Acute Pancreatitis

SURGERY 2

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Case No 4 …continue

• His physical examination reveals a BP of 110/60, HR of 110, respiratory rate of
• 24/min, and a body temperature of 38 °C. There are crackles in his lung bases,
• no murmurs or extra cardiac sounds, and a tender abdomen in the
• mid-epigastrium with guarding and rebound tenderness. Bowel sounds were not heard

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Which test is LEAST LIKELY to add pertinent information at this point?

• CT scan of the abdomen with contrast → not that imp → not good for gallstones
• Electrocardiogram → imp to rule out MI
• Troponin
• Ultrasound of the gallbladder → To rule out Cholecystitis
• Serum amylase and lipase → imp for Pancystitis → simple (blood investigations, Det Side)

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Which test is LEAST LIKELY to add pertinent information at this point?

• CT scan of the abdomen with contrast
• Electrocardiogram
• Troponin
• Ultrasound of the gallbladder
• Serum amylase and lipase

Although a CT scan may eventually be useful, it will not be as helpful as the other choices at this point. It is best used at 72 hours of illness to assess the degree of pancreatic necrosis in patients with predicted severe disease. A cardiogram and troponin will help to rule in or rule out a myocardial infarction while the serum amylase and lipase will give information about pancreatitis. The gallbladder ultrasound will be important in this patient with a strong family history for cholelithiasis and cholecystitis

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Results:

• A chest x-ray shows mild bilateral atelectasis.
• The electrocardiogram shows sinus tachycardia;
• troponins are normal.
• The gallbladder ultrasound revealed no gallstones, no wall thickening, and no evidence for gallstones or sludge.

Which statement is MOST ACCURATE about the amylase and lipase?

• An elevated 2-hour urinary amylase is diagnostic for acute pancreatitis
• Any elevation of the serum lipase is diagnostic for acute pancreatitis
• A three-fold elevation of the amylase and lipase should be considered supportive of the diagnosis of acute pancreatitis
• The higher the amylase and lipase levels, the greater the severity of the pancreatitis
• Daily amylase and lipase levels are helpful because they correlate with the recovery and prognosis

diagnostic but not prognostic

3x the normal is diagnostic

done for any Patient

with abd. Pain

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• Results:
• A chest x-ray shows mild bilateral atelectasis.
• The electrocardiogram shows sinus tachycardia;
• troponins are normal.
• The gallbladder ultrasound revealed no gallstones, no wall thickening, and no evidence for gallstones or sludge.

Which statement is MOST ACCURATE about the amylase and lipase?

• An elevated 2-hour urinary amylase is diagnostic for acute pancreatitis
• Any elevation of the serum lipase is diagnostic for acute pancreatitis
• A three-fold elevation of the amylase and lipase should be considered supportive of the diagnosis of acute pancreatitis
• The higher the amylase and lipase levels, the greater the severity of the pancreatitis
• Daily amylase and lipase levels are helpful because they correlate with the recovery and prognosis

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Explanation:

• The diagnosis of acute pancreatitis is best supported by a three-fold increase in amylase and lipase.
• The lipase is considered a little more specific than amylase but situations other than pancreatitis can cause lipase elevations.
• Serum amylase may be elevated for many reasons other than acute pancreatitis (eg, mumps, perforated viscus, tubo-ovarian abscess,), as can the serum lipase (eg, intestinal infarction and perforation, severe peptic ulcer disease).
• The severity of pancreatitis does not correlate well with the magnitude of the elevation of the serum amylase or lipase.
• Lipase and amylase levels also do not correlate with recovery or prognosis.

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management

• NPO
• Nasogastric aspiration
• IV fluids with dextrose and water (D5W)
• IV antibiotics
• IV hyperalimentation

All patients with acute pancreatitis should initially be made NPO.

