Life threatening causes of pain abdomen / Acute pancreatitis

DR R PADHI

Location of Mode of Onset Associated Physical Pain and Prior and Type of Gastrointestina Examination Attacks Pain l Symptoms Acute Periumbilical Insidious to Anorexia Low-grade appendicitis or localized acute and common; fever, generally to persistent nausea and epigastric right lower vomiting in tenderness abdominal some initially; later, quadrant right lower quadrant

Disease

Life threatening causes of pain abdomen

Perforated Epigastric; duodenal history of ulcer ulcer in many

Abrupt onset; steady

Anorexia; nausea and vomiting

Intestinal obstruction

Diffuse

Sudden onset; Crampy

Vomiting common

Acute Epigastric pancreatitis penetrating to back

Acute; persistent, dull, severe

Anorexia; nausea and vomiting common

Helpful Tests and Examinations Slight leukocytosis; CT scan of the abdomen or ultrasound of the appendix may be helpful if diagnosis is uncertain Epigastric Upright tenderness; abdominal Xinvoluntary ray shows air guarding under diaphragm; CT scan Abdominal Dilated, fluiddistention; filled loops of high-pitched bowel on rushes abdominal Xray Epigastric Elevated serum tenderness lipase; CT scan shows pancreatic inflammation

.Acute pancreatitis Acute pancreatitis is defined as an inflammatory process that occurs in a gland that was morphologically and functionally normal before the attack and can return to that state after resolution of the attack.

especially after biliary manometry (5 – 20%) Hypertriglyceridemia (1.Etiological Factors       Gallstones (including microlithiasis) (30 -60%) Alcohol (acute and chronic alcoholism) (15 – 30%) Endoscopic retrograde cholangiopancreatography (ERCP).3–3.8%) Trauma (especially blunt abdominal trauma) 2–5% are drug related .

Miscellaneous Etiologies of Acute Pancreatitis Trauma Postoperative setting Common duct exploration Sphincteroplasty Distal gastrectomy Cardiopulmonary bypass Cardiac or renal transplantation Endoscopic retrograde cholangiopancreatography .

and V Penetrating ulcer Connective tissue disorders Scorpion bite Renal failure Hereditary pancreatitis .Miscellaneous Etiologies of Acute Pancreatitis Translumbar aortography Metabolic disorders Hyperparathyroidism Hyperlipoproteinemias types I. IV.

Drug Induced pancreatitis Azathioprine* Estrogenes* Corticosteroids L-asparaginase Phenformin Procainamide Thiazide diuretics Furosemide Ethacrynic acid Sulfonamides Tetracycline Valproic acid Clonidine Pentamidine Dideoxyinosine H2 antagonist .

3. 6. 8. 5. 7. Edema Exudation Hemorrhage Suppuration Necrosis Fat necrosis (combination of liberated fatty acids from hydrolized fat with calcium) Fluid loss  Hypovolemia Pseudocyst . 2. 4.Surgical Pathology 1.

Pain (sudden.Clinical features (Symptoms) 1.intense. .continuous. upper abdomen back. bizarre position) Nausea and Vomiting 2.

Grey Turner sign Local .Clinical features (Signs) General Shock Fever Jaundice Left pleural effusion Acute pulmonary failure Subcutaneous necrosis Cerebral abnormalities Peritonitis Paralytic ileus Abdominal mass Cullen’s sign.

amylase S. methemalbumin Peritoneal fluid analysis Radiology Chest X-ray Abdominal X-ray Ba. amylase isoenzymes (P+S types) Urinary amylase Amylase-creatinine clearance ratio S. lipase S. Ca+2 Blood glucose Laboratory Tests S. Meal US CT scan MRI .Investigation General CBC S. electrolytes Lft S.

Intra-abdominal Disorders associated with Hyperamylasemia Pancreatic disorders Acute pancreatitis Chronic pancreatitis Trauma Carcinoma Pseudocyst pancreatic ascites Abscess Non pancreatic disorders Ruptured aortic aneurysm Ruptured ectopic pregnancy Intestinal obstruction Acute appendicitis Perforated peptic ulcer Biliary tract disease Mesenteric infarction Afferent loop syndrome .

