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IN

1. Acute Pancreatitis

and diaphoretic, and she has icteral sclerae.


Abdomen is soft, mildly distended with marked
RUQ and epigastric tenderness to palpation,
hypoactive bowel sounds, and no masses or
organomegaly appreciated.
PWI: Acute Pancreatiitis; Cholelithiasis
Summary of the Case:

ACUTE PANCREATITIS
pancreatic secretory response is directly related
to the functional mass of pancreatic tissue.
Definition:
Clinical: An acute condition presenting with
abdominal pain usually associated with raised
blood/urine pancreatic enzymes as a result of
pancreatic inflammation
Pathological: Reversible pancreatic parenchymal
injury associated with inflammation

Case 1
56yo male, presents with severe midepigastric
abdominal pain that radiates to the back and
improves when he leans forward. He also reports
anorexia, nausea, and vomiting. He is an
alcoholic and has spent the past 3 days binge
drinking
PWI : Acute Pancreatitis
Differentials:
1. Peptic Ulcer Disease
2. Cholecystitis/Choledocholithiasis
3. Gastritis
4. Abdominal aortic aneurysm
5. Mesenteric ischemia
6. Boerhaave syndrome
Case 2
42yo female, presents with 24 hours of severe,
steady epigastric abdominal pain, radiating to the
back, with several episodes of nausea and
vomiting. She has experienced similar painful
episodes in the past, usually in the evening
following heavy meals, but the episodes always
resolved spontaneously within an hour or two.
However, this time, the pain did not improve, so
she sought medical attention. She has no medical
history and takes no meds. Nonsmoker,
nonalcoholic beverage drinker.
On examination, she is afebrile, tachycardic with
a heart rate of 104 bpm, BP 115/74 mm Hg, and
shallow respirations of 22 cpm. She is moving
uncomfortably on the stretcher, her skin is warm

A 42yo female with a prior history consistent with


symptomatic cholelithiasis (abdominal pain in the
evening after heavy meals & resolves
spontaneously) now presents with epigastric pain
and nausea for 24 hours, much longer than would
be expected with uncomplicated biliary colic.
Her symptoms are consistent with acute
pancreatitis. She also had hyperbilirubinemia and
an elevated alkaline phosphatase level,
suggesting obstruction of the common bile duct
caused by a gallstone, which is the likely cause of
her pancreatitis.
Common Etiologies: (GATED)
Gallstones: most common cause
Alcohol: 2nd most common cause
HyperTriglyceridemia: trig >1000mg/dL
- Lipase liberates large amounts of toxic
afatty acids into pancreatic
microcirculation
- Leading to endothelial injury, sludging
of blood cells and consequent ischemic
states
ERCP
Drugs
Trauma
Postoperative
Sphincter of Oddi dysfunction
For recurrent attacks of pancreatitis, the 2 most
common etiologies: alcohol and cholelithiasis
Pathophysiology:
- Autodigestion of pancreatic substance by
inappropriately activated pancreatic
enzymes (especially trypsinogen)
- Proteolytic enzymes (trypsinogen,
chymotripsinogen, proelastase) are
activated in the pancreas rather than in
the lumen
Enzymes
Activated
Prekallikrein
Hageman factor-XII
Trypsinoge
n
-->
Trypsin

Phospholipase
Lipase
Elastase

Results
Kinin system
Clotting &
complement
thrombosis
Prostaglandins
& Bradykinins
Hypocalcemia
3rd space seq.
of blood/fluid
hemorrhage