If they continue to vomit, nasogastric aspiration may be indicated,. Vigorous hydration with isotonic fluids (Ringer’s lactate or normal saline) is indicated to maintain blood volume, especially in the face of severe pancreatitis in which patients may sequester large amounts of fluids in the retroperitoneal space. Use of IV antibiotics is controversial. In this patient, antibiotics are not indicated, as the severity of the disease has not been established. Immediate IV hyperalimentation is not required, especially in patients with mild pancreatitis.

*most pancreatitis is mild or moderate

*severe pancreatitis is rare

is not only affect abdominal, will be general (affect all

organs of body) → due to Production of cytokines →

UD all over body → leak of fluid from intravascular

compartment into interstetial compartment → fluid will

be going into 3rd space → spaces where there is

no fluid but potentially it can accumulate

fluid eg. pleura, peritoneum. → pleural effusion, ascites, pulmonary

leaky membrane syndrome

→ occur with sepsis, pancreatitis

due to leaking of fluid into alveoli ↓ lead to inflammatory in oxygenation.

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Prognosis

• On admission, the patient’s Hct was 50% and his WBC was greater than 15,000/cu mm.
• His LDH, AST, and serum glucose levels were not able to be determined.
• He was hypotensive and had a heart rate consistently higher than 110 beats per minute.
• At 48 hours, his HCT was 35%, BUN was 35 mg/dL, calcium was 8.1 mg/dL, PaO2 was 60 mmHg, PCO2 was 30 mmHg, and pH was 7.33.

Tells the Prognosis

IMP Parameters (in 1st 24 hours) (to know what investigations to order) (no need to remember #5)

Ranson’s Criteria

At Admission

• Age > 55 years
• WBCs > 16,000/mm³
• Glucose > 200 mg/dl
• LDH > 350 IU/L
• AST > 250 SF units

48 hours After Admission

• Hematocrit fall >10%
• BUN rise > 5 mg/dl
• Calcium < 8 mg/dl
• PO₂ < 60 mm Hg
• Base deficit > 4 mEq/L
• Fluid sequestration > 6 L

Score	Associated Mortality Rate
0-2	1%
3-4	15%
5-6	40%
> 7	100%

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Which is NOT ONE of Ranson’s criteria at the time of admission

• Age > 55 years
• WBC > 16,000/cu mm

Calcium < 8 mg/dL

• AST > 250 IU/L
• Glucose > 200 mg/dL

Although low calcium is an important criterion for helping to predict mortality in acute pancreatitis, it is one of the factors used to evaluate severity at 48 hours following admission, not at the time of admission.

All of the others are part of Ranson’s criteria at admission. The fifth criterion at admission is LDH > 350 IU/L.

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Which is NOT ONE of Ranson’s criteria at the time of admission

• Age > 55 years
• WBC > 16,000/cu mm
• Calcium < 8 mg/dL
• AST > 250 IU/L
• Glucose > 200 mg/dL

Although low calcium is an important criterion for helping to predict mortality in acute pancreatitis, it is one of the factors used to evaluate severity at 48 hours following admission, not at the time of admission.

All of the others are part of Ranson’s criteria at admission. The fifth criterion at admission is LDH > 350 IU/L.

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most common pancreatitis is biliary pancreatitis (milk form)

Cullen sign abd Grey Turner sign

occur with hemorrhagic → rare pancreatitis → bleeding inside abdomen, but its not severe, so down around umbilicus and on flanks

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Case No: 5

• A 68-year-old man with a history of adult-onset diabetes, obesity, and tobacco use presents to the emergency department.
• He is febrile on arrival with a temperature of 39 C, a blood pressure of 95/50, and a heart rate of 106.
• His primary complaint is of right upper-quadrant pain of 24-hour duration. He notes that he has had similar pain on occasion before but always had complete resolution of pain within a couple of hours.
• He reports his urine has been very dark for the last 12 hours.
• On exam, he has tenderness of his right upper quadrant with voluntary guarding.
• The sclerae are mildly icteric. → Jaundice

Charcot triad + hypotension → Should assess mental status for confusion

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DD: -Cholangitis

(Reynold’s pentad. charcot with septicemia)