Extra-abdominal Disorders associated with Hyperamylasemia Salivary gland disorders + Impaired amylase excretion Mumps Parotitis +Miscellaneous Pneumonia Pancreatic pleural effusion Trauma Calculi Irradiation sialadenitis Renal failure Macroamylasemia Mediastinal pseudocyst Cerebral trauma Severe burns Diabetic ketoacidosis Pregnancy Drugs bisalbuminemia .

Differential Diagnosis of Acute Pancreatitis  Perforated hollow viscus Cholecystitis/cholangitis Bowel obstruction Mesenteric ischemia/infarction .

effusion) . 4. Mortality rate is 6-20% Causes of death: Hypovolaemic shock Electrolyte disturbances Toxaemia Renal failure Respiratory failure (collapse. 5. 3. consolidation. 2.Mortality and Prognosis   1.

BMI >30  Comorbid disease tors for Severity .Severe Acute Pancreatitis  Risk Factors  Age >60 years  Obesity.

Imrie's Prognostic Signs  Age >55 yr White blood cell count >15.000/mm3 Blood glucose >10 mmol/L Serum urea >16 mmol/L Partial pressure of oxygen <60 mm Hg Serum Ca2+ <2.0 mmol/L Lactic dehydrogenase >600 µg/L Aspartate aminotransferase/alanine aminotransferase >100 µg/L Serum albumin <32 g/L .

mm Glucose > 200mg/dl BUN rise 5mg/dl Ca+2 < 8 mg/dl LDH > 350 IU/L SGOT > 250 U/dl PO2 < 60 mm.Ranson’s Criteria At admission Age >55 During initial 48 hours Hematocrite fall > 10% WBC > 16000/cu.Hg Base deficit > 4 meq/L Fluid sequestration > 6 L .

Mortality and Prognosis (3) ¨ ¨ ¨ ¨ <2  no mortality 3-4  15% mortality 5-6  50% mortality  7  test the limits of modern medicine .

Trasylol . methaemalbumin. assisted respiration . fluid balance Daily Ca+2 . abd signs. electrolytes replacement NG tube. Mg+2 ) O2 .Treatment (When diagnosis certain Rest the patient (Relief pain) Rest the pancreas Rest the bowel Resuscitation Resist enzymatic activity Resist infection Repeated examination Repeated serum estimations Respiratory support Pethidine 100mg/4hr + antispasmodic NPO. NJ tube Replacement therapy Protease inhibitors. PPI. glucacon ? Antibiotics ? General features. WBC ( fibrinogen. IV fluid.

Urgent ERCP (within 24 hours) Severe acute biliary pancreatitis with organ failure and/or cholangitis .

1. Octreotide: a reduced mortality rate but no change in complications with octreotide 2. Gabexate (antiprotease): no effect on the mortality rate but reduced pancreatic damage with gabexate. A dynamic contrast-enhanced CT (CECT) scan performed three to five days after hospitalization provides valuable information on the severity and prognosis of acute pancreatitis .

CT Findings and Grading of Acute Pancreatitis [CT Severity Index (Ctsi)] .

Peritoneal lavage Laparotomy . 2.Treatment (When diagnosis uncertain) 1.

3. 2.Treatment (When complications become apparent ) 1. Toxic patient Abdominal mass Persistently high gastric aspiration .

Systemic complications Cardiovascular collapse Respiratory failure Renal failure Metabolic encephalopathy Disseminated intravascular coagulation Gastrointestinal bleeding MOF .Complications of Acute Pancreatitis 1.

Complications of Acute Pancreatitis  Local complications Acute fluid collection Pancreatic necrosis ± infection Pancreatic pseudocyst Pancreatic abscess Pancreatic ascites Pancreatic-pleural fistula Duodenal obstruction Bile duct obstruction Splenic vein thrombosis Pseudoaneurysm + hemorrhage .

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