Acute Pancreatitis

By Baskarapandian Santhosh Babu

Patient data
Name: Alexander Alexanderovich
Age: 50
Residence: 50, Semeonskaya, Vladivostok
History
The patient presents to the emergency department with vomiting and epigastric
pain which radiates through to the back. The pain was of gradual onset, coming
on over the last 2 days. He denies any previous episodes. He is not on any
regular medication but admits to drinking more than eight cans of lager a day.
He is a heavy smoker but denies any recreational drug use. He is homeless and
relates his heavy drinking to depression.
Examination
The patient is sweaty and agitated. He says he is unable to lie flat for the
examination and vomits persistently. His blood pressure is 150/80 mmHg, and
he has a pulse rate of 120/min. Palpation of his abdomen reveals tenderness in
the epigastrium. The abdomen is not distended, and he has normal bowel
sounds. Rectal examination is unremarkable.
Physical Examination
Appearance of the patient
 Patient appears to be pale and in distress because of the abdominal pain.
Vitals
Temperature
 Elevated body temperature is present.
Pulse Rate
 Tachycardia may be present.
Rhythm
 The pulse is regular.
Strength
 The pulse may be weak.
Blood Pressure
 Hypotension may be present.
Respiratory Rate
 Tachypnoea may be present.
Skin
 Grey-Turner's sign - hemorrhagic discoloration of the flanks.
 Cullen's sign - hemorrhagic discoloration of the umbilicus.
 Grünwald sign - appearance of ecchymosis, large bruise, around the
umbilicus due to local toxic lesion of the vessels.
 Jaundice may be present.
 Pallor may be present.
 Erythematous skin nodules of size less than 1 cm may be seen due to
subcutaneous fat necrosis.
Eye
 Ischemic changes in the retina on ophthalmoscopic exam - Purtscher
retinopathy. Caused by the activation of complement system.
Lung
 Rapid shallow breaths are seen.
 Reduced breath sounds when auscultated due to possible pleural effusion.
 Basilar rales may be present.
Abdomen
 Abdominal distention may be present.
 Abdominal tenderness may be present.
 Rebound may be present.
 An acute abdomen is present.
 An abdominal mass may be present.
 Guarding is present.
 Körte's sign (pain or resistance in the zone where the head of pancreas is
located (in epigastrium, 6–7 cm above the umbilicus).
 Kamenchik's sign (pain with pressure under the xiphoid process).
  Mayo-Robson's sign (pain while pressing at the top of the angle lateral to
the Erector spinae muscles and below the left 12th rib (left costovertebral
angle (CVA).
 Mayo-Robson's point - a point on border of inner 2/3 with the external
1/3 of the line that represents the bisection of the left upper abdominal
quadrant, where tenderness on pressure exists in disease of the pancreas.
At this point the tail of pancreas is projected on the abdominal wall.
Extremities
 Muscular spasms may be noted - due to hypocalcaemia.
CT Scan
In acute pancreatitis, the CT features range from a normal-appearing pancreas
with no peripancreatic abnormalities to diffuse enlargement and heterogeneous
attenuation of the gland with ill-definition of the border. Peripancreatic
inflammation results in hazy or reticular stranding of the surrounding fat. In up
to 18% of cases, mild pancreatitis demonstrates segmental–focal involvement,
usually of the pancreatic head and uncinate process. This can result in groove
pancreatitis with scar tissue forming in the space between the postcranial part of
the head of the pancreas, the duodenum, and the common bile duct. This focal
pancreatitis is common in patients with a history of chronic alcohol abuse.

Investigation
Haemoglobin 12 g/dL 11.5–16.0 g/dL
 Mean cell volume 102 fL 76–96 fL
White cell count 13.3 109/L 4.0–11.0 109/L
Platelets 310 109/L 150–400 109/L
Sodium 132 mmol/L 135–145 mmol/L
Potassium 4.2 mmol/L 3.5–5.0 mmol/L
Urea 5 mmol/L 2.5–6.7 mmmol/L
Creatinine 72 µmol/L 44–80 µmol/L
Amylase 4672 IU/dL 0–100 IU/dL
Aspartate transaminase 30 IU/L 5–35 IU/L
(AST)
Gamma-glutamyl 212 IU/L 11–51 IU/L
transferase (GGT)
Albumin 25 g/L 35–50 g/L
Bilirubin 12 mmol/L 3–17 mmol/L
Glucose 5 mmol/L 3.5–5.5 mmol/L
Lactate dehydrogenase 84 IU/L 70–250 IU/L
(LDH)
Total serum calcium 2.35 mmol/L 2.12–2.65 mmol/L

Diagnosis
The most obvious abnormal result is the raised amylase, giving a diagnosis of
acute pancreatitis. The history and macrocytosis would suggest this are of
alcoholic aetiology, but it is important to ultrasound the abdomen to exclude
gallstones as the cause. The pain is typically severe and radiates through to the
back, due to the retroperitoneal position of the pancreas. Vomiting is also a
common feature, because of gastric stasis caused by the local inflammation. The
severity of the attack has no relation to the rise in serum amylase. Twenty per
cent of cases of pancreatitis have a normal serum amylase, particularly when
there is an alcoholic aetiology. It is important to exclude a perforated peptic
ulcer in this patient. This should be done with an erect chest X-ray, which
would show free subphrenic air in 90 per cent of cases. The serum amylase can
be elevated in a patient with gastric perforation due to the systemic absorption
of pancreatic enzymes from the abdominal cavity. An amylase rises of over
1000 IU/dL, however, is usually diagnostic of acute pancreatitis. Ranson’s
criteria are used to grade the severity of alcoholic pancreatitis, but it takes 48 h
before the score can be used. Each fulfilled criterion scores a point, and the total
indicates the severity.
On admission:
 age > 55 years
 white cell count >16 *109 L
 LDH >600 IU/L
 AST >120 IU/L
 glucose >10 mmol/L
 fluid sequestration >6 L
Within 48 h:
 haematocrit fall >10 per cent
 urea rise >0.9 mmol/L
 calcium< 2mmol/L
 partial pressure of oxygen (pO2) < 60 mmHg
 base deficit >4
Estimates on mortality are based on the number of points scored: 0–2 = 2 per
cent; 3–4 = 15 per cent; 5–6 = 40 per cent; >7 = 100 per cent
Causes of acute pancreatitis
Common (80 per cent): gallstones, alcohol
Rare (20 per cent): idiopathic, infection (mumps, coxsackie B virus),
iatrogenic
(Endoscopic retrograde cholangiopancreatography [ERCP]), trauma,
ampullary or
pancreatic tumours, drugs (salicylates, azathioprine, cimetidine), pancreatic
structural
anomalies (pancreatic divisum), metabolic (hypertriglyceridaemia, raised
Ca2+),
hypothermia