Acute pancreatitis

Etiology,clinical features, differential diagnosis, investigation and treatment

1. topic ------ goniometer ACUTE PANCREATITIS ---( An inflammation of pancreas) PRATIGYA DEUJA

2. AETIOLOGY Alcohol Gall stones Hypertriglyceridemia Biliary Drugs( corticosteriods , HIV drugs, Diuretics, Valporic acid) Idiopathic Trauma Scorpion string

3. PATHOGENESIS It consists of three phases : First phase is characterized by intrapancreatic digestive enzymes activation and acinar cell injury. Second phase is characterized by the activation of chemoattraction and sequestration of leucocytes and macrophage in pancreas. Intrapancreatic acinar cell trypsinogen activation. Third and final phase is an activated proteolytic enzyme ( trypsinogen ); not only digest the pancreatic and peripancreatic area but also causes activation of phospholypase A2

4. SYMPTOMS Abdominal pain Nausea Vomiting Abdominal distension

5. SIGNS Patient appears distress and anxious. Low grade fever Tachycardia Hypotension Shock ( Hypovolameic shock because of increase release of kinin peptites which causes vasodilatation and increase vascular permeability

6. SIGNS contd … Jaundice is rarely seen. 10-20% of patient’s have pleural effusion and basal atelectasis . Bowel sounds are diminished. Discoloration around umbilicus( cullen’s sign) Grey- Turners sign (discoloration around the flanks)

7. INVESTIGATION Serum Amylase and serum lipase: more than three times upper limits of normal. Serum lipase is more specific than serum amylase. Serum lipase remains elevated for 7-14 days. Total count raised about 15,000 to 20,000/- Patient’s with severe disease show haemoconcerntration i.e , hematocrit is raised more than 44% and blood urea also raised.

8. MORPHOLPGICAL CLASSIFICATION Endosteal pancreatitis Acute pancreatitic fluid collection Necrotizing pancreatitis Pancreatitic pseudocyst Walled off pancreatitis

9. DIFFERENTIAL DIAGNOSIS Perforated viscous Acute cholecystitis Acute intestinal obstruction Mesentric vascular occlusion Renal colic Diabetic ketoacidosis

10. SEVERITY OF ACUTE PANCREATITIS Moderately severe acute pancreatitis is characterized by transient organ failure ( e.g , kidney or lungs) or local or systemic complication but in the absence of persistent organ failure (>48 hours) Interstitial pancreatitis occur in 90-95% of patient with pancreatitis and is characterized by diffuse gland enlargement and mild inflammatory changes. Symptoms resolves within 1 week of hospitalization.

11. MANAGEMENT Iv fluids resuscitation Bolus of 1300ml followed by 3mg/kg to keep urine output more than 0.5cc/hr Pain management; tramadol , morphine, fentalin Targeted recesses patient strategy along with hematocrit Pancreatic necrosis -- surgical resection

12. LOCAL COMPLICATION Pancreatic fluid collection Pancreatic pseudosis Pancreatic ascites Bowel infection

13. SYSTEMIC COMPLICATION Pulmonary: Pleural effusion, ARDS, Atelectasis Heamatological : DIC Cardiovascular: Hypotension, Hypovolaemia , Pericardial effusion GI: Peptic ulcer, Erosive gastritis, Portal vein thrombosis Renal: Acute tubular necrosis, Azotemia Metabolic: Hyperglycemia, Hpercalcemia , Hypertriglyceredemia CNS: psychosis