Acute pancreatitis is a distressing condition characterized by severe abdominal pain and inflammation of the pancreas. It can have various causes, including gallstones, alcohol consumption, trauma, and certain medical conditions. In this comprehensive guide, we will explore the etiology, clinical features, examination findings, diagnostic investigations, and management strategies for acute pancreatitis. Whether you're seeking information for personal knowledge or researching for a medical assignment, this blog post will provide valuable insights into this acute abdominal condition.
Etiology of Acute Pancreatitis:
Acute pancreatitis can arise from various factors, including:
1. Biliary calculi (50-70%): The presence of gallstones in the biliary system increases the risk of acute pancreatitis.
2. Alcohol (25%): Excessive alcohol consumption can lead to the development of pancreatitis.
3. Post ERCP (1-3%): In some cases, endoscopic retrograde cholangiopancreatography (ERCP) may result in acute pancreatitis.
4. Trauma: Physical trauma to the abdomen or pancreas can trigger the onset of pancreatitis.
5. Surgical procedures: Certain surgeries involving the biliary, upper gastrointestinal, or cardiothoracic regions may lead to pancreatitis.
6. Other causes: These include ampullary tumors, certain drugs (such as corticosteroids, azathioprine, and thiazides), hyperparathyroidism, pancreas divisum, viral infections (e.g., mumps, coxsackie B), malnutrition, scorpion bites, and idiopathic cases.
Clinical Features and Examination Findings:
Acute pancreatitis presents with distinct clinical features, including:
1. Severe abdominal pain: The pain typically originates in the epigastric region but may radiate to the back. It is sudden, progressive, constant, and refractory to analgesics.
2. Nausea and vomiting: Patients may experience repeated vomiting and retching, even if their stomach is empty.
3. Physical signs: Examination may reveal a gravely ill appearance, profound shock, tachypnea, tachycardia, and hypotension. Abdominal distension and muscle guarding in the upper abdomen may also be observed.
Additionally, certain findings may indicate complications or specific causes of pancreatitis, such as mild icterus in cases of biliary obstruction, acute swinging pyrexia in cholangitis, and bluish discoloration of flanks (Grey Turner's sign) or umbilicus (Cullen's sign). Subcutaneous fat necrosis and small red tender nodules on the skin of the legs may also be present.
Diagnostic Investigations:
To confirm the diagnosis and assess the severity of acute pancreatitis, the following investigations are commonly employed:
1. Imaging (CT, MRI, or Ultrasonography): These imaging techniques are used to detect gallstones, choledocholithiasis, and local complications. They also aid in determining the degree and extent of necrosis.
2. Amylase and Lipase Levels: Elevated levels of amylase and lipase in the serum support the diagnosis of acute pancreatitis.
Effective Management Strategies:
To properly manage acute pancreatitis, a multidisciplinary approach is crucial. Key management strategies include:
1. Resuscitation: Fluid resuscitation is essential to maintain adequate urine output and perfusion. Intravenous fluids are administered to address fluid and electrolyte imbalances.
2. Pain Management: Analgesics, including opioids, are prescribed to alleviate severe abdominal pain.
3. Nutritional Support: Enteral feeding is initiated within 48 hours to provide necessary nutrients and
promote healing. Nasojejunal feeding may be considered.
4. Prognostic Scoring: Various scoring systems (e.g., BISAP, RANSON, APACHE-II) help assess the severity of pancreatitis and guide treatment plans.
5. Antibiotics: If infection is suspected, empirical antibiotic therapy may be initiated.
6. Radiology-Guided Interventions: Percutaneous catheter drainage, guided by ultrasound or CT, is helpful in managing necrosis and can serve as bridging therapy until surgical management.
7. ERCP: Endoscopic retrograde cholangiopancreatography is performed within 72 hours if there is cholangitis or severe acute pancreatitis with persistent obstruction.
8. Surgical Intervention: Surgery may be necessary in cases of severe necrosis unresponsive to conservative management, pseudoaneurysm with bleeding, infected necrosis, pancreatic abscess, or bowel perforation.
