Acute pancreatitis

USG finding in acute pancreatitis

- Can see pancreatitis with edema and peripancreatic effusion

Symptoms of acute pancreatitis

1) Severe epigastric pain that radiates to back -worse with lying down, eating fatty food, alcohol -relief with leaning forward 2) Anorexia, nausea, vomiting 3) Low grade fever 4) Pale stool, dark urine 5) Diminished bowel sounds

Ranson's score 3-4

15% mortality

Ranson's score 0-2

2% mortality

When does acute necrotizing pancreatitis usually occur?

2nd-3rd week after onset of disease

Ranson's score 5-6

40% mortality

2 Common cause of acute pancratitis

Alcohol and Gallstones

What is ERCP used for?

Allows identification and removal of common bile duct stones in suspected gallstones pancreatitis [performed only in setting of ongoing biliary obstruction and cholangitis]

When do we opt for surgery in acute pancreatitis?

Indication for surgery -Definitive dx cant be made [peritoneal lavage] -Pancreatic necrosis [debridement, lavage and drainage] -Pancreatic abscess

Mild acute pancreatitis

No organ failure, no local or systemic complications

Glasgow Imrie scoring

PANCREAS Pa02 < 60 mmHg Age > 55 Neutrophils (WBC) > 15 x 10^9/l Calcium < 2 mmol/l Raised urea >16 mmol/l Enzyme (LDH) >600 units/l Albumin < 32 g/l Sugar (glucose) > 10 mmol/l More than 3/8 positive ---> Severe

What is CECT used for in acute pancreatitis?

To look up for necrosis

DDx for Acute Pancreatitis

Gastroenteritis PUD Appendicitis Perforated ulcer Small bowel obstruction Ruptured AAA

Etiology of acute pancreatitis

I GET SMASHED Idiopathic Gallstones Ethanol ( Alcohol) Trauma Scorpion bite Mumps Autoimmune Steroids Hyperlipidemia ERCP Drugs like azathioprine , thiazide , valproic acid , sulphasalazine

What is CECT finding in acute pancreatitis?

If there is necrosis, the image wont "light up" However necrosis may not appear in initial 48-72hr

Moderately severe acute pancreatitis

- Transient organ failure [resolves in 48hrs] and or -Local or systemic complication without persistent organ failure

Signs of acute pancreatitis

-Mid epigastric tenderness and fullness (Paralytic ileus) -Cullen's sign : periumbilical discolouration -Grey turners sign : discolouration of flanks -Fox's sign : discolouration around inguinal ligament -Epigastric guarding -Pleural effusion

Early management for severe acute pancreatitis?

-NPO -Admit ICU (48hr observation) -Analgesic: Opiod [pethidine, tramadol] -Antiemetics -IV fluid -O2 supplemental -Monitor biochem parameters -ANTIBIOTICS ONLY IF CHOLANGITIS SUSPECTED -CT is a must if organ failure suspected -ERCP within 72hr for severe gallstones

Severe acute pancreatitis

-Organ failure [persistent, >48hrs] -Single organ failure -Multiple organ failure

Lab investigations of Acute pancreatitis

-WBC increase -HCT [inc in dehydration/dec in hemorrhage] -ABG: met & resp acidosis, hypoxia -Urinary amylase increase -Serum :- *Lipase inc x 2 (more specific & sensitive) *Amylase inc x 3( less specific ) *BUN, creatinine inc *Liver enzyme , bilirubin inc *CRP inc *Glu inc !! Ca2+ decrease !! Imaging: X ray, USG, CECT, ERCP

How many scoring system are there in acute pancreatitis?

1. BISAP score (the best) 2. Glasgow-Imrie 3. Balthazar 4. Ranson's

AXR finding in acute pancreatitis

1. Sentinel loops -non-functioning & aperistaltic dilatation of jejunum/ileum due to its location near to inflammed pancreas 2. Colon cut off sign

Ranson's score 7-8

100% mortality

What is the classification for acute pancreatitis?

Atlanta classification -Mild acute pancreatitis -Moderately severe acute pancreatitis -Severe acute pancreatitis

What is the BISAP score?

Bedside Index for Severity of Acute Pancreatitis

Ranson's criteria after 48 hrs

C HOBBS •Calcium < 8.0 mg/dL •Hematocrit drop of > 10% •Oxygen (hypoxemia PaO2 < 60 mmHg) •BUN increased by 5 or more mg/dL after IV fluid hydration •Base deficit (negative base excess) > 4 mEq/L •Sequestration of fluids > 6 L

What is the Balthazar score used for in acute pancreatitis?

CT severity index

Ranson's criteria on admission

GA LAW (Georgia law) • glucose >200 •Age >55 •LDH >350 •AST >250 •WBC >16,000

How to assess severity of acute pancreatitis?

Ranson's scoring

Complications of acute pancreatitis

Shock due to peripancreatic hemorrhage, Pancreatic PSEUDOcyst - just lined by fibrous tissue surrounding the liquefactive necrosis and enzymes.(Causes persistent elevation of amylase), DIC and ARDS(enzymes can activate coagulation, can also destroy lung tissue if they get into blood)

What is ERCP finding in gallstone pancreatitis ?

Slightly dilated common bile duct with calculus , normal pancreatic duct

Balthazar scoring

TOTAL SCORE = CT grade + Necrosis 0-3 : 3% mortality 4-6 : 6% mortality 7-10 : 17% mortality

pathology of acute pancreatitis

injury to acinar cells intrapancreatic premature activation of proteolytic enzyme leads to auto-digestion of pancreas leading to inflammation and edema