Acute Pancreatitis

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Acute pancreatitis is the acute inflammation of the pancreas. Serum amylase levels are more than 3 times normal levels. Amylase decreases after 2-3 days. Serum lipase levels remain elevated for 7-14 days. Important complications may develop weeks after the event. Significant morbidity and potential mortality is associated with this condition.

Acute pancreatitis is an important and serious condition. Patient should be managed in the ICU except mild cases. Daily clinical, lab and severity score assessment must be performed. Patient can have life threatening complications weeks after the index event but prompt recognition can be rewarding.

Amylase levels may be increased in:

  • Acute Cholecystitis
  • Intestinal Infarction
  • Diabetic Ketoacidosis
  • Perforated ulcer
  • Salpingitis
  • Ectopic Pregnancy
  • Macroamylasemia

Etiology

Acute pancreatitis may result due to several causes, most common include:

Gallstones
Alcohol
Acidosis (Diabetic Ketoacidosis)
Hypertriglyceridemia
Hypercalcemia
Trauma
Pancreatic Cancer (Obstruction of ampulla of Vater)
Post ERCP (5-20%)
Idiopathic (biliary microlithiasis, cystic fibrosis, hereditary pancreatitis)

Drugs may also be responsible for development of acute pancreatitis, drugs implicated inlcude:

Furosemide & Thiazides
Estrogens
Valproate
Azathioprine
Tetracyclines & Sulphonamides
Pentamidine

Severity Assessment

Severity may be judged by the following:

Overweight, BMI > 25, especially > 29
Hemoconcentration with hematocrit > 50% in men, > 44% in women
SIRS
Severe clinical response to insult
Two or more of:
Tachycardia (> 90/min)
Tachypnea (RR > 20 or pCO2 < 32)
Temperature (< 36 or > 38 oC)
WBC (> 12,000 or < 4000/µL or > 10% bands)
Ranson’s and APACHE II or III Scores

Ranson’s Criteria

0 hours

Age >55
White blood cell count >16,000/mm3
Blood glucose >200 mg/dL (11.1 mmol/L)
Lactate dehydrogenase >350 U/L
Aspartate aminotransferase (AST) >250 U/L

48 hours

Hematocrit fall by 10 percent
Blood urea nitrogen increase by 5 mg/dL (1.8 mmol/L) despite fluids
Serum calcium pO2 4 MEq/L
Fluid sequestation >6000 mL
Mortality rises with > 4 criteria

Cullen’s Sign
Faint blue discoloration around the umbilicus (hemoperitoneum)
Grey-Turner’s Sign
Bluish-reddish-purplish discoloration of flanks (retroperitoneal bleed)

Diagnosis

Diagnosis is made on the basis of:

Baseline tests including Amylase/Lipase & Triglycerides
Ultrasound abdomen
CECT / MRI Scan
SIRS / Ranson’s / APACHE II or III evaluation

Treatment

About 80-90% of the cases resolve spontaneously. The patient is kept nil per oral (NPO). Intravenous fluids are administered. Enteral feed is superior to total parenteral nutrition. Antibiotic cover is given in:

Severe Pancreatitis
Established Infection
Pancreatic Necrosis

Antibiotic that are excreted in pancreas are used including Imipenem and Cefuroxime.

Fluids/Masses in Acute Pancreatitis
Acute fluid collection with high amylase level occurs in 50% of the cases within 48 hours. These resolve spontaneously.

Necrotic Pancreas
Inflammed, edematous, necrotic pancreas may occur in 1-2 weeks. This may simulate pseudocyst formation (which occurs later). Ultrasonography is done for making the diagnosis. This is a serious condition, and may require drainage.

Infected Necrosis
Recurrence of abdominal pain, fever, jaundice may be due to infected necrosis. This is diagnosed by CT guided aspiration. Bacterial smears and cultures are obtained. This requires surgery.

Pseudocysts
Pseudocysts develops in 10-15% of cases. Patient is recovering normally, suddenly the condition gets worse. It requires 2-4 weeks to develop. Collection of pancreatic fluid takes place. It resolves spontaneously, if small but if the size is greater than 5 cm, it may not resolve. If it persists beyond 3 months, surgical drainage is required.

Pancreatic Abscess
Pancreatic abscess is a very serious condition with fever and shock. It develops 4-6 weeks after the onset of severe pancreatitis. It is preceded by severe necrosis. “Soap bubble” sign is present on upright X-ray. Diagnosis is made with CT guided aspiration. Surgical debridement and drainage is necessary

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The writer enjoys medical education and has special interest in community medicine.