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					Acute Pancreatitis
   By Hans Rosenberg
                Objectives
 Definition
 Etiology
 Clinical Presentation
 Diagnosis
 Prognosis
 Treatment
               Definition
Acute Pancreatitis
 reversible inflammatory process of the
  pancreas
 usually associated with severe acute upper
  abdominal pain and elevated blood levels
  of pancreatic enzymes
 pancreatic tissue or peripancreatic tissues
  and distant organs
 mild to severe
                 Etiology
 Incidence: 4.8-24.2 per 100,000
 Mortality in hospitalized patients: 10% (2-
  22%), severe acute pancreatitis 30%
 Mortality in first two weeks usually due to
  SIRS and organ failure, > two weeks due
  to sepsis
                        Etiology
   Idiopathic (30%) /Infection
                                 Other:
   Gallstones (35%)             Pancreatic Divisum
   Ethanol (10%)                Sphincter of Oddi Dysfunction
                                 Congenital Anomalies
   Trauma/Tumor                 Hypothermia
                                 Vasculitis
   Steroids                     CF
   Mumps
   Autoimmune – eg. SLE
   Scorpion Bites
   Hypertriglycideremia/Hypercalcemia/Hyperparat
    hyroid
   Drugs – eg. diuretics
          Clinical Presentation
   Symptoms
    – Acute onset persistent upper abdominal pain
    – Nausea and vomiting
    – +/- radiate to back, chest, flanks
    – Appears restless
    – Bent forward provides relief
    – If severe: ++distress
             Clinical Presentation
   Signs
    –   Fever
    –   Hypotension/tachycardia
    –   Severe Abdominal Tenderness
    –   Peritoneal Signs
    –   Abdominal Distension
    –   Respiratory Distress
    –   Cullen’s, Grey-Turner’s, Fox’s Sign
    –   If severe: marked tenderness, guarding, distension,
        signs of hypotension shock, jaundice, respiratory
        findings
                       Diagnosis
   No single test, but clinical picture and labs
    –   Lipase (> Sens and >Spec)
    –   Amylase
    –   CBC
    –   BUN/Cr
    –   LFT’s – ALT >150 IU/L high Spec for Stones
    –   Ca2+ Profile
    –   Triglycerides (acute or post-resolution)
    –   Urinalysis
    –   ABG

    *Bold must be done with first episode for etiology*
                   Diagnosis
   CT w/ Contrast – standard technique, used in
    ALL with unclear diagnosis or in severe disease
    (as per APACHE II) at 72hrs
   Endoscopic Retrograde
    Cholangiopancreatography (ERCP)
   Trans-abdominal U/S – 1st episode, etiology
   Chest/Abdo XR
   Magnetic Resonance Cholangiopancreatography
    (MRCP)
   Endoscopic Ultrasonography
               Prognosis
 Goal to differentiate/stratify 
  mild/moderate/severe disease
 Acute Physiology and Chronic Health
  Evaluation (APACHE II)
 Computed Tomography Severity Index –
  most accurate predicting severity of Acute
  Pancreatitis
 Ranson’s Criteria
                 Prognosis
 APACHE II scale includes the following factors:
  age, rectal temperature, mean arterial pressure,
  heart rate, PaO2, arterial pH, serum potassium,
  serum sodium, serum creatinine, hematocrit,
  white blood cell count, Glasgow Coma Scale
  score, chronic health status
 Scoring: Can be calculated at
  http://www.sfar.org/scores2/apache22.html#cal
  cul
 Severe if >8
    Computed Tomography Severity
               Index
 Scoring: CT grade + Necrosis
 CT Grade
    – A = normal pancreas (0)
    – B = edematous pancreas (1)
    – C = B + mild extrapancreatic changes (2)
    – D = severe extrapancreatic changes and 1
      fluid collection (3)
    – E = multiple or extensive fluid collections (4)
    Computed Tomography Severity
               Index
   Necrosis Score
    – None (0)
    – <1/3 (2)
    – >1/3 but <1/2 (4)
    – >1/2 (6)
    Computed Tomography Severity
               Index
 CT Severity Index score >5 correlated
  with prolonged hospitalization and higher
  rates of mortality and morbidity.
 CT Severity Index score >5 associated
  with a mortality rate 15 times higher than
  in those with a score of less than 5
Contrast-enhanced axial computed tomographic section of the upper
abdomen showing peripancreatic and retroperitoneal edema. Large non-
enhancing areas of necrosis are visible in the body and neck of the
pancreas (arrows)
                 Ranson’s Criteria
   Mild if <3, Severe if >3 with one point for each of below
   At admission or diagnosis:
    –   Age > 55 yo
    –   WBC > 16 x10e9/L
    –   BS > 11.1 mmol/L
    –   Serum LDH > 350 U/L
    –   AST > 250 U/L
   During initial 48hrs:
    –   BUN > 1.8 mmol/L
    –   Serum Ca2+ < 2 mmol/L
    –   Hematocrit Decrease > 10%
    –   Base Deficit > 4 meq/L
    –   Fluid Sequestration > 6 L
    –   PaO2 < 60 mm Hg
                    Treatment
   Volume Repletion – eg. D5W 1L/hr until U/O
    >0.5-1cc/kg/hr
   Analgesia – eg. Morphine 5-10mg IV prn, Gravol
    50mg IV prn
   Monitoring Hemodynamics and Volume
   NG tube if vomiting
   Nutrition: Total Enteral Nutrition > Parenteral
    Nutrition
    – Begin once pain improves and labs normalize
    – Enteric Options include: oral, nasgastric and
      nasojejunal
                  Treatment
 If severe consider: ICU, Surgical
  Debridement for infected necrosis, no oral
  intake first 48hr, emergent ERCP if
  gallstones/obstructive etiology suspected,
  Antibiotic Prophylaxis if suspected
  infection - gram neg and anaerobes, fine
  needle aspiration to guide therapy
 Admission Algorithm at Ottawa Hospital
    – Obstructive Etiology  General Surgery
    – Other Etiology  CTU/Family Medicine
     Questions??



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              References
 Acute Pancreatitis: Diagnosis, Prognosis,
  and Treatment. JENNIFER K. CARROLL et
  al. American Family Physician May 15,
  2007 Vol. 75 No. 10
 Diagnosis and management of acute
  pancreatitis. Munoz A, Katerndahl DA. Am
  Fam Physician. 2000 Jul 1;62(1):164-74.
 UpToDate

				
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