Acute pancreatitis

Acute pancreatitis

Etiology– Gallstone(<0.5cm), ethanol, hyperlipidemia, hypocalcemia, infection, drug, trauma, ERCP, vasculitis, ishemia, CFTR, PRSS1, SPINK1

Presentation– Epigastric pain. nausea, vomiting, knee-chest position relief pain, Cullen’s sign, Grey Turner’s sign

Lab– Amylase(6~12hrs elevated, 3~5 days subsided), lipase(4~8hrs elevated, day 1 reach the peak, 8~14 days subsided), Trypsinogen activation peptide (TAP)

KUB– Colon cut off sign(bowel gas of descending colon dissappears), sentinel loop

Ultrasound– Enlarged, hypoechoic, peripancreatic fluid

CT– Enlargement

Diagnosis– Pain characteristic, enzyme, image, 2 of these

DDx– Peptic ulcer, cholecystitis, cholangitis, hepatitis, perforated viscus, intestinal obstruction, mesenteric ischemia

Local complication

1.Acute peripancreatic fluid collection(APFC)- <4wks, 7~10 days self-limited

2.Acute necrotic collection(ANC)- <4wks, may infect

3.Pancreatic pseudocyst- >4wks, Most common

4.Walled-off necrosis(WON)- >4wks, may infect

Infected necrosis– presence of gas within the necrosis, carbapenam, quinolone, ceftazidime, cefepime+metronidazole, necrosectomy

Sterile necrosis– Indications for intervention(intestinal obstruction, 4~8wks)(persistent symptoms, >8wks)(disconnected dust syndrome, >8wks)

Peripancreatic complication:

1.Splanchnic venous thrombosis

2.pseudoaneurysm- bleeding

3.Abdominal compartment syndrome- >20mmHg

Systemic complication

Organ failure– transient(<48hrs), persistent(>48hrs), Modified Marshall scoring system for organ dysfunction(>=2 score)

Management:

1.Fluid-  5 to 10 mL/kg per hour(N/S, lactated ringer)→  20ml/Kg over 30 mins → 3 mL/kg/hour for 8 to 12 hours, → Observe U/O, HR, BUN

2.Pain control- Hydromorphone or fentanyl, meperidine

3.Monitor- SaO2>95, UO>0.5 to 1 cc/kg/hour, Hypocalcemia, glucose>200mg/dL

4.Nutrition- oral, enteral, TPN, low-residue, low-fat, and soft diet

Atlanta classification– Interstitial edematous acute pancreatitis, Necrotizing acute pancreatitis

Severity: Mild acute pancreatitis(no organ failure, local complication, systemic complication), Moderately severe acute pancreatitis: transient organ failure/local/systemic complication

Severe acute pancreatitis: persistent organ failure

Scoring system:

1.Ranson criteria- <3(0~3%), >=3(11~15%), >=6(40%)

2.APACHE II score- <8(<4%), >8(11~18%)

3.SIRS score

4.BISAP score- 0(<1%), 5(22%)

5.CT severity index(CTSI)- >=6/10 was severe disease

Glu>200Age>55LDH>350AST>250WBC>16000
Base deficit>4BUN>5Sequestration>6LCa<8Hct↓>10%PaO2<60

*Hemosuccus pancreaticus- Pancreatitis causes splenic artery pseudoaneurysm bleed into pancreatic duct

Published by Steve Johnson

I am a doctor who like to organise knowledges and share ideas with others. As a doctor, a lot of knowledges influx everyday and need some patient to organise and absorb. Here was my notes to share with you and hope to save your time to know it.

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