ACUTE PANCREATITIS Part 01

Causes ( I GET SMASHED ) I diopathic: 3rd most common - thought to be hypertensive sphincter or microlithiasis G allstone...

Causes ( I GET SMASHED)

1. Idiopathic: 3rd most common - thought to be hypertensive sphincter or microlithiasis
2. Gallstones (45%)
3. Ethanol (35%)
4. Tumors: pancreas, ampulla, choledochocele
5. Microbiological
   • Bacterial: mycoplasma, Campylobacter, TB, MAI, legionella,eptospirosis
   • viral: mumps, rubella, varicella, viral hepatitis, CMV, EBV,HIV, Coxsackievirus, echo virus, adenovirus
   • parasites: Ascariasis, Clonorchiasis, Echinococcosis
6. Autoimmune: lupus, PAN, Crohnís
7. Surgery/trauma
   • manipulation of sphincter of Oddi (e.g. ERCP), post-cardiac surgery, blunt trauma to abdomen, penetrating peptic ulcer
8. Hyperlipidemia (TG >11.3 mmol/L), hypercalcemia, hypothermia
9. Emboli or ischemia
10. Drugs/toxins: azathioprine, mercaptopurine, DDI, furosemide, estrogens, H2 blockers, valproic acid, antibiotics, acetaminophen,
    methyldopa, salicylates, ethanol, methanol, organophosphates

 

Pathology

 

Mild

1. peripancreatic fat necrosis
2. interstitial edema 

 

Severe

1. extensive peripancreatic and intrapancreatic fat necrosis
2. parenchymal necrosis and hemorrhage --->  infection in 60%
3. release of toxic factors into systemic circulation and peritoneal space 
4. severity of clinical features may not always correlate with pathology

Presentation

 

Clinical:

 

1. patient can look well or pre-morbid!
2. pain: epigastric, noncolicky, constant, can radiate to back, may  improve when leaning forward (Inglefinger's sign); tender rigid abdomen; guarding
3. nausea and vomiting
4. abdominal distension from paralytic ileus
5. fever: chemical, not due to infection
6. jaundice: compression or obstruction of bile duct
7. Tetany: transient hypocalcemia
8. hypovolemic shock: can lead to renal failure
9. adult respiratory distress syndrome
   • breakdown of phospholipase A2
10. coma 
11. body wall ecchymoses occur, around the umbilicus (Cullen's sign) or in the flanks (Grey Turner's sign)

 

 

Laboratory

1. increased pancreatic enzymes in blood
   • increased amylase: sensitive but not specific
   • increased lipase: > sensitivity and specificity - and stays elevated longer
2. increased WBC
3. imaging
4. x-ray: “sentinel loop” (dilated proximal jejunem), calcification and “colon cut-off sign” (colonic spasm)
5. U/S: best for evaluating biliary tree (67% SENS, 100% SPEC)
6. C/T scan with IV contrast: useful prognostic indicator because contrast seen only in viable  pancreatic tissue.  Non-viable areas can be biopsied percutaneously to diagnose infected pancreatic necrosis
7. ERCP + manometry: if no cause found

 

Course

1. usually a benign, self-limiting course, single or recurrent
2. occasionally severe leading to
   • shock
   • renal and pulmonary insufficiency
   • pancreatic abscess
   • coagulopathy
   • hyperglycemia and hypoglycemia
   • GI ulceration due to stress
   • death
3. functional restitution to normal occurs if primary cause and complications are eliminated (exception: alcohol)
4. occasional persistence of scarring and pseudocysts
5. rarely does chronic pancreatitis ever develop