Acute Pancreatitis

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INTRODUCTION

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Acute pancreatitis is an acute inflammatory process of the pancreas.

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It is usually associated with

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severe acute upper abdominal pain and elevated blood levels of pancreatic enzymes.

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Most cases are associated with

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alcoholism or gallstones

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Acute pancreatitis can be suspected clinically, but requires

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biochemical, radiologic, and sometimes histologic evidence to confirm the diagnosis.

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Demographic features — The two most common causes of acute pancreatitis in adults are

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gallstones and alcoholism.

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Symptoms —

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acute upper abdominal pain at the onset [2].

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The pain is

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steady and may be in the mid-epigastrium, right upper quadrant, diffuse, or, infrequently, confined to the left side.

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Biliary colic, which may herald or progress to acute pancreatitis, may occur

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postprandially.

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On the other hand, acute pancreatitis related to alcohol frequently occurs after a binge or cessation of drinking

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one to three days

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Unlike biliary colic, which may last for six to eight hours, the pain of pancreatitis can last for

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days.

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Its onset is rapid, but not as

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abrupt as that with a perforated viscus, reaching maximum intensity in many cases within 10 to 20 minutes.

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One characteristic of the pain that is present in about one-half of patients, and that suggests a pancreatic origin, is

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band-like radiation to the back.

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Painless disease is

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uncommon (5 to 10 percent) and may be seen in the postoperative setting (especially renal transplantation), in patients receiving peritoneal dialysis, and those with Legionnaire's disease [3].

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The abdominal pain is typically accompanied (in approximately 90 percent of patients) by

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nausea and vomiting, which may persist for many hours.

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Patients with fulminant attacks may present in

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shock or coma.

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Hemorrhagic complications are

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rare.

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Ecchymotic discoloration of the flanks

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(Grey-Turner's sign) is due to retroperitoneal bleeding in patients with pancreatic necrosis.

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Bleeding may also occur into

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pseudocysts [4] or rarely bleeding into the pancreatic duct is visible on endoscopy as blood coming from the ampulla (hemosuccus pancreaticus).

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Systemic features include

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fever, tachycardia, and, in severe cases, shock and coma.

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In mild disease, the epigastrium may be

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minimally tender.

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However, severe episodes are often associated with

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abdominal distention, especially in the epigastrium, and tenderness and guarding

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dyspnea may occur if there is

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an associated pleural effusion.

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Ecchymotic discoloration in the flank

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(Grey-Turner's sign)

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Ecchymotic discoloration in periumbilical region

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(Cullen's sign)

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These signs reflect intraabdominal hemorrhage and are associated with a

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poor prognosis.

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Obstruction of the common bile duct, due to choledocholithiasis or edema of the head of the pancreas, can lead to

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jaundice.

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Less common features include

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subcutaneous nodular fat necrosis (panniculitis), thrombophlebitis in the legs, and polyarthritis .

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Pancreatic enzymes —

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synthesis continues while there is a blockade of secretion. As a result, digestive enzymes leak out of acinar cells through the basolateral membrane to the interstitial space and then the systemic circulation.

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Serum amylase — It rises within

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6 to 12 hours of onset,

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Serum amylase is cleared

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fairly rapidly from the blood (half-life approximately 10 hours).

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In uncomplicated attacks, serum amylase is usually elevated for

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three to five days.

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An elevated serum amylase level is a nonspecific finding because it occurs in a number of conditions other than acute pancreatitis

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The serum amylase concentration in acute pancreatitis is usually more than

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three times the upper limit of normal

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the serum amylase may be normal or minimally elevated

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thrue

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... percent of filtered amylase is excreted, increases to approximately ...percent

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3-10

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Serum lipase — Because lipase measurements have been .........., they have been less frequently ordered than serum amylase

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difficult to perform and lacked precision

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The sensitivity of serum lipase ranges from

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85 to 100 percent

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The level of pancreatic enzyme elevation correlate with severity of disease.

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Falsh

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Other pancreatic enzymes

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phospholipase A, trypsin, carboxylester lipase, carboxypeptidase A, and co-lipase

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Nonenzymatic pancreatic secretory products

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Pancreatitis-associated protein (PAP) ,trypsinogen activation peptide (TAP),

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Markers of immune activation/nonspecific markers

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IL-6, IL-8, IL-10, TNF, PMN elastase, and C-reactive protein.

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Levels of C-reactive protein above discriminates severe from mild disease

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150 mg/dL at 48 hours

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Abdominal plain film

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exclude other causes of abdominal pain such as obstruction and bowel perforation.

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The radiographic findings

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range from unremarkable in mild disease to localized ileus of a segment of small intestine ("sentinel loop") or the "colon cutoff sign" in more severe disease.

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.....of patients with acute pancreatitis have abnormalities on the chest roentgenogram

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one-third

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Abdominal ultrasound

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A diffusely enlarged, hypoechoic pancreas ,gallstones in the gallbladder

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CT scan

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most important imaging test

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The severity of acute pancreatitis has been classified into five grades based upon findings on unenhanced CT

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Grade A — Normal pancreas consistent with mild pancreatitis ,
Grade B — Focal or diffuse enlargement of the gland, including contour irregularities and inhomogeneous attenuation but without peripancreatic inflammation
Grade C — Abnormalities seen in grade B plus peripancreatic inflammation ,
Grade D — Grade C plus associated single fluid collection ,
Grade E — Grade C plus two or more peripancreatic fluid collections or gas in the pancreas or retroperitoneum

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The advantages of MRI over CT include:

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lack of nephrotoxicity of gadolinium, ability of MRI to better categorize fluid collection as acute fluid collections, necrosis, abscess, hemorrhage, and pseudocyst [37], and the greater sensitivity of MRI to detect mild acute pancreatitis compared to CT.

