ACUTE PANCREATITIS.

DEFINITION

  • Inflammatory disease of the pancreas characterized by abdominal pain and elevated serum amylase and lipase.

ETIOLOGY/ PATHOGENESIS

  • Leakage of pancreatic enzymes into the peri-pancreatic tissue
  • Often secondary to gallstones or alcoholism
  • 85% self-limiting
  • Other causes include: trauma, drugs, hyperlipidemia, and genetics, post-surgery (ECRP), infection, hypercalcemia, pancreatic tumor.

PERTINENT HISTORICAL FINDINGS/ CLINICAL SYMPTOMS

  • Abrupt constant epigastric pain often radiating to the back
  • Nausea, vomiting

PERTINENT PHYSICAL EXAM FINDINGS

  • Fever and shock (hypotension when severe)
  • Pain aggravated by walking and lyin
  • Improved by sitting and leaning forward
  • If associated with severe necrotizing pancreatitis, flank discoloration (Gray-Turner sign) may be present

DIFFERENTIAL DIAGNOSIS

  • Gall stones
  • Perforated duodenal ulcers
  • Chronic pancreatitis
  • Leaking aortic aneurysm
  • Mesenteric ischemia

DIAGNOSTIC EVALUATIONS Cancer

  • Elevated amylase
  • Elevated lipase, remains elevated longer than amylase
  • Decreased Ca if very severe
  • CT is useful in diagnosis
  • Plain abdominal x-rays may show signs of obstruction due to Ileus, “sentinel loop” or “colon cutoff”
  • U/S not helpful

MEDICAL MANAGEMENT

  • Subsides spontaneously in a few days
  • Remove offending agent (alcohol or stones (ERCP))
  • Supportive care: IV fluids, Pain control, Nutritional support, May require respiratory support
  • Pain control

SURGICAL MANAGEMENT

  • Surgical referral for severe acute pancreatitis
  • Surgical correction may be beneficial in necrotizing pancreatitis, clinical deterioration with multi-organ failure.
  • Surgical drainage of a potential abscess may be necessary

EMERGENCY MANAGEMENT

  • Surgical referral for severe acute pancreatitis.
  • If pancreatic infection, Imipenem 500 mg every 8 hours intravenously

PATIENT EDUCATION/ MAINTENANCE – PREVENTION

  • Remove offending agent (alcohol if cause)
  • Oral feedings should be initiated once the patient’s pain and anorexia resolve
  • Close follow-up (~ 7 – 10 days)

576-0550x0475  afp20000701p164-f2

Contrast-enhanced axial computed tomographic section of the upper abdomen showing peripancreatic and retroperitoneal edema (large arrows) and stranding. The pancreas itself (small arrow) appears relatively normal.

Dr. Zachary Lahlou

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