Acute Pancreatitis notes, Study Guides, Projects, Research of Medical Sciences

Download Acute Pancreatitis notes and more Study Guides, Projects, Research Medical Sciences in PDF only on Docsity! Acute Pancreatitis Acute Pancreatitis * Incidence : Rare in Egypt . Liver, Gallbladder, Pancreas and Ducts Copyriht © The UecrcH Companes Ine. Pera waned reprtucion ot ipay Gallbladder Left and right hepatic ducts Common hepatic duct Cystic duct Hepatic portal vein Common bile duct Accessory pancreatic duct \ Pancreatic duct \ pancreas papilla Hepatopancreatic ampulla Duodenum _Y (cutaway view) 2439 Anterior view G~ pat ; Acute Pancreatitis * Aetiology: (get 31) 1. Migrating GB stones: (50% biliary pancreatitis) a) Reflux of infected bile into the pancreatic ducts as a result of obstruction of ampula of Vater by migrating stone, stenosis or spasm of sphincter of Oddi. b) Astone may obstruct the pancreatic ducts. c) Passage of a stone through the ampulla may initiate the attack. 2. Excess alcohol intake (35%). 3. Trauma: e.g. ERCP is the third common cause , operation or accident. 4. Infection e.g. mumps or influenza. 5. Vascular insufficiency — infarction of pancreas — release of enzymes. 5. Idiopathic with no detectable cause . 6. Rarely , autoimmune , hyperparathyroidism & corticosteroid . BS) Acute Pancreatitis Lesser sac Stomach Greater omentum (Cut) Caudate lobe of liver Gastrosplenic lig. (cut) Splenorenal lig. Epiploic foramen jorenal lig. Netter 264 Greater omentum (cut) Transverse mesocolon “i PANCREAS j PORTAL VEIN PSEUDO-CYST * Complications: I. General complications: 1. Hypovolaemic shock: due to loss of plasma and blood into the peritoneum and retroperitoneal spaces. Acute Pancreatitis 2. Multiple organ failure: Adult respiratory distress syndrome & hepato-renal failure due to prolonged hypovolaemic shock. 3. Consumption coagulopathy. 4. Tetany due to hypocalcaemia. 5.Acute gastrointestinal stress ulcers and hemorrhage . II. Local complication: 1. Peritonitis & paralytic ileus. 2. Pancreatic pseudocyst 3. Pancreatic abscess. * Clinical Picture: You should answer the following questions I) Is this case is acute pancreatitis : 1) Fever , headach , anorexia & malaise (FAHM) & tachycardia . 2) History of the cause followed by acute onset of the followings: 3) Epigastric or upper abdominal pain : = It is the main , commonest and early symptom in all cases . = It is radiating to the back, improved by sitting or leaning forwards and aggravated by lying down . 4) Mild epigastric tenderness , rebound tendernss , rigidity & limitation of movenents of abdominal wall with respiration ( pancreas is retroperitoneal structure away from sensitive parietal peritoneum)which become severe and generalized when peritonitis occur. 4) Anorexia , nausea & vomiting. 5) Collapse and manifestation of shock (mention in short). 6) Manifestations of peritonitis & paralytic ileus with shifting dullness and reduced intestinal sounds in late cases. Acute Pancreatitis 7) Rarely & late after few days , retroperitoneal haematoma — bluish discolouration in the flanks (Grey Turner's sign),around the umbilicus (Cullen’s sign) or distal to inguinal ligament (Fox sign). 8) 2-3 weeks after the acute attack palpable mass in the epigastrium (Pancreatic pseudocyst). Fox’s Sign Acute Pancreatitis 8. Cardiac enzyme creatine phosokinase & ECG to exclude myocardial infarction . B) Radiological: 1. Plain X-ray of the abdomen may show: a) Dilated short segment of the small intestine (sentinel loop). b) Distension of the transverse colon and collapse of the descending colon (colon cut — off sign). Sentinel loop colon cut — off ae) ne nel “ a1 2. Abdominal U/S : show G.B stones and dilatation of biliary passage above CBD stone . 3. CT scan with IV contrast (main investigation in any pancreatic disease )may show gall stones, intra-peritoneal fluid and enlargement of the pancreas ,peri-pancreatic edema, areas of pancreatic necrosis (part of parynchema is not enhanced after contrast ) & later on pancreatic pseudocyst. 4. Magnetic resonance cholangiopancreatography (MRCP) to detect any pathology in the biliary passage . 5. Diagnostic ERCP after subside of the attack of biliary pancreatitis C) Abdominal paracentesis shows pancreatic ascites. 10 Acute Pancreatitis Massive pancreatic necrosis II) Investigations to exclude other causes of upper abdominal pain . * Diagnosis of acute pancreatitis by the presense of 2 feature of the following : 1) Severe persistent pancreatic pain . 2) Raised serum amylase or lipase . 3) Chanacteristic features of pancreatitis on CT or MRI. * Treatment: I) Conservative: (main treatment). e Severe cases are admitted to ICU e Aim: Support the different body systems. e Method: (7R). " Relief of pain: by pethidine (Morphine is avoided) with atropine derivative (to prevent spasm of sphincter of Oddi). " Replacement of the lost fluids by Ringer's lactate, plasma & blood may be needed with addition of calcium to the infusion. Replacement is monitored by vital signs, urine output, CVP & haematocrit. 1 Acute Pancreatitis " Rest of the pancreas and bowel: nothing is taken orally & nasogastric suction & somatostatin. " Respiratory support by oxygen mask, or endotracheal tube and mechanical ventilation if there is respiratory failure. " Resistance of infection by prophylactic antibiotics is controversial but it is important in hemorrhagic & necrotizing pancreatitis to avoid infection e.g. imipenem . " Reassessment of the patient by vital signs , urine output , blood gases ,blood PH , hematocrite . fluid intake & relieve of symptoms . = Removal of bile duct stone and sphincterotomy are recommend after subside of the attack of biliary pancreatitis by ERCP except if there is obstructive jaundice or cholangitis , this can be one during the attach . II) Surgical: e Indicated in uncertain diagnosis or local complications. e Method: a)Recently, acute abdomen is explored through laparoscope: « If acute pancreatitis is detected, the patient is spared the trouble of laparotomy. « If other cause of acute abdomen is detected, it is treated either by laproscopic or open surgery. b) If necrotizing pancreatitis is detected by CT scan ,open exploration, remove necrotic tissues, peritoneal lavage & close the abdomen with drainage ( can allow postoperative lavage). 12