycardia +/- Fever; +/- Hypotension or shock
- Grey Turner sign - flank discoloration due to
retroperitoneal bleed in pt. with pancreatic necrosis (rare)

Grey Turner sign

Cullens sign

Acute Pancreatitis
Clinical Presentation

Abdominal pain
- Epigastric - Radiates to the back

Nausea and vomiting Fever

Acute Pancreatitis
Differential Diagnosis

Choledocholithiasis Perforated ulcer Mesenteric ischemia Intestinal obstruction

Acute Pancreatitis
Diagnosis

Symptoms
- Abdominal pain

Laboratory
- Elevated amylase or lipase > 3x upper limits of normal

Radiology
- CT

Prognosis
Many different scoring systems
- Ranson (most popular & always taught in medschool) No association found with score, and mortality or length
of hospitalization

- APACHE II - CT severity Index


Recent studies show this to be most predictive of
adverse outcomes - CT score > 5 associated with 15x mortality rate - Problem is 1 CT study showing this was conducted 72
hours after admission (Ranson/Apache are 24 & 48 hours)

Ranson Criteria
Admission
Age > 55 WBC > 16,000 Glucose > 200 LDH > 350 AST > 250

During first 48 hours


- Hematocrit drop >
10% - calcemia < 2mmol

- Increase in BUN > 5 - Fluid sequestration >


6L - Arterial PO2 < 60

5% mortality risk with <2 signs 15-20% mortality risk with 3-4 signs 40% mortality risk with 5-6 signs 99% mortality risk with >7 signs

Therapy
hospitalization. fasting. Hydration with electrolytes. SNG vomits. analgesics. (paracetamol and morphines) realimetacion enteral starting 48 hours. prevent thromboembolism with low molecular
weight heparin.

cholecystectomy

Complications Local
Necrosis
- Sterile - Infected - abscess

Pseudocyst Ascites Intraperitoneal hemorrhage Thrombosis Obstructive jaundice

Complications Systemic
Pulmonary
Pleural effusions Atelectasis Mediastinal abscess ARDS

Gastrointestinal
- Erosive gastritis - Blood vessel erosion - Portal vein thrombosis

Cardiovascular
- Hypotension - Sudden death - Pericardial effusion

Renal
- Oliguria - Azotemia - Renal artery/vein
throbosis

Hematologic

Complications Long Term


Chronic Pancreatitis
- Abdominal Pain - Steatorrhea - Exocrine insufficiency (pancreas has a 90%
reserve for the secretion of digestive enzymes) - DM, i.e.Endocrine Insufficiency

GRACIAS