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 


Primary Sclerosing Cholangitis

Primary sclerosing cholangitis (PSC) is a progressive disease characterized by inflammatory strictures involving the intrahepatic and extrahepatic biliary tree. 

-It eventually results in secondary biliary cirrhosis

-Men are more commonly affected than women (70:30 ratio), with a mean age at onset near 40 years.

A vast majority of patients (prevalence rates range from 70% to 90%) have underling inflammatory bowel disease, especially ulcerative colitis. 

-Smoking is associated with a decreased risk of primary sclerosing cholangitis in patients who also have inflammatory bowel disease. 

-Coffee consumption is also associated with a decreased risk of primary sclerosing cholangitis. 

Symptoms & Signs 

Fatigue, right upper quadrant abdominal pain, pruritus, jaundice, and acute cholangitis 

Diagnosis 

Labs: Disproportionate elevation of serum alkaline phosphatase; hypergammaglobulinemia, increased serum IgM levels, p-ANCA 

Imaging: MRCP is the diagnostic study of choice with  “beads on a string” apperance 

Liver biopsy: The most characteristic histologic finding is ‘onion skin pattern due to fibrous obliteration of small bile ducts with concentric replacement by connective tissue 

Treatment 

-There is no specific proven treatment for PSC

-Medical management is largely supportive 

-Pruritis: Cholestyramine, naltrexone, rifampin, doxepin 

-surveillance colonoscopy with biopsies should be carried out at 1–2-year intervals.

-screen for osteopenia at 2–3-year intervals after an initial evaluation.

-Liver transplantation is best choice for patients with advanced PSC

Prognosis 

-Complications: Fat-soluble vitamin deficiencies (A,D,E and K), Metabolic bone disease, cholangitis, cholelithiasis, gallbladder cancer, cholangiocarcinoma, liver cancer, colon cancer 

-Patients with PSC have an 8–15% lifetime risk of developing cholangiocarcinoma. 

-With liver transplantation, 5-year survival is up to 85% 



Biliary stricture

Introduction

-A bile duct stricture is an abnormal narrowing of the common bile duct. 

-Most benign strictures of the extrahepatic bile ducts result from surgical trauma (95% of cases) 

-Causes: injury to the bile ducts, cancer of the bile duct, liver or pancreas, pancreatitis, primary sclerosing cholangitis 

Symptoms & Signs

RUQ abdominal pain, fever, chills, itching, jaundice, pale or clay-colored stools 

Diagnosis 

Labs: bilirubin level is higher than normal, elevated serum alkaline phosphatase 

Imaging: Ultrasound, CT, ERCP, MRCP, Percutaneous cholangiography  

Treatment 

-The goal of treatment is to correct the narrowing. This will allow bile to flow from the liver into the intestine.

-Fluid resuscitation, antibiotic coverage 

-ERCP, MRCP, Sphincterotomy to allow closure of a bile leak, dilation of the stricture and stent placement

-Surgery in select cases 

Prognosis 

Long-term success depends on the cause of the stricture. Good prognosis with benign causes and bad prognosis with malignant causes.