Acute Pancreatitis

Etiology
Gall stone and alcohol cause 80-90% of all cases
of acute pancreatitis
Gall stone : the most common
Gall Stone (impacted)

Alcohol
The amount of alcohol is all that matters
heavy drinking (usually more than 150gr alcohol)
Oddi sphincter spasm
Endothelium destruction and enzyme leakage
concentration of pancreatic secretions
Ischemic injury due to local blood flow decrease
activation of trypsin
other causes
drugs: corticosteroids, estrogen, thiazide, tetracycline,etc
increased VLDL: especially type 1,and 5, TG>1000
post surgical (gall bladder, CABG, kidney transplant, splenectomy, pancreatectomy)
tumor
trauma
CABG: due to hypotension during surgery
Viral infections
Ascaris and Liver fluke
ERCP (5%)
Hyperparathyroidism
Idiopathic: the most common after gall stone and alcohol
presentation
Sudden onset severe epigastric pain:usually after eating, or drinking alcohol
with radiation to back
Relieved by leaning forward
Fever
Tachycardia
tachypnea
Hypoactive bowel sounds
epigastric tenderness
in hemorrhagic form: massive bleeding posterior to peritoneum, echymosis in flanks (Grey Turners
sign), around umbilicus (Cullen sign)
Pleural effusion (high amylase)
Multiorgan failure, ARDS, ATN, DIC
Differential Diagnoses
Cholecystitis
Perforated Appendicitis
Small bowel obstruction
Livers diseases
Ovary tumors
peritonitis
high serum amylase but urine amylase not as high as pancreatitis
Lab Data
Hyperglycemia
Hypoalbuminemia
Hypocalcemia: poor prognosis
leukocytosis, Hb increase, Thrombocytosis,
Abnormal LFT
Hypoxia in ABG
Diagnosis
Mostly based on clinical presentations
Serum amylase level: the most common diagnostic test
increases instantly until 3-5 days
increses to 2.5 times after 6 hours
usually >1000
Amylase increases in gall stone pancreatitis
Lipase increases in alcoholic pancreatitis
Urine amylase: more than 5000 in 24h
Serum lipase: of great diagnostic value
more specific and of more maintenance
Severity evaluation
Double contrast CT scan :gold standard
no enhancement in fast phase means necrosis
Aspiration and culture
+culture: Antibiotics and debridment
-culture: no antibiotics
Serum levels:
high CRP indicates necrotizing pancreatitis (the
most important)
the lower the level of a2 macro globulin, the
poorer the prognosis
a1 protease c3 and c4
Ransons criteria
to evaluate prognosis, not for diagnosis
Pancreatitis complications

Pancreatic Pseudocyst
usually occurs after 3 weeks
mostly in lesser sac (posterior to stomach)
presents with fullness, nausea, pain (not severe)
more common in male
10-20% of acute pancreatitis and 20-40% of chronic
pancreatitis
diagnosis: CT with contrast

Pancreatic Abscess
2-6 weeks after pancreatitis
Necrosis in CT scan
first, drainage under sono or CT guide, if not
possible> surgery