Dr.Alaa Mohammed Fouad Mousli Surgical Demonstrator Acute pancreatitis Dr.Alaa Mohammed Fouad Mousli Surgical Demonstrator

Acute pancreatitis INTRODUCTION :  Acute pancreatitis is an acute inflammatory process of the pancreas. It is usually associated with severe acute upper abdominal pain and elevated blood levels of pancreatic enzymes. Most cases are associated with alcoholism or gallstones, but the precise pathogenetic mechanisms are not fully understood

Acute pancreatitis can be suspected clinically, but requires biochemical, radiologic, and sometimes histologic evidence to confirm the diagnosis. Clinical, biochemical, and radiologic features need to be considered together since none of them alone is diagnostic of acute pancreatitis

Etiology: Gallstones and alchohol are by far the most common etiologies accounting for more than 90% of cases of acute pancreatitis. 1- Gallstones 2- Alchohol 3-Hyperlipidemia (types 1, 4, 5,) 4- Hypercalcemia 5-Trauma ( eternal biunt trauma, post opreative, or by ERCP) 6-Ischemia e.g (shock, emboli, vasculitis,….etc) 7- pancreatic duct obstruction 8- drugs ( estrogens, thiazide, furosomide, tetracyclin,….) 9- infections ( mumbs, hepatitis B, cytomegalovirus, mycoplasma) 10- Scorpion bitee 11- Familial 12- Idiopathic

Clinical features  Symptoms — Almost all patients with acute pancreatitis have acute upper abdominal pain at the onset .The pain is steady and may be in the mid-epigastrium, right upper quadrant, diffuse, or, infrequently, confined to the left side. Biliary colic, which may herald or progress to acute pancreatitis, may occur postprandially. On the other hand, acute pancreatitis related to alcohol frequently occurs one to three days after a binge or cessation of drinking

The abdominal pain is typically accompanied (in approximately 90 percent of patients) by nausea, vomiting, and anorexia which may persist for many hours. Restlessness, agitation, and relief on bending forward are other notable symptoms. Patients with fulminant attacks may present in shock or coma. The pain of acute pancreatitis is usually severe enough to require a visit to the emergency department and admission to the hospital.

Physical examination  Physical findings vary depending upon the severity of an attack. Systemic features include fever, tachycardia, and, in severe cases, shock and coma. In mild disease, the epigastrium may be minimally tender. However, severe episodes are often associated with abdominal distention, especially in the epigastrium, and tenderness and guarding, which are less than expected from the intensity of the patient's discomfort. Respirations may be shallow due to diaphragmatic irritation from inflammatory exudate, and dyspnea may occur if there is an associated pleural effusion.

Ecchymotic discoloration in the flank (Grey-Turner's sign) or the periumbilical region (Cullen's sign) occurs in 1 percent of cases but is not diagnostic. These signs reflect intraabdominal hemorrhage and are associated with a poor prognosis. Obstruction of the common bile duct, due to choledocholithiasis or edema of the head of the pancreas, can lead to jaundice.

Ecchymotic discoloration in the flank (Grey-Turner's sign) or the periumbilical region (Cullen's sign) occurs in 1 percent of cases but is not diagnostic. These signs reflect intraabdominal hemorrhage and are associated with a poor prognosis. Obstruction of the common bile duct, due to choledocholithiasis or edema of the head of the pancreas, can lead to jaundice. An epigastric mass due to pseudocyst formation may become palpable in the course of the disease.

There may also be findings indicative of underlying disorders such as hepatomegaly in alcoholic pancreatitis, xanthomas in hyperlipidemic pancreatitis, and parotid swelling associated with mumps.

LABORATORY TESTS 1-Pancreatic enzymes: Ther is early rise in serum concentrations of pancreatic digestive enzymes in acute pancreatitis. *Serum and urinary amylase — Serum amylase is the most frequently ordered test to diagnose acute pancreatitis. It rises within 6 to 12 hours of onset, and is cleared fairly rapidly from the blood (half-life approximately 10 hours). In uncomplicated attacks, serum amylase is usually elevated for three to five days. An elevated serum amylase level is a nonspecific finding because it occurs in a number of conditions other than acute pancreatitis (Pancreatic trauma, carcinoma, pseudocyst, ascitis, and abcess). The serum amylase concentration in acute pancreatitis is usually more than three times the upper limit of normal. However, the serum amylase may be normal or minimally elevated

*Serum lipase : the magnitude of increase in serum lipase above upper normal reference limits can vary widely depending upon the method used. The sensitivity of serum lipase for the diagnosis of acute pancreatitis ranges from 85 to 100 percent in various reports [13]. Lipase measurement is more specific than serum amylase and urinary total amylase in diagnostic accuracy both on day one and day three.

Radiological procedures 1- Chest radiography: findings suggestive but not specific for acute pancreatitis include left pleural effusion, elevated left hemidiaphragm, or basilar atelectasis. 2- Abdominal radiograph (non specific findings): *Most frequently air in a dilated loop of intestine adjacent to the pancreas. *Sentinil loop sign *colon cut-off sign *non specific ileus pattern *Others: Cholelithiasis, loss of psoas margins, pancreatic calcifications. 3-abdominal Ultrasound: usefull in the evaluation of gallstones and pseudocyst.

4- CT Scan: More sensitive and specific Dynamic CT (contrast enhanced) is more preferred because it can identify pancreatic perfusion, ischemia, and necrosis. The severity of acute pancreatitis has been classified into five grades based upon findings on unenhanced CT Grade A — Normal pancreas consistent with mild pancreatitis Grade B — Focal or diffuse enlargement of the gland, including contour irregularities and inhomogeneous attenuation but without peripancreatic inflammation Grade C — Abnormalities seen in grade B plus peripancreatic inflammation Grade D — Grade C plus associated single fluid collection Grade E — Grade C plus two or more peripancreatic fluid collections or gas in the pancreas or retroperitoneum

5- ERCP: Contraindicated in the diagnosis of acute pancreatitis; indicated after resolution of the recurrent disease if anatomical abnormality suspected.