IN
Activates
Lysolecithinase
Release of inflam.
mediators

+ hypovol
shock
Necorsis
Systemic
complications

Clinical Manifestations:
Abdominal pain
- Steady & boring (knifing) in character
- Located in the epigastrium and
periumbilical region
- Radiation to the back, chest, flanks and
lower abdomen
- More intense when supine
- Relieved upon sitting with the trunk flexed
and knees drawn up (Muhammedan
Prayer Sign) = due to shifting forward of
abdominal contents and taking pressure
off from inflamed pancreas
Other symptoms: nausea, vomiting and
abdominal distention (due to ascites)
Fever complicated pancreatitis or because of
cytokine release as part of the inflammatory
process
Signs of Acute Pancreatitis
1. General PE
- Distressed and anxious patient
- Low grade fever, tachycardia and
hypotension
2. Shock
- Hypovolemia secondary to exudation of
blood and plasma proteins into the
retroperitoneum
- Hypovolemia signs: decreased skin turgor,
dry mucous membranes, hypotension)
- Systemic effects of proteolytic enzymes
released into the circulation
3. Abdominal tenderness
- Voluntary guarding to palpation of the
upper abdomen
4. Bowel sounds
- Decreased or absent (if ileus is present)
5. Jaundice
- Due to edema of the pancreatic head with
compression of the intrapancreatic portion
of the CBD
6. Pulmonary findings
- Basilar rales, atelectasis, pleural effusion
(decreased breath sounds, more common
on the left side)
7. Complicated hemorrhagic pancreatitis
- Cullens sign
o Blue discoloration around the
umbilicus (results from
hemoperitoneum) falciform
ligament
- Turners sign
o
Blue red purple or green brown
discoloration of the flanks (reflects
tissue catabolism of hemoglobin)
- Foxs sign

Ecchymotic discoloration over the


inguinal ligament
8. Hypocalcemia
- Chvostecks sign: fascial muscle spasm
when facial nerve is tapped
- Trousseasus sign: Carpopedal spasm
when blood pressure cuff is applied
o

Differentials
1. Perforated viscous, especially peptic ulcer
- Signs: Long standing epigastric pain but
does not generally radiate to the back;
refllux, heart burn and anorexia
- May improve with PPIs, lifestyle
modifications
- Normal lipase and amylase
- Tonometry show evidence of reflux
- Endoscopic evaluation will be diagnostic
after visualizing erosions, erythema or
ulcers and allow biopsies to be performed
Perforated viscus
- Present with acute abdomen, peritoneal
signs, tachycardia and sepsis.
- Generally, abdomen is rigid and tender in
all 4 quadrants, with guarding
- Normal lipase. May have elevated amylase
- Plain Xray shows sub-diaphragmatic air
2. Acute cholecystitis and biliary colic
Common channel theory
Acute panc
Cholelithiasis
Rule in
- Abdominal
- Abdominal
pain (steady)
pain (steady)
- Triggered by
- Triggered by a
a meal
fatty/heavy
meal
- High amylase - High amylase
levels
levels

Rule out

Jaundice
due to
pancreatic
head edema
blocking
common bile
duct

Jaundice
stone
obstructing
the bile duct

nausea
vomiting

nausea,
vomiting

Fever as a
complication
of cholelith
Periumilical
pain or left
upper
quadrant is
more severe
Radiation to
interscapular
area, right
shoulder, or
scapula
Ileus present
Young men

Fever as
complication:
cholecystitis

More right
sided or
epigastric

Radiation to
back chest
flanks lower
abdomen

Ileus absent
Old women

IN
-

(+) Murphys
sign

3. Acute intestinal obstruction


Rule in:
- SBO periumbilical or supraumbilical pain
- Colonic obs: infraumbilical pain, but more
of colicky in nature rather than the steady
and boring type of pain in pancreatitis.
o Pain is crescendo-decrescendio
- (+) ileus, abdominal distention, vomiting
and constipation, tympanism, decreased
bowel sounds, anorexia, emesis
- (+) history of abdominal surgeries
- (+) hernias in physical exam
-

Normal lipase and amylase


Acute abdominal series show ground glass
appearance, air-fluid levels, distended
bowel loops, absence of distal gas,
pneumatosis

