| What is acute pancreatitis? | Acute inflammation of pancreas involving other tissue organs.
Clinically if 2 out of 3 criteria are found:
1-symptoms consistent with pancreatitis (sever pain)
2-Serum Lipase level more than 3X the normal value.
3-Pancreatitis seen on imaging usually CT or MRI |
| What are the two appearances of acute pancreatitis (natural history)? | 2 phases: interstitial and necrotizing.
Interstitial: mild case involving 2/3 of pancreatitis, severity of the case depends on extra-pancreatic organs involved, presents with the normal signs of inflammation (fever, tachycardia, hypotension, respiratory distress, leukocytosis (SIRS -system inflammatory response syndrome)
Necrotizing: severe, in 1/3 of cases, lasting weeks to months, mortality due to infection of necrosis and organ failure |
| What are the etiologies causing acute pancreatitis? | Obstruction (of wirsung, most important is gall stones, tumor maybe, parasites, diverticulia...)
Alcohol or other toxins (not imp in lebanon, but major cause in US and europe)
Metabolic abnormalities (TGs, DM, hypercalcemia (due to hyperPTH))
Infection (rare)
Vascular (rare, more in gut and liver)
Trauma (maybe unpredictable, pancreas can rupture)
PostOp (cardiac surgery for example)
Post ERCP (papillary injury causing inflammation)
Sphincter of Oddi (dysfunction)
Drug association (IBD - sulfasalazine, most important is furosemide (lasix)) |
| How does acute pancreatitis present clincally? | Abdominal pain, epigastric radiating dorsally, abrupt and sudden onset, knife like relieved with back flexion (max intensity 10-20 min, not as sudden as viscus))
most patients present with nausea |
| What are the physical exam findings of acute pancreatitis? | Nothing seen, maybe tenderness of abdomen, in severe pancreatitis, we see abdominal distention, tachycardia, HTN, may have fever (all these are due to extra-pancreatic organs) |
| What are the labs made to reveal acute pancreatitis? | Lipase (sensitivity>85%, and more specific than amylase)
WBC we see leukocytosis
Hyperglycemia, Liver enzymes elevated (we look at them to see gall stone or acute biliary pancreatitis)
Hypocalcemia, the more severe the worse prognosis
MCV increases (due to alcohol, we can also see gamma GT) |
| What are the diagnostic imaging techniques used for acute pancreatitis? | US (not for pancreas and more for gall bladder)
CT and Endoscopic US (EUS) are more important, and we use Balthazar grades to assess the pancreatitis.
EUS is a gastroscopy with an US inside, put on the wall of stomach to see the pancreas posteriorly. |
| What are the indicators of CT scan of pancreatitis? | (1) exclude other serious intra-abdominal conditions (e.g., mesenteric infarction or a perforated ulcer),
(2) stage the severity of acute pancreatitis, and
(3) determine whether complications of pancreatitis are present (e.g., involvement of the GI tract or nearby blood vessels and organs, including liver, spleen, and kidney). |
| How does pancreatic necrosis appear? | Pancreatic necrosis manifested as perfusion defects after IV contrast may not appear until 48 to 72 hours after onset of acute pancreatitis |
| What is Balthazar scale? | Grading from A to E (most severe)
A: normal pancreas mild pancreatitis
B: Enlargement of the gland
C: B + peripancreatic inflammation
D: C + single fluid collection
E : D + perpancreatic fluid accumulation or gas... |
| Why is EUS used? | Not helpful if early, but reveals small tumors, pancreas divisum, bile duct stones...
equivalent to ERCP and MRCP but more sensitive
Best method evaluating necrotizing pancreatitis.
If bilirubin increased --> do ERCP |
| What are the predictors of disease severity? | Our management of the disease is purely symptomatic
Most important score of evaluation is SIRS (systemic inflammatory response syndrome) where we see if we have a sever acute pancreatitis by seeing other organs involvement, SIRSS 2 of 4 criteria (pulse >90 bpm, Rectal Temp <36 or >38, WBC <4000 or >12000, RR >20 or Pco2 <32 mmHg
We also use scores like APACH (in ICU since it takes time (48 hours))
We could see CRP as well At a cutoff of 21 mg/dL, the sensitivity of CRP in detecting severe disease in patients with acute pancreatitis is only 60%, but the test is highly specific.
At a lower cutoff (10 mg/L), CRP becomes highly sensitive, but the test specificity drops to 75%. |
| When should we manage SIRS? | 48 hours within the start of organ failure and SIRS (MR = 0% and else it becomes >36%) |
| What are risk factors of severe pancreatitis? | Old age, Obesity, Comorbidities, SIRS, inflammation, increased creatinine, extrapulmonary symptoms (pleural effusion, pulmonary infiltrate, extrapancreatic fluid accumulation) |
| What is the treatment of acute pancreatitis? | IV hydration, analgesics, NPO (stopping nausea), NG tube not used frequently, monitoring and Abx in case of biliary sepsis or infection pancreatic or extrapancreatic
Nutrition: when there is no nausea or vomiting it is important to feed the patient to prevent floral translocation from gut to the site of pancreatitis and necrosis causing infectious necrosis.
Surgery (Cholecystectomy (after ERCP to stop any new stone from happening - should happen in same hospitalization of pancreatitis), Necrosectomy or abscess drainage |
| What are the complications of acute pancreatitis? | Pseudocysts, Necrosis (sterile or infected), Abscesses, GI bleed, splenic complications, systemic failure
THE MOST IMPORTANT ARE: Pseudocyst, Necrosis and Infected Necrosis |
| What is a pseudocyst? | Secondary to acute pancreatitis, takes 4 weeks to develop, secondary to pancreatitis or trauma.
No distinct border, just a liquid with inflammatory tissue as a border.
If asymptomatic just monitor (may resolve on its own)
If symptomatic (see with EUS linear view to drain it with a needle, put a guidewire in the cyst and put a metallic stent half in the cyst and half to the intestine in order to drain it.
In patients with known pseudocysts, new symptoms such as abdominal pain, chills, or fever should alert the clinician to the emergence of an infected pseudocyst or abscess. Treatment choices include surgical, radiologic, and endoscopic drainage |
| What is necrotizing pancreatitis? | pancreatic necrosis is defined, in the absence of laparotomy or autopsy, by the presence of greater than 30% of nonenhancement of the pancreas on a contrast-enhanced CT scan
May be infected or sterile |
| How does infection of pancreatic necrosis occur and how do abscesses form? | Bacterial translocation to necrotic tissue 10 days after hospitalization, recur with sepsis, fever, pain and leukocytosis, seen by CT guided FNA.
Abx should be provided
early debridement of pancreatic necrosis within the first 4 to 5 weeks of an attack will require surgery, WON can be treated laproscopically, percutaneously, or endoscopically |
| What is algorithm of mananging acute pancreatitis? | . |
