Life threatening causes of pain abdomen / Acute pancreatitis

DR R PADHI

Location of Mode of Onset Associated Physical Pain and Prior and Type of Gastrointestina Examination Attacks Pain l Symptoms Acute Periumbilical Insidious to Anorexia Low-grade appendicitis or localized acute and common; fever, generally to persistent nausea and epigastric right lower vomiting in tenderness abdominal some initially; later, quadrant right lower quadrant

Disease

Life threatening causes of pain abdomen

Perforated Epigastric; duodenal history of ulcer ulcer in many

Abrupt onset; steady

Anorexia; nausea and vomiting

Intestinal obstruction

Diffuse

Sudden onset; Crampy

Vomiting common

Acute Epigastric pancreatitis penetrating to back

Acute; persistent, dull, severe

Anorexia; nausea and vomiting common

Helpful Tests and Examinations Slight leukocytosis; CT scan of the abdomen or ultrasound of the appendix may be helpful if diagnosis is uncertain Epigastric Upright tenderness; abdominal Xinvoluntary ray shows air guarding under diaphragm; CT scan Abdominal Dilated, fluiddistention; filled loops of high-pitched bowel on rushes abdominal Xray Epigastric Elevated serum tenderness lipase; CT scan shows pancreatic inflammation

Acute pancreatitis
Acute pancreatitis is defined as an inflammatory process that occurs in a gland that was morphologically and functionally normal before the attack and can return to that state after resolution of the attack.

Etiological Factors

Gallstones (including microlithiasis) (30 -60%) Alcohol (acute and chronic alcoholism) (15 30%) Endoscopic retrograde cholangiopancreatography (ERCP), especially after biliary manometry (5 20%) Hypertriglyceridemia (1.33.8%) Trauma (especially blunt abdominal trauma) 25% are drug related

Miscellaneous Etiologies of Acute Pancreatitis

Trauma Postoperative setting Common duct exploration Sphincteroplasty Distal gastrectomy Cardiopulmonary bypass Cardiac or renal transplantation Endoscopic retrograde cholangiopancreatography

Miscellaneous Etiologies of Acute Pancreatitis

Translumbar aortography Metabolic disorders Hyperparathyroidism Hyperlipoproteinemias types I, IV, and V Penetrating ulcer Connective tissue disorders Scorpion bite Renal failure Hereditary pancreatitis

Drug Induced pancreatitis

Azathioprine* Estrogenes* Corticosteroids L-asparaginase Phenformin Procainamide

Thiazide diuretics
Furosemide Ethacrynic acid Sulfonamides Tetracycline

Valproic acid
Clonidine Pentamidine Dideoxyinosine H2 antagonist

Surgical Pathology
1. 2. 3. 4.

5.
6. 7. 8.

Edema Exudation Hemorrhage Suppuration Necrosis Fat necrosis (combination of liberated fatty acids from hydrolized fat with calcium) Fluid loss Hypovolemia Pseudocyst

Clinical features (Symptoms)

1.

Pain (sudden,intense,continuous, upper abdomen back, bizarre position)

Nausea and Vomiting

2.

Clinical features (Signs)

General
Shock Fever Jaundice Left pleural effusion Acute pulmonary failure Subcutaneous necrosis Cerebral abnormalities Peritonitis Paralytic ileus Abdominal mass Cullens sign. Grey Turner sign

Local

Investigation
General
CBC S. electrolytes Lft S. Ca+2 Blood glucose

Laboratory Tests
S. amylase S. amylase isoenzymes (P+S types) Urinary amylase Amylase-creatinine clearance ratio S. lipase S. methemalbumin Peritoneal fluid analysis

Radiology
Chest X-ray Abdominal X-ray Ba. Meal US CT scan MRI

Intra-abdominal Disorders associated with Hyperamylasemia Pancreatic disorders

Acute pancreatitis Chronic pancreatitis Trauma Carcinoma Pseudocyst pancreatic ascites Abscess