Investigation & Treatment:

• DX test and Radiology

• Intravenous fluid

• Antibiotics:

• A fluoroquinolone with added metronidazole

• or extended-spectrum beta lactam (piperacillintazobactam) can provide adequate empiric coverage

• Drainage → if didn’t have ability to remove stone → To alleviate obstruction to dec pressure in biliary system to stop reflux of bacteria to blood

→ labs: CBC, LFT → US → store in gall bladder, dilatation of biliary system → indicate gall stone → do GPCF to remove

• store
• give antibiotic:
• Tazosin
• then do cholecystectomy

SURGERY

PRINCIPLES OF PERIOPERATIVE CARE

VIII. Acute Pancreatitis:

Serum Amylase can rise over 3-6 hours reach peak 24 hours then cleared in urine (4-8 days), while lipase reabsorbed into the circulation

• Normal: 30-110 U/L
• Pancreatitis suspected: > 200 U/L

Serum lipase peaks at first 24 hours with serum concentration elevated for 8 – 14 days. So Elevated lipase levels are more specific to the pancreas than elevated amylase levels.

• A normal lipase level can range from 0-160 U/L. Pancreatitis suspected: > 200 U/L
• {Testing both discouraged for cost-effectiveness}

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Investigations

1. The key to diagnosis:
   • a high index of suspicion
   • measurement of the serum amylase concentration. (*3). Serum lipase is an alternative and more specific.
2. Other underlying causes of hyperamylasemia:
   • mesenteric vascular ischemia, bowel strangulation,
   • perforated duodenal ulcer,
   • ruptured aortic aneurysm,
   • ruptured ectopic pregnancy,
   • acute cholecystitis.

Cullen sign and Grey Turner sign

Amylase and Lipase in Acute pancreatitis

The diagnosis of acute pancreatitis is best supported by a three-fold increase in amylase and lipase.

The lipase is considered a little more specific than amylase but situations other than pancreatitis can cause lipase elevations.

Serum amylase may be elevated for many reasons other than acute pancreatitis (eg, mumps, perforated viscus, tubo-ovarian abscess,), as can the serum lipase (eg, intestinal infarction and perforation, severe peptic ulcer disease).

The severity of pancreatitis does not correlate well with the magnitude of the elevation of the serum amylase or lipase.

Lipase and amylase levels also do not correlate with recovery or prognosis. Z

• CBC, urea, electrolytes, liver function test, LDH, lipid profile, coagulation profile, serum calcium, C-reactive protein, blood glucose.

• Imaging:

  • Chest X-ray: look for pleural effusion, air under the diaphragm in cases of perforated peptic ulcer.
  • Ultrasound abdomen: gallstone.
  • Abdominal CT: diagnosis, complications of acute pancreatitis, evidence of necrotizing pancreatitis.

CT abdomen Pancreatitis

• Although a CT scan may eventually be useful, it will not be as helpful as the other choices at this point. It is best used at 72 hours of illness to assess the degree of pancreatic necrosis in patients with predicted severe disease.

• A cardiogram and troponin will help to rule in or rule out a myocardial infarction while the serum amylase and lipase will give information about pancreatitis.

• The gallbladder ultrasound will be important in this patient with a strong family history for cholelithiasis and cholecystitis

Pancreatitis: Initial Management

• All patients with acute pancreatitis should initially be made NPO

• If they continue to vomit, nasogastric aspiration may be indicated. Vigorous hydration with isotonic fluids (Ringer’s lactate or normal saline) is indicated to maintain blood volume, especially in the face of severe pancreatitis in which patients may sequester large amounts of fluids in the retroperitoneal space.

• Use of IV antibiotics is controversial. In this patient, antibiotics are not indicated, as the severity of the disease has not been established. Immediate IV hyperalimentation is not required, especially in patients with mild pancreatitis.

Assessment of severity of acute pancreatitis

The aim of severity assessment is the early recognition of the patients with severe pancreatitis and to ensure that they are admitted to a high dependency unit or critical care unit for intensive management.

