ACUTE PANCREATITIS

GERARD P. PERLAS MD
FPCP,FPSG,FPSDE
MCU FDTMF HOSPITAL

ETIOLOGY
Alcohol
Biliary

Tract Dse. - Gallstones

Drugs Sulfonamides, diuretics
Infections Mumps, Viral Hepatitis
Metabolic- inc. triglycerides, inc. Ca.

Pathogenesis (enzymes elaborated)

Trypsinogen
Chymotrypsinogens
Proelastase
Phospholipase

Active enzymes

proteolysis
edema
hemorrhage
Vascular injury

coagulation, fat & cell

necrosis

Bradykinin, Histamine

vasodilatation
inc. vascular permeability
edema

Clinical Features
Acute onset of Upper abdominal
pain lesser by knee-chest position,
w/ radiation to the back
vomiting

Physical examination
Distressed,

anxious
Tachycardia
Fever
Shock may be present
Jaundice
Abdominal tenderness, rigidity
Cullens sign
Grey Turners sign

Laboratory Tests:
Amylase
85-100%

sensitivity
3 fold rise is diagnostic
Goes down in 48-72 hrs.

Other causes of Hyperamylassemia

Mumps
Gut

perforation
Biliary tract dse
Ruptured viscus
Peritonitis
Ruptured ectopic pregnancy
Pancreatic psudocyst
Diabetic ketoacidosis

Serum Lipase
More

specific for acute pancreatitis

Equally as sensitive as Amylase
Elevated on first day of illness
Elevated longer than amylase

Laboratory Tests
Leukocytosis
Hyperglycemia
Hypocalcemia
Hyperbilirubinemia
Hypoalbuminemia
High

LDH
hypoxemia

Radiologic Studies
Plain abdominal Xrays
localized

ileus, usually involving the

jejunum ("sentinel loop");
generalized ileus
the "colon cutoff sign," which results
from isolated distention of the
transverse colon;
duodenal distention with air-fluid levels;
a mass, which is frequently a
pseudocyst.

Upper GI series
Displacement

of the stomach by a
retroperitoneal mass
Widening of the duodenal C-loop

Ultrasound of Pancreas
Enlarged

pancreas
Pseudocyst
To rule out mass lesion Pancreatic
CA

CT scan
Most

sensitive test
Pancreatic necrosis

Differential Diagnoses
perforated

viscus; peptic ulcer

acute cholecystitis and biliary colic
acute intestinal obstruction
mesenteric vascular occlusion
renal colic
myocardial infarction
dissecting aortic aneurysm
connective tissue disorders with
vasculitis
Pneumonia

Factors that Adversely Affect

Survival in Acute Pancreatitis
Ransons

criteria
Acute Physiology and chronic health
evaluation (APACHE) score > 12
Obesity

Key indicators of Organ Failure

Hypotension

BP < 90 mmHg or
CAR > 130 beats/min
PO2 < 60 mmHg
Oliguria
> creatinine

Metabolic Indicators
Serum

Calcium < 8.0 mg/dl

Serum albumin < 32 g/L

Criteria for Severe Acute

Pancreatitis
Organ Failure
Shock
Pulmonary
insufficiency PO2
< 60 mmHg
Renal Failure :
creatinine > 2mg/dl
GI bleeding > 500
ml/ 24 hrs

And/or Local
Complications
Necrosis
Abscess
Pseudocyst

Unfavorable Early Prognostic Signs

Equal

or > 3 Ransons signs

Equal or > 8 APACHE II points

Mild Pancreatitis or Acute Interstitial

Pancreatitis
Treatment
NPO

Fluid

resuscitation
Meperidine 50 100 mg iv q 3-4 hrs
Prognosis is Excellent

Severe or Necrotizing Pancreatitis

+

Fluid resuscutation
O2 inhalation for hypoxemia
Inotropics for Shock
Correct electrolytes
Antibiotics Imipenem
CT Scan
Parenteral Nutrition
10% Mortality rate

Surgery
Pancreatic
Abscess

Pseudocyst