Abdominal Xray may show volvulus. NCCT


shows collapsed bowel with proximal dilation.
Rule out: pain is more colicky in nature
4. Mesenteric vascular ischemia
- Usually older patients
- (+) hx of atrial fibrillation and risk factors
for peripheral vascular disease
(dyslipidemia, obesity, smoking)
- Mild continuous or cramping diffuse pain
for 2 or 3 days before vascular collapse or
findings of peritoneal inflammation
- Absence of tenderness and rigidity in the
presence of continuous, diffuse pain (pain
out of proportion to physical findings) in a
patient likely to have vascular disease is
quite characteristic of occlusion of the
SMA
- Early discomfort is due to hyperperistalsis
increased bowel sounds
5. Viral gastroenteritis
- Generalized non-specific abdominal pain,
anorexia, nausea, emesis, diarrhea and
dehydration
- Usually self-limiting viral infection but if
fever is documented, bacterial and
invasive organsism should be suspected
- Consider in travelers and
immunosuppressed patients
- Consider osmotic and secretory diarrhea
from hx
- Hypokalemia and alkalosis may be seen
secondary to diahrrea, vomiting and
dehydration
- Stool exam may help in diagnosis
6. Renal colic
- Dull low-intensity pain in the suprapubic
region
- Pancreatitis can present as isolated left
flank pain (CT showed pancreatitis in the

tail with abnormal fluid collected


extending to the left peri-renal space.)
Presence of nausea or vomiting
Male sex
Short duration of pain
Non black race
Microscopic hematuria
Symptoms: Dysuria, frequency,
Amylase and lipase are normal

7. inferior myocardial infarction


- pain is usually retrosternal with radiation
to jaw, neck and left upper extremity
- (+) shortness of breath and diaphoresis
- (+ Nausea and vomiting
- (+) Cardiovascular risk factors in PMHx
and FHx
- Elevated cardiac enzymes, ECG changes
- Normal lipase and amylase]
8. dissecting aortic aneurysm
- cardiovascular risk factors:
hyperlipidemia, tobacco, diabetes
mellitus,
- Acute tearing like abdominal pain,
pulsating abdominal mass, hypotension
and mottled lower extremities with
decreased pulses
- Radiation to the sacral region, flank or
genitalia
- (+) abdominal distention
- In stable patients, CT angiography may be
useful as a rapid way to make diagnosis
9. pneumonia,
- Referred pain of thoracic origin is often
with splinting of the involved hemithorac
with respiratory lag and decrease in
excursion more marked than that seen in
the presence of intraabdominal disease
- Abdominal muscle spasm will diminish
during the inspiratory phase of respiration,
10. CTD with vasculitis
- Family history of CTD
11. DKA
- Pain of uremia or diabetes is nonspecific,
and the pain and tenderness frequently
shift in location and intensity.
- Also elevated amylase levels
- Serum lipase not elevated

Laboratory Work Up: (PRIORITIZE!!)


LABS
1. Serum
Lipase
2. Serum
amylase
3. CBC

EXPECTED RESULTS
3x elevated
Preferred test
Remains elevated for 7-10 days
3x elevated
Returns to normal after 3-7 days
Leucocytosis
WBC 15,000-20,000u/L
Hct >0.44, hemoconcentration =

IN
pancreatic necrosis = severity
Hypoxemia PaO2 <60%
Seen in 5-10% px
Herald onset of ARDS
5. ECG
Could be MI: ST elevation, T
wave inversion
Serum Chemistry
6. BUN
BUN >22mg/dL
Azotemia
Assess renal function: significant
factor for mortality
Due to loss of plasma into the
retroperitoneal space and
peritoneal cavity
7.
Hyperglycemia: due to insulin
FBS/CBG release; glucagon release,
adrenal glucocorticoids and
catecholamines
8. Ca
Hypocalcemia: Saponification of
Fatty Acids in areas of fat
necrosis
9. TB, IB, Hyperbilirubinemia
DB
>4.0mg/dL with transient
jaundice
Point to gallbladder related
disease or inflammation of
pancreatic head
10.
Transiently elevated
ALT/AST
AST:
ALT:
Point to gallbladder related
disease or inflammation of
pancreatic head
11.
Marked increase = poor
Serum
prognosis
LDH
12. Trig
Hypertriglyceridemia:
>1000mg/dL
due to lipase activation
Imaging
Abdomin - Indicates severity and the risk
al CT
of morbidity and mortality
Clearly outlines morphologic
scan
features of acute pancreatitis:
interstitial, necrotizing, acute
fluid collection, pancreatic
pseudocyst, acute necrotic
collection, walled off
pancreatic necrosis
- Best eval 35days HD if
patient is not responding
to supportive care
WAB-UTZ Initial imaging modality of
choice
To evaluate gallbladder if
gallstone disease is suspected
Evaluates pancreatic head
4. ABG

