Acute pancreatitis

Introduction 

-Acute pancreatitis is an acute inflammatory disorder of the pancreas that involves the pancreas and peripancreatic tissues. 

-It can vary in presentation from mild to severe.

-It is the most common inpatient gastrointestinal diagnosis in the United States. 

-The most common causes of acute pancreatitis in the United States are gallstones and alcohol abuse. 

-Other causes: infections, ischemia, hypercalcemia, hypertriglyceridemia, neoplasms, toxins, drugs, trauma 

Symptoms & Signs 

Abdominal pain: Acute onset of a severe constant epigastric pain that radiates through to the mid back; often made worse by walking and lying supine and better by sitting and leaning forward; nausea, vomiting, fever, tachycardia, tachypnea, Cullen sign (periumbilical ecchymoses), Grey Turner sign (flank ecchymoses), tetany as a result of hypocalcemia 

Memory Aid: CUllen Sing: PeriUmbilical 

Diagnosis 

Labs: Elevated serum amylase and lipase; leukocytosis, elevated serum creatinine, BUN, elevated C-reactive protein; Elevated immunoreactive trypsinogen more sensitive in infants; In hypertriglyceridemia-induced pancreatitis, serum amylase is spuriously normal

Imaging

Plain radiographs:  may show a “sentinel loop” (a segment of air-filled small intestine most commonly in the left upper quadrant), the “colon cutoff sign” (a gas-filled segment of transverse colon abruptly ending at the area of pancreatic inflammation); calcified gallstones 

Contrast-enhanced CT is the most common currently available imaging technique for staging the severity of pancreatitis

Treatment 

-The most important first step in the evaluation is to identify risk of progression to severe pancreatitis 

-All patients with suspected acute pancreatitis should be admitted to hospital. 

-The severity is assessed using scoring systems: Ranson criteria, SOFA score, APACHE II score, BISAP score 

-Treatment depends on the severity of symptoms 

Mild disease: Fluid resuscitation, pain control,  resume intake of fluid and foods when the patient is pain free; clear liquids, low-fat diet; mild disease subsides spontaneously within several days. 

Severe disease: Admission to ICU; IV fluids; Bowel and pancreatic rest;  calcium gluconate if there is hypocalcemia with tetany; treat coagulopathy; Enteral nutrition; antibiotics for infected pancreatitis; Surgical consultation 

Prognosis 

Mortality rate 25% with infected necrosis; 30% with multiorgan failure 

Complications: acute tubular necrosis, ARDS, pancreatic abscess, pseudocyst, chronic pancreatitis, pericardial effusion, peptic ulcer disease, hyperglycemia, psychosis 

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