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MRI was reliable for staging the severity of AP, had prognostic value, and was associated with fewer contraindications compared to CT, and was able to

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detect pancreatic duct disruptions

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Gallstones and alcohol abuse account for

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60 to 75 percent and should be diligently looked for in all patients presenting with acute pancreatitis.

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patients with acute biliary pancreatitis discharged from the hospital without a cholecystectomy,

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30 to 50 percent develop recurrence of pancreatitis ,occurring an average of 108 days after discharge

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removing the gallbladder in biliary pancreatitis is

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imperative.

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conventional transabdominal ultrasonography should be performed in every patient with a first attack of acute pancreatitis to search for

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gallstones in the gallbladder

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gallbladder visualization may be inadequate due to excessive bowel gas in ___________ percent of patients. In such cases, a ..............should be performed after resolution of acute pancreatitis

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25 to 35
repeat ultrasound

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MRCP may be an alternative to detect

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common duct stones in such patients.

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A randomized trial showed that laparoscopic exploration of the common bile duct was as __________as postoperative ERCP in clearing the common duct of stones

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safe and effective

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An increase in serum alanine aminotransferase (ALT) is suggestive of

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gallstone pancreatitis
value greater than 150 IU/L strongly suggests gallstone pancreatitis

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lipase-to-amylase ratio greater than 2.0 was 91 percent sensitive and 76 percent specific for detecting

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alcoholic pancreatitis

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Idiopathic recurrent pancreatitis
no obvious etiology is identifiable in approximately

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30 percent of patients

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T/F extensive investigation for unusual causes of pancreatitis is required after the first episode of idiopathic pancreatitis

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False

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GENERAL PRINCIPLES OF THERAPY

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correcting any underlying predisposing factors and at the pancreatic inflammation itself.

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Mild pancreatitis is treated for several days with supportive care including

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pain control
intravenous fluids
nothing by mouth.

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Supportive treatment

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monitoring of vital signs and urine output every few hours in the first 24 to 48 hours.
Fluid resuscitation
Oxygen
Prophylaxis against deep vein thrombosis

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Inadequate hydration can lead to In addition,

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hypotension and acute tubular necrosis.

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fluid depletion damages pancreatic microcirculation and results in

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pancreatic necrosis.

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approximately _______cc of intravenous fluids per hour are typically required for ______ hours if the cardiac status permits

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250 to 300
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Pain management

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Meperidine
Fentanyl

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morphine caused an _______in sphincter of Oddi pressure

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increase

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Approximately _______of patients with pancreatic necrosis develop infected necrosis

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one-third

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The important organisms causing infection

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Escherichia coli, Pseudomonas, Klebsiella, and Enterococcus spp.

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Fungal infection and infection with gram-positive organisms are

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uncommon

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Three approaches have been taken to decrease bacterial infections in acute necrotizing pancreatitis

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Enteral feeding to avoid central line related infections, maintain gut barrier integrity, and decrease bacterial translocations
Selective decontamination of the gut with nonabsorbable antibiotics
Prophylactic systemic antibiotics

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Selective decontamination of the gut

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combination of oral norfloxacin, colistin, and amphotericin

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Systemic antibiotics

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cefuroxime (1.5 g three times daily)
ceftazidime, amikacin, and metronidazole given intravenously for 10 days
imipenem

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Cefuroxime is given until clinical recovery and normalization of the .

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CRP level

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contrast-enhanced CT scan is indicated only in patients who are

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deteriorating or have severe pancreatitis determined clinically and by APACHE II score

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T/F A CT scan is required on the first day

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False

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If there is necrotizing pancreatitis (involving more than approximately 30 percent of the pancreas), we initiate

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antimicrobial therapy with imipenem/meropenem and continue it for at least one week.

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If at any time the patient becomes unstable from pulmonary, cardiovascular, or renal complications, we perform a

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minimally invasive necrosectomy, (endoscopic, or percutaneous radiologic) if possible

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If there has been no improvement after one week of antibiotics, we perform a

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percutaneous CT-guided aspiration

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If there is bacterial infection, we consider performing a

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necrosectomy

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CT-guided percutaneous catheter drainage may also be an option before considering

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surgical debridement

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We suggest open surgical debridement for patients with infected necrosis (and rarely for sterile necrosis) who have

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persistent pain and cannot tolerate oral intake if the minimally invasive methods fail to resolve the fluid collections

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T/F nutritional support is required in patients with severe pancreatitis

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True

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A major potential benefit of enteral nutrition is its ability to maintain the

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intestinal barrier

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Enteral nutrition was associated with a

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significantly lower incidence of infections (RR 0.45, 95% CI 0.26 to 0.78), reduced surgical interventions (RR 0.48, 95% CI 0.22 to 1.0), and a reduced length of hospital stay (mean reduction 2.9 days

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Nasojejunal feeding with

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high protein, low fat preparations such as Peptamen

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Initiation of oral feedings

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We begin oral feedings by giving 100 to 300 mL of clear liquids every four hours for the first 24 hours.

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GALLSTONE PANCREATITIS

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early endoscopic or surgical intervention to remove bile duct stones may lessen the severity of gallstone pancreatitis.
early endoscopic papillotomy is of proven benefit in humans with acute biliary pancreatitis

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T/Fearly ERCP and papillotomy is beneficial in patients with acute biliary pancreatitis without obstructive jaundice or biliary sepsis

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False