| ID | 58 |
|---|---|
| Name | ACUTE PANCREATITIS |
| Cause | |
| Signs Symptoms | |
| Diagnosis | |
| Investigations | Investigation: 1. Blood for-a. TC & DC b. Blood glucose; albumin c. Blood urea d. Serum amylase (normal 50-300 u/1) e. Serum LDH, AST f. Serum calcium g. Blood gas analysis (PO2) 2. Urine for amylase 3. Plain X-ray of the abdomen (non-specific) & chest (often shows a left pleural effusion, collapse or consolidation of the lung). 4. Ultrasonography of HBS including pancreas (enlarged pancreas- indicates inflammation) 5. C.T scan (if needed)-confirmatory 6. Laparotomy- when the condition requiring surgery, such as to exclude perforated duodenal ulcer. Assessment of severity:1,2 There are different study procedures have been applied to assess the severity of acute pancreatitis, such as- i. Glasgow criteria, ii. Acute Physiology and Chronic Health Evaluation score (APACHE II), iii. Ranson criteria, iv. Sequential Organ Failure Assessment score (SOFA). Glasgow criteria2 are generally used to assess the severity and prognosis of acute pancreatitis. When 3 or more of following critiria are present on admisson a severe case of acute pancriatitis can be predicted: 1. Age over 55 years 2. Arterial PO2 of lass than 60mm Hg 3. White blood cell count over 15,000/ml V 4. Albumin less then 32gm/l 5. Serum Ca++ of less than 8mg/dl 6. Blood glucose over 180mg/dl 7. Urea more than 45mg/dl(16mmol/l) 8. Alanine aminotransferase (ALT) more than 200 IU/1 9. Serum lactate dehydrogenase (LDH) over 600 IU/1 Ranson criteria are generally used to assess the severity of acute alcoholic pancreatitis. When 3 or more of following critiria are present on admisson a severe course of complicated pancriatitis with necrosis can be predicted: 1. Age over 55 years 2. White blood cell count over 16,000/ml 3. Blood glucose over 200mg/dl 4. Serum lactic dehydrogenase (LDH) over 350 IU/1 5. Aspartate aminotransferase (AST) over 250 IU/1 The development of the following in the first 48 hours indicate a worsening prognosis: 1. Haematocrit drop of more than 10% points 2. BUN rise greater than 5mg/dl 3. Arterial PO2 of less than 60mm Hg 4. Serum Ca-H- of less than 8mg/dl 5. Base deficit over 4 meq/lit. 6. Estimated fluid sequestration of more than 6 lit. Mortality rates correlate with the number of criteria present: Number of criteria Mortality rate 0-2 1% 3-4 16% 5-6 40% 7-8 100% |
| Management | Management: Management of a patient with severe acute pancreatitis requires immediate hospitalization & resuscitation in intensive care unit (if available). Close follow-up & assessment of condition is also essential. 1. Bed rest & bowel rest - bed rest, nothing by mouth, nasogastric suction (if severe pain, vomiting, paralytic ileus or abdominal distention). 2. I/V fluid - for maintenance of fluid and electrolyte by isotonic fluid and plasma. 1-2 litres normal saline and then 4 litres of plasma in first 24 hours. 3. Parenteral nutrition- a total parenteral nutrition should be considered in sever pancreatitis with paralytic ileus, for at least 7-10 days. Enteral nutrition via a nasojejunal feeding tube is preferable in the absence of ileus.i-2 4. Antibiotics - one course of appropriate antibiotic should be given in susceptible pancreatic infection or in sterile necrotizing pancreatitis to reduce the risk of infection, such as- Imipenem (500mg i.v 8 hourly) or Cefuroxime (l.5gm i.v 8 hourly, than 250mg orally twice daily)!. 5. Analgesics - pethidine 50-100mg may be given i.m or i.v. 6. 02 therapy - hypoxic patients and patients who develop acute respiratory distress syndrome (ARDS). 7. Correction of renal insufficiency - if poor renal output (<30ml/m) persists inspite of adequate fluid replacement, then give manitol or frusemide for increased diuresis. 8. Correction of hypocalcaemia - addition of plasma protein (albumin) & 10ml of cal. gluconate i.v. 9. If shock present- treatment should be given accordingly. 10. When symptoms subside, a low-fat diet may be given by mouth. 11. ERCP- Patients with severe acute pancreatitis associated with cholangitis or jaundice, should undergo urgent ERCP to diagnose & treat choledocholithiasis (if any). In less severe cases, ERCP may be done after acute phase is over. 12. Prophylaxis of thromboembolism - a low-dose heparin injection may be given subcutaneously. 13 .Indications for surgery - a. When conservative treatment fails b. Pancreatic abscess or pseudocyst c. With cholecystitis and cholelithiasis d. Relief of obstruction & drainage (if ERCP fails) e. Cholangitis. |
| Introduction | Acute pancreatitis is an acute inflammatory condition of pancreas & subsequent involvement of surrounding structures, presenting typically with abdominal pain, and often associated with raised pancreatic enzymes in the blood or urine. It is thought that, acute pancreatitis is a consequence of premature activation of pancreatic enzymes and its escape from acinar cells into surrounding tissues. The released proteases then digest the pancreatic tissues itself and tissues of adjacent structures. Commonly involved organs are common bile duct, duodenum, transverse colon & splenic vein. Most cases are related to biliary tract disease or heavy alcohol intake, but the exact pathogenesis in not known. About 80% of acute pancreatitis patients are mild with a mortality rate less than 5%; 98% of deaths occur in the 20% of severe patients. Average mortality rate is about 10% in all cases of acute pancreatitis. |
| History | |
| Etiology | Etiology : Common causes: 1. Biliary disease or gallstones (50% cases) 2. Alcoholism (20%) 3. Unknown causes (20%) Rare causes: 4. Organ transplantation - renal or liver transplantation. 5. Trauma or surgery - abdominal trauma, surgery, ERCP etc. 6. Drugs- corticosteroids, sulfonamides, thiazides, oral contraceptives, azathioprine, sodium valproate 7. Metabolic- hyperthyroidism, hyperlipidaemia. 8. Infections - mumps, coxsackie virus 9. Renal failure 10. Hereditary |
| Clinical Features | Clinical feature : Symptoms: 1. Pain in the epigastrium or bypochondrium associated with nausea and vomiting following consumption of alcohol or heavy meal. 2. Pain is persistent and radiates to the back, shoulder, iliac fossa & then whole abdomen. 3. Shock may present (as in late stage). 4. Pain may decrease while leaning forward (such as- during mohamedan’s prayer position). Signs: Thready pulse, hypotension, hurried respiration, abdominal rigidity and tenderness. Jaundice may present. Signs of shock as cold clammy skin may be present in late stage. |
| Preventions | |
| Treatment | |
| Complications | Complications: 1. Shock & renal failure. 2. Chronic pancreatitis. 3. Pancreatic abscess or pseudocyst. 4. Pancreatic ascites or pleural effusion. 5. Diabetes mellitus. 6. Hypoxia due to acute respiratory distress syndrome or pulmonary oedema. 7. Duodenal obstruction. 8. Obstructive jaundice. 9. Hyperglycaemia (due to altered insulin/glucagon secretion axis). 10. Hypocalcaemia (sequestration of Ca++ in fat necrosis). 11. Hypoalbuminaemia (due to increased capillary permea-bility). |
| Prognosis | |
| Types | |
| Classification | |
| Observation | |
| Pathology |
© Pakistan Drug Directory. All Rights Reserved.
Designed By: Pakistan Drug Directory Team