Conclusion:
Acute pancreatitis is a serious condition that requires prompt recognition, accurate diagnosis, and appropriate management. By understanding the etiology, recognizing clinical features, conducting diagnostic investigations, and implementing effective treatment strategies, healthcare professionals can optimize patient outcomes. If you or someone you know experiences severe abdominal pain, it is important to seek immediate medical attention to determine the underlying cause and receive timely treatment. Remember, early intervention and multidisciplinary care are key to managing acute pancreatitis successfully.
Notes :
Etiology
- Biliary calculi ( 50-70%)
- Alcohol ( 25%)
- Post ERCP(1-3%)
- Trauma
- Billiary , upper GI , Cardio thoracic surgery
- Ampullary tumor
- Drugs ( corticosteroids, azathioprine, asparaginase , valproic acud , thiazides , oestrogen)
- Hyperparathyroidism
- Pancreas divisium
- Hypercalcemia
- Autoimmune Pancreatitis
- Hereditary Pancreatitis
- Viral ( mumps, coxsackie B)
- Malnutrition
- Scorpion bite
- Idiopathic (20%)
- Small gallstones and wide cystic duct - higher risk of passing stones. If etiology gallstones , cholecystectomy is done during same admission.
- Alcohol toxicity concomitant tobacco smoking hypersecretion duct obstruction hyperlipidemia.
- Duct disruption, enzyme extravasation
- Hereditary Pancreatitis - mutation of hereditary cationic trypsinogen gene. Acute pancreatitis in teens , chronic in next two decades , 40% cancer by the age 70
Clinical Feature
- Experienced firstly on epigastrium ( may be localized to any upper quadrant or diffusely throughout the abdomen), Sudden ( within minutes) , progressive , continuous ( even days) , severe , constant , refractory to analgesic ,
- Radiation of pain to the back ( 50% ) , relieved by sitting is leaning forward
- Dd Peptic ulcer perforation , biliary colic or acute cholecystitis , MI , pneumonia , pleuritic pain
- Nausea , repeated vomiting, retching( even in an empty stomach with NG tube), hiccough( gastric distension , diaphragm irritation)
- Mild icterus in biliary obstruction
- Acute swinging pyrexia - cholangitis
- Bluish discoloration of flanks- Grey Turner's sign / umblical - cullen's sign
Cullen's sign in ectopic pregnancy rupture
- Subcutaneous fat necrosis , small red tender nodules on skin of legs
Examination
- Gravely ill, profound shock, toxicity, confusion.
- Tachypnea , tachycardia , hypotensive.
- Temperature may rise due to increase inflammation.
SIRS - presence of two or more of following criteria
- Heart rate - >90/ min
- Core temperature <36° or >38°C
- Respiration - >20/ min or pCO² <32 mmHg
- WBC <4000 or 12000/mm³
- Distended abdomen d/t ileus or ascites
- Mass in epigastrium can develop due to inflammation
- Muscle guarding in the upper abdomen
Mnemonics
Investigations:@iPA-NCREAS
Imaging (CT, MRI or Ultrasonography)
Prognostic screen to identify severe pancreatitis
Amylase and lipase levels
Initial treatment:
Nutritional support
Cholecystectomy if suspected/proven gallstone pancreatitis
Resuscitation of fluids
ERCP within 72 hours of pain onset if gallstone pancreatitis
Antibiotics
Supplemental oxygen
PANCREAS
Perfusion:Fluid resuscitation to maintain urine output 0.5-1 ml/kg/hr
Oxygenation in order to maintain SpO2 >95% in severe pancreatitis
Analgesia: including opioids
Nutrition: Enteral feeding within 48 hours (+/- nasojejunal feeding)
Clinical: Prognostic scoring e.g. BISAP, RANSON, APACHE-II
Radiology:
USG: to detect gallstones, choledocholithiasis and local complications
CECT: after 48-72 hours of pain onset to determine degree and extent of necrosis
Percutaneous catheter drainage guided by USG or CECT is helpful in management of necrosis and as bridging therapy until surgical management
ERCP: with 72 hours if cholangitis or severe acute pancreatitis with persistent obstruction
Antibiotics: Empirical antibiotics if infection is suspected
Surgery: for –
MODS with necrosis unresponsive to conservative management and percutaneous drainage
Pseudo-aneurysm of surrounding vessels with bleeding
Infected necrosis
Pancreatic abscess
Bowel perforation