Write a Review
x
Feedback General Surgery

Acute Pancreatitis

  • Severe inflammation of the pancreas
    • Initially it is aseptic inflammation, but later has secondary septic complications
  • Disease course – mild parenchymal edema → severe hemorrhagic pancreatitis → gangrene and necrosis

Etiology

  • Alcohol – most common in men
  • Trauma – most common in children
  • Familial
  • Biliary tract disease
  • Iatrogenic – ERCP, operative, CT contrast, CABG
  • Tumour
  • Hyperlipidemia
  • Drugs – azathioprine, OCP, furosemide

Pathogenesis

  • Biliary stones/tumour – leads to obstruction of pancreatic duct, causing ductal hypertension
  • Alcohol intake – leads to several consequences
    • Hypersecretion of gastric acid and pancreatic juice
    • Free radicals cause injury
    • Spasm of sphincter of Oddi
    • Activation of trypsinogen into trypsin → activates proelastase to elastase → activates prolipase to lipase
  • Autodigestion of pancreas and necrosis of exocrine cells

Classification

  • Pancreatic edema
  • Destructive, necrotic form
    • Local inflammation and complications
    • Systemic complications, sepsis, multiple organ dysfunction (kidneys, liver, lungs)
    • Fulminant form – kidney and liver insufficiency within 24 hours; death within 72 hours

Clinical Features

  • Abdominal pain – epigastric, radiates to back due to plexus and nerves (relieved by leaning forward)
  • Nausea and vomiting, fever, tachycardia
  • Retroperitoneal haemorrhage
    • Grey Turner’s sign – bruising of the flanks
    • Cullen’s sign – periumbilical bruising
  • Decreased peristalsis
  • Severe attack – hypotension, hypoperfusion, hypovolemia
    • Can occur in the absence of Acute abdomen
  • Extra-abdominal manifestations
    • Left pleural effusion
    • Acute pulmonary failure
    • Subcutaneous fat necrosis
    • Cerebral insufficiency

Investigations

  • Blood
    • 3 fold increase in amylase
    • Haemoconcentration – increased hematocrit and Hb
    • Hyperglycemia – post-pancreatic diabetes
    • Hypocalcemia, azotemia, abnormal LFTs
  • XR, CT, US, MRI
  • Ranson’s Prognostic Criteria (see pic)
    • Clinical prediction rule for predicting the prognosis and mortality risk of acute pancreatitis

Treatment

Non operative – Mnemonic PANCREAS

  • Pain relief, Protease inhibitors
  • Antibiotics, Anticholinergics
  • Nasogastric aspiration
  • Calcium gluconate
  • Rehydration, Ranitidine
  • Endotracheal intubation, Electrolyte management
  • Antacids
  • Swan-Ganz catheter for CVP, Somatostatin analogue (octreotide)

Operative treatment

  • Open surgery is the gold standard for infected pancreatic necrosis – laparotomy and necrosectomy
  • Indications
    • Septic complications – abscess, cyst, necrosis, fever
    • Organ failure – kidney, liver
    • Biliary form of acute pancreatitis
    • Fulminant form of acute pancreatitis

Differential diagnosis of hyperamylasemia

  • Trauma, burns, abscess
  • Carcinoma
  • Biliary tract disease, intestinal obstruction, perforated peptic ulcer
  • Salivary gland disorder, mumps, renal failure, diabetic ketoacidosis
Feedback