Pancreatitis
Definition
Acute pancreatitis
Is the inflammation of the pancreas and is a serious disorder of the pancreas
There is a range of severity from mildest to the severest - in very severe cases the mortality is high.
Chronic pancreatitis is often undetected until 80 % to 90 % of the exocrine and endocrine tissue is destroyed
Aetiology
Autodigestion
Obstruction to the duct
Hypersecretion of the exocrine enzymes of the pancreas
Enzymes enter the bile duct - get activated - refluxes into the pancreatic duct ' pancreatitis
Long term alcohol use is a common cause
But undiagnosed chronic pancreatitis with exacerbation may mimic acute attack
Bacterial and viral infections
Blunt injury abdomen,
Peptic ulcer disease,
Ischaemic vascular disease,
Hyperlipidemia,
Hypercalcemia
The use of corticosteroids,
Thiazide diuretics
Oral contraceptives
All the above have been associated with an increased incidence of pancreatitis
Acute Pancreatitis
Range : Mild Pancreatitis (self limiting) to Severe Pancreatitis (rapidly fatal disease)
Mild Acute Pancreatitis
Oedema and inflammation confined to the pancreas
Minimal organ dysfunction
Return to normal usually occurs within 6 months,
Patient is acutely ill and at risk for shock,
Fluid and electrolyte disturbances
Sepsis
Types of Acute Pancreatitis
Severe acute pancreatitis
(formerly termed necrotizing or haemorrhagic pancreatitis) is characterized by a more wide-spread and complete enzymatic digestion of the gland.
The tissue becomes necrotic spreads into the retroperitoneal tissues.
Local complications : : pancreatic cysts or abscesses and acute fluid collection in or near the pancreas
Systemic complications : acute respiratory distress syndrome, shock, disseminated intravascular coagulation
Haemorrhagic pancreatitis or acute necrotizing pancreatitis
Complete recovery may occur
But may recur
Recovery may be without permanent damage or may progress to chronic pancreatitis
Clinical Manifestations
Severe abdominal pain, acute in onset
Tenderness and back pain
Pain starts about 24 to 48 hours after a heavy meal or alcohol ingestion
Diffuse or difficult to locate
More severe after meals and is unrelieved by antacids
Abdominal distention
A poorly defined, palpable abdominal mass
peristalsis may be decreased
Vomiting, nausea
Patient is acutely ill
Abdominal guarding
Boardlike rigidity may develop - an ominous sign
Ecchymosis (bruising) in the flank or around the umbilicus may indicate severe pancreatitis.
Fever, jaundice, mental confusion, and agitation also may occur
Hypotension - hypovolemia - shock - cold clammy skin, tachycardia loss of large amounts of protein-rich fluid into the tissues and peritoneal cavity
Cyanosis
Respiratory distress and hypoxia
Dyspnoea tachypnoea and abnormal blood gas values
Myocardial depression, hypocalcemia hyperglycemia and
Disseminated intravascular coagulopathy may set in
The mortality rate in acute pancreatitis is high because of :-
Hypotension
Shock
Anoxia
Fluid and electrolyte imbalances.
Investigations
Serum amylase - peak level in 24 hours rapid fall to normal levels within 48 to 72
Serum lipase - rises after 48 hours and remains elevated for 5 to 7 days
Hb, TC - bleeding, Leucocytosis
Serum Calcium - Hypocalcemia - proportionate to the severity of the pancreatitis
Serum Bilirubin level - and elevated serum bilirubin levels
Blood glucose - Transient hyperglycemia
Urinary glucose - glucosuria
Urinary amylase levels also become elevated and remain elevated longer than serum amylase levels
Peritoneal fluid or peritoneal lavage analysed for pancreatic enzymes
Fibrinogen level
C-reactive protein, trypsinogen activation peptide and polymorphonuclear elastase.
Stool examination : pale foul smelling
X-ray abdomen - to detect other problems like pleural effusion and for differential diagnosis.
USGM - Peripancreatic and retropancreatic oedema
CT scan to detect pancreatic cysts, abscesses or pseudocysts.
ERCP - useful in gallstone pancreatitis
Fluid in the retroperitoneum due to pancreatitis
Necrosis in body and neck with peri pancreatic oedema
Criteria for predicting severity of pancreatitis
Criteria on Admission:-
Age > 55 years
WBC > 16000/mm3
Serum glucose > 200 mg/dL (>11.1 mmol/L)
Serum LDH > 350 IU/L
SGOT > 250 U/ml (120 U/L)
Criteria within 48 hours:-
Fall in haematocrit > 10%
BUN increase > 5 mg/ dL (1.7 mmol/L)
Serum calcium < 8 mg/dL (<2mmol/L)
Base deficit > 4 mEq/L (4 mmol/L)
Fluid retention or sequestration >6 L
PO2< 60 mmHg
Mortality Prediction:
2 or fewer signs : 1 % mortality
Presence of 3 or more = severe pancreatitis
3-4 signs 15% mortality
5-6 signs 40 % mortality
> 6 signs 100 % mortality
Medical management
Nil by mouth
Total parenteral nutrition (TPN)
Nasogastric suction
Tramadol or any other drug for pain relief
Antiemetics - emeset, perinorm
Correction of hypovolemia - fluid balance - arterial blood gas monitoring
Antibiotics
Insulin if needed
Respiratory care - humidified oxygen admn or intubation and mechanical ventilation
Biliary drain - drainage of the pancreas → decreased pain and increased weight gain
Surgical intervention
Poor surgical risk - resection or debride a necrotic pancreas - multiple drains after surgery - a surgical incision may be left open and irrigated and repacked every 2 to 3 day to remove necrotic debris