MANAGEMENT
Orders:
Admit to:
o Ward: if px responds to initial fluid
resuscitation in the emergency
ward
o ICU: if px does not respond to
aggressive fluid resuscitation,
hemodynamically unstable,
evidence of pancreatic necrosis,
and evidence of organ failure
Diet:
- NPO strictly (to rest the pancreas)
- resume diet slowly after the 3rd-6th day
if without pain and vomiting
IVF: LR at 15-20cc/kg bolus, followed by
3mg/kg/hr to maintain urine output
>0.5cc/kg/hr
o Targeted resuscitation strategy:
measure hematocrit and BUN every
8-12 hours to ensure adequacy of
fluid resus and monitor response to
therapy
o LR shown to decrease systemic
inflammation and may be a better
crystalloid than NSS
Monitor VS q2hours including progress of
abdominal pain
I & O qshift; CBG monitoring every 4
hours
Hook to supplemental oxygen via nasal
cannula @ 2lpm
Place NGT if with ileus or vomiting
(reduce risk of aspiration)
Therapeutics:
1. H2blockers: Ranitidine (Zantac) 50mg
IV q8
or PPI IV
2. Pain Relief (Intravenous narcotic
analgesics) to control abdominal pain
Meperidine HCl (Demerol) 25-50mg
IV q6hr
Defer for BP < 100 systolic
3. Antibiotics for established infections or
severe pancreatitis
Cefoxitin +- Metronidazole or
Ceftazidime IV +- Metronidazole or
Ciprofloxacin IV or
Imipenem IV
4. Low Calcium levels
Calcium gluconate slow IV or
incorporate in IVF
5. TPN for malnutrition or prolonged NPO
of more than 5 days. Check

IN
triglyceride level first. Should be less
than 400mg/dL
6. ERCP: for patients with eveidence of
ascending cholangitis within 24-48hrs.

Surgical options
1. If with severe hemorrhage, necrotizing
pancreatitis, pancreatic abscess or
large pseudocyst (5-6cms), do surgical
drainage (necrosectomy). This may
have to be done repeatedly.
2. If associated with gallstone ileus,
insert NGT to decompress bowel
3. Cholecystectomy prior to discharge for
gallstone-induced pancreatitis since
recurrence rate is high.
Follow up Care
- Assess for development of diabetes,
exocrine insufficiency, recurrent
cholangitis, or development of
infected fluid collections
- Follow up after 2 weeks of admission;
after 1 week if with surgical procedure
Complications:
Local
Necrosis (sterile or
infected)
Pancreatic fluid
collections
(pseudocyst,
abscess)
Pancreatic ascites
Obstructive jaundice

Systemic
Pulmonary: ARDS,
effusion, pneumonitis
CVS: hypotension,
sudden cardiac death
Hema: DIC
GI: ulcer formation,,
gastritis
Renal: oliguria,
azotemia, acute
tubular necrosis
Metab:
hypergkycemia,
hypocalcemia

Revised Atlanta Classification:


1. Phases of Acute Pancreatitis
EARLY
Most exhibit SIRS & predisposed
(<2wk
to OF
s)
Assess Organ Failure
Persistent OF (>48hrs): most
important clinical finding with
regard to severity of the acute

LATE
(>2wk
s)

pancreatitis episode
May require imaging
Peristent organ failure
May require supportive
measures (dialysis, ventilator
support, TPN)

2. Severity of Acute Pancreatitis


MILD
Without local complications or OF
Self limiting 3-7d after tx initiated
Oral intake presumed if px is
hungry, NABS, no nausea/vomiting
MOD
Transient organ failure (resolves
Severe <48h)
With local complications in the
absence of persistent organ failure
SEVER Persistent organ failure (>48h)
E
CT or MRI should be obtained to
assess for necrosis and or
complications