TOC | GI
Sx of pancreatitis:
increased serum amylase & lipase, marked increased peritoneal or pleural fluid amylase > 1500 u/dL; leukocytosis, hyperglycemia, hypocalcemia (in 25% of pts), hyperbilirubinemia (in 10% of pts), transient elevation of LFT, decreased albumin, hypoxemia (in 25% of pts); ECG occasionally show ST-segment & T-wave abnormalities simulating myocardial ischemia. Plain abd. x-ray may show ileus, GB stone, or pancrease calcification; ultrasound of abd; Abd. CT scan; ERCP findings; pancreatic biopsy with US or CT guidance.
abd. pain, N&V, fever, tachycardia, elevated amylase & lipase, leukocytosis.
Diff-DX: See also
Perforated PUD or viscus, acute cholecystitis & biliary colic, acute intestinal obstruction, mesenteric vascular occlusion, renal colic, myocardial infarction, dissecting aortic aneurysm, connective tissue disorders with vasculitis, pneumonia, diabetic keoacidosis.
CAUSES of Pancreatitis:
Factors adversely affecting survival in acute pancreatitis:
LOCAL COMPLICATIONS of acute
RX of acute pancreatitis:
Contrast-Enhanced CT scan provides valuable information on the severity & prognosis of acute pancreatitis:
Grade of Acute Pancreatitis:
Degree of Pancreatic Necrosis:
Pts with CT severity index scores of 3-6 are unlikely to have prolonged pancreatitis or a serious cojplication is negligible. Pts with scores of 7-10 had a 92% morbidity & 17% mortality. A CE-CT scan is indicated in pts with 3 or more Ranson's signs, in all seriously ill pts, & in pts who show evidence of clnical deterioration.
Laparotomy with adequate drainage & removal of necrotic tissue should be considered if conventional Rx does not halt the pt's deterioration.
Pts with severe fallstone-induced pancreatitis may improve dramatically if paipillotomy is carried out within the first 36-72 h of the attack.
It should be suspected if abd. pain, fever, leukocytosis, & hyperamylasemia persist for >5days & esp. if an abd. mass is also present. Occasionally, extensive necrosis develops in phlegmons & require incision & drainage, esp. if infected. Phlegmons also may be secondarily infected, resulting in abscess in 10% of pts. The early dx of pancreatic infection can be accomplished by CT-guided needle aspiration.
The characteristic signs of abscess are fever, leukocytosis, ileus, and rapid deterioration in a pt initially recovering from pancreatitis. Drainage of pancreatic abscesses by nonsurgical percutaneous catheter techniques under CT-guidance has 50-60% resolution rate. Accordingly, laparotomy with radical sump drainage & possibly resection of necrotic tissue is usually required because the mortality rate for undrained pancreatic abscess approaches 100%. Multiple abscesses are common.
Pancreatic Pseudocysts are collections of tissue, fluid, debris, pancreatic enzymes, & blood which develop over a period of 1-4 weeks in approximately 15% of pts. They do not have epithelial lining. Abd. pain is the usual presenting complaint. a palpable, tender mass may be present. The serum amylase is elevated in 75% of pts. Sonogram is reliable in detecting pseudocysts. CT scan complements the use of sonogram in the dx of pseudocyst, esp. when it is infected. They resolved in 25-40% of pts. Those >5cm & that persist for >6weeks rarely disappear.
The complications of pseudocysts are: pain caused by expansion of the lesion & pressure on other viscera, rupture with peritonitis & shock, hemorrhage (triad of findings: increase in mass size, localized bruit over the mass, & a sudden decrease in Hgb & Hct without obvious signs of external blood loss), & abscess.
Sterile chronic pseudocysts can be treated safely with single or repeated needle aspiration or more prolonged catheter drainage with 45-75% success rate. Pts not responding to drainage require surgical Rx with internal or external drainage of the cyst.
Pseudoaneurysms develop in up to 10% of pts with acute pancreatitis, involving splenic artery, followed by the inferior & superior pancreatic duodenal arteries. The dx should be suspected in pts with pancreatitis who develop either UGI bleeding without an obvious cause in in whom a contrast-enhanced lesion is demonstrated within or adjacent to a suspected psudocyst as determined by thin-cut CT scan. Arteriography is ncecessary to confirm the dx.
Pancreatic Ascites & Pancreatic Pleural Effusions
Pancreatic ascites is usually due to disruption of the main pancreatic duct, or a leaking pseudocyst. The dx is suggested by elevated serum amylase, elevated ascitic fluid amylase & albumin >3.0 g/dL. In addition, ERCP will often demonstrate passage of contrast material from a major pancreatic duct or a pseudocyst into the peritoneal cavity. The diff-dx include intraperitoneal carcinomatosis, TB peritonitis, constrictive pericarditis, & Budd-Chiari syndrome.
Rx of pancreatic ascites inludes NG suction & PIN., paracentesis. Octreotide which inhibits pancreatic secretion is also useful in pancreatic ascites & pleural effusion. If ascites continues to recur after 2-3 weeks of med. Rx, surgery following pancreatography to define the anatomyh of the abnormal duct should be done.