Ranson’s Criteria Z

The criteria for point assignment is that a certain breakpoint be met at any time during that 48-hour period, so that in some situations it can be calculated shortly after admission. It is applicable to non-gallstone pancreatitis.

1) For non-gallstone pancreatitis, parameters are:

At admission: < 24 HR Z

1. Age in years > 55 years
2. (WBC) White blood cell count > 16000 cells/mm3
3. Blood glucose > 10 mmol/L (> 200 mg/dL)
4. Serum AST > 250 IU/L
5. Serum LDH > 350 IU/L

Within 48 hours:

1. Serum calcium < 2.0 mmol/L (< 8.0 mg/dL)
2. Hematocrit fall > 10%
3. Oxygen (hypoxemia PaO2 < 60 mmHg)
4. BUN increased by 1.8 or more mmol/L (5 or more mg/dL) after IV fluid hydration
5. Base deficit (negative base excess) > 4 mEq/L
6. Sequestration of fluids > 6 L

2) For gallstone pancreatitis, the parameters are:

At admission:

1. Age in years > 70 years
2. White blood cell count > 18000 cells/mm3
3. Blood glucose > 12.2 mmol/L (> 220 mg/dL)
4. Serum AST > 250 IU/L
5. Serum LDH > 400 IU/L

Within 48 hours:

1. Serum calcium < 2.0 mmol/L (< 8.0 mg/dL)
2. Hematocrit fall > 10%
3. Oxygen (hypoxemia PaO2 < 60 mmHg)
4. BUN increased by 1.8 or more mmol/L (5 or more mg/dL) after IV fluid hydration
5. Base deficit (negative base excess) > 5 mEq/L
6. Sequestration of fluids > 4 L

Interpretation of Ranson’s criteria

• If the score ≥ 3, severe pancreatitis is likely.
• If the score < 3, severe pancreatitis is unlikely Or
• Score 0 to 2: 2% mortality
• Score 3 to 4: 15% mortality
• Score 5 to 6: 40% mortality
• Score 7 to 8: 100% mortality..

Alternatively, pancreatitis severity can be assessed by any of the following: Y

• APACHE II score ≥ 8
• Organ failure
• Substantial pancreatic necrosis (at least 30% glandular necrosis according to contrast-enhanced CT)

Treatment

Most attacks of acute pancreatitis will settle with conservative treatment including:

1. NPO +/- NG tube

2. Pain relief: opiates administration

3. Fluid resuscitation: patients with severe pancreatitis require large volumes of fluid to maintain adequate urine output and blood pressure. Adequate early resuscitation in such cases is the most important consideration in early treatment.

4. Antibiotics prophylaxis: it is indicated in severe necrotizing pancreatitis and the recommended antibiotic is imipenem or meropenem

5. Nutritional support: patients with severe pancreatitis who are unable to resume normal oral diets within 72 hours require nutritional support. This is best delivered by an enteral rather than parenteral route.

6. Endoscopic treatment: gallstone pancreatitis is due to the transient impaction of a stone at the papilla causing pancreatic duct obstruction. ERCP with sphincterotomy is indicated in patients with acute pancreatitis with persistent obstructive jaundice with or without cholangitis.

7. Surgical treatment: patients with gallstone-related acute pancreatitis should undergo cholecystectomy (mild pancreatitis during the index admission while severe pancreatitis interval cholecystectomy in 8 – 12 weeks after resolution of the attack of severe acute pancreatitis).

Note: Surgery is indicated in patients with infected necrotizing pancreatitis or in patients with sterile necrotizing pancreatitis who deteriorate and develop progressive multi-organ failure.

Complications of acute pancreatitis

A) Gallstone Pancreatitis

B) Infected pancreatic necrosis

C) pancreatic pseudocyst

D) Pancreatic abscess

E) Gastrointestinal bleeding

F) Progressive jaundice 

G) Left sided portal hypertension