Non pancreatic disorders

Ruptured aortic aneurysm Ruptured ectopic pregnancy Intestinal obstruction Acute appendicitis Perforated peptic ulcer Biliary tract disease Mesenteric infarction Afferent loop syndrome

Extra-abdominal Disorders associated with Hyperamylasemia

Salivary gland disorders + Impaired amylase excretion
Mumps Parotitis

+Miscellaneous
Pneumonia Pancreatic pleural effusion

Trauma
Calculi Irradiation sialadenitis Renal failure Macroamylasemia

Mediastinal pseudocyst
Cerebral trauma Severe burns Diabetic ketoacidosis Pregnancy

Drugs
bisalbuminemia

Differential Diagnosis of Acute Pancreatitis

Perforated hollow viscus Cholecystitis/cholangitis Bowel obstruction Mesenteric ischemia/infarction

Mortality and Prognosis

1. 2.

3.
4. 5.

Mortality rate is 6-20% Causes of death: Hypovolaemic shock Electrolyte disturbances Toxaemia Renal failure Respiratory failure (collapse, consolidation, effusion)

Severe Acute Pancreatitis

Risk Factors Age >60 years Obesity, BMI >30 Comorbid disease tors for Severity

Imrie's Prognostic Signs

Age >55 yr White blood cell count >15,000/mm3 Blood glucose >10 mmol/L Serum urea >16 mmol/L Partial pressure of oxygen <60 mm Hg Serum Ca2+ <2.0 mmol/L Lactic dehydrogenase >600 g/L Aspartate aminotransferase/alanine aminotransferase >100 g/L Serum albumin <32 g/L

Ransons Criteria
At admission
Age >55

During initial 48 hours

Hematocrite fall > 10%

WBC > 16000/cu.mm Glucose > 200mg/dl

BUN rise 5mg/dl Ca+2 < 8 mg/dl

LDH > 350 IU/L

SGOT > 250 U/dl

PO2 < 60 mm.Hg

Base deficit > 4 meq/L Fluid sequestration > 6 L

Mortality and Prognosis (3)

<2 no mortality 3-4 15% mortality 5-6 50% mortality 7 test the limits of modern medicine

Treatment (When diagnosis certain

Rest the patient (Relief pain) Rest the pancreas Rest the bowel Resuscitation Resist enzymatic activity Resist infection Repeated examination Repeated serum estimations Respiratory support Pethidine 100mg/4hr + antispasmodic NPO, IV fluid, electrolytes replacement NG tube; NJ tube Replacement therapy Protease inhibitors, Trasylol , PPI, glucacon ? Antibiotics ? General features, abd signs, fluid balance Daily Ca+2 , WBC ( fibrinogen, methaemalbumin, Mg+2 ) O2 , assisted respiration

Urgent ERCP (within 24 hours)

Severe acute biliary pancreatitis with organ failure and/or cholangitis

1. Octreotide: a reduced mortality rate but no change in complications with octreotide 2. Gabexate (antiprotease): no effect on the mortality rate but reduced pancreatic damage with gabexate. A dynamic contrast-enhanced CT (CECT) scan performed three to five days after hospitalization provides valuable information on the severity and prognosis of acute pancreatitis

CT Findings and Grading of Acute Pancreatitis [CT Severity Index (Ctsi)]

Treatment (When diagnosis uncertain)

1.
2.

Peritoneal lavage Laparotomy

Treatment (When complications become apparent )

1.
2. 3.

Toxic patient Abdominal mass Persistently high gastric aspiration

Complications of Acute Pancreatitis

1.

Systemic complications Cardiovascular collapse Respiratory failure Renal failure Metabolic encephalopathy Disseminated intravascular coagulation Gastrointestinal bleeding MOF

Complications of Acute Pancreatitis

Local complications Acute fluid collection Pancreatic necrosis infection Pancreatic pseudocyst Pancreatic abscess Pancreatic ascites Pancreatic-pleural fistula Duodenal obstruction Bile duct obstruction Splenic vein thrombosis Pseudoaneurysm + hemorrhage