Acute Pancreatitis ENCC 1

ACUTE PANCREATITIS
Adugna Ch.
(BSc, MSc-EMcc)
Out line
• Definition
• Etiology
• Pathophysiology
• Clinical feature
• Differential diagnosis
• Investigation
• Classification of acute pancreatitis
• Management
Definition
Acute pancreatitis is an acute inflammatory process of

the pancreas.
•It is usually associated with severe acute upper abdominal

pain and elevated blood levels of pancreatic enzymes.
• Most cases are associated with alcoholism or gallstones,
but the precise pathogenetic mechanisms are not fully
understood
Etiology:
• Gallstone
• Alcohol
• ERCP(endoscopic retrograde cholangiopancreatography)
• Trauma
• Drugs
• Infection
• Hereditary
• Hypercalcemia
• Developmental abnormalities of pancreas
• Tumors
• Toxins, vascular abnormalities, autoimmune pancreatitis
Pathogenesis
In gallstone
•Reflux of bile into the pancreatic duct due to transient obstruction
of the ampulla during passage of gallstones, or
•Premature activation of pancreatic zymogens within the pancreas

has also been proposed as the pathogenetic mechanism for the
acute attacks of pancreatitis
•Activation proteolytic enzymes,

enzymes which ultimately leads to an
autodigestive injury to the gland
Cont…
• Activated pancreatic enzymes, microcirculatory impairment,

and the release of inflammatory mediators lead to rapid
worsening of pancreatic damage and necrosis
• Cause edema, interstitial hemorrhage, vascular damage,

coagulation, and cellular necrosis.
• Rapidly causes a local inflammatory reaction that further

contributes to the vascular dilatation, permeability, and
edema.
Clinical Features
History Taking
• Gallstones
• Alcohol use
• History of hypertriglyceridemia or
• Hypercalcemia
• Family history of pancreatic disease
• Prescription and nonprescription drug history
• History of trauma
Clinical Features…
Abdominal Pain:
• Sever, stay 12-24h after eating a large meal
or consuming alcohol, radiate to the back or
to the shoulder.
• Pain is worse by walking or laying supine &
better after sitting or leaning forward.
• Nausea and vomiting
• Sever may cause dehydration and low blood
pressure.
• If bleeding occurs in the pancreas, shock and
even death may follow.
Clinical Features…
Physical Examination
• Abdominal tenderness
• Mild abdominal distention( if the purulytic
ileus develop).
• In sever advanced case:
1.Grey turners sign.
sign A bluish discoloration of
the flanks, are characteristic but rare signs of
hemorrhagic pancreatitis.
2.Cullen’s sign.
sign A bluish discoloration around
the umbilicus
Grey turners sign Cullen’s sign
Differential Diagnosis
• Cholecystitis
• Choledocholithiasis
• PUD
• Gastritis
• Bowel obstruction
• Mesenteric ischemia
• Appendicitis
• Hepatitis
• Pyelonephritis and renal colic
• DkA
Investigation:
• Serum amylase
• Serum lipase
• WBC
• Cholesterol screening, LDH>500 U/dl
• Electrolyte
• Liver function test , ALT
• ABG show Hypoxia
• Glucose level
X-ray of Abdomen:
• Gall stones.
• Air filled in the LUQ.
Helps to exclude other causes of abdominal
pain such as obstruction and bowel
perforation.
U/S:
-Gall stones.
-Bilary obstruction.
-Psudocyst.
• CT:
(is the dignostic even with normal amylase)
-Enlarged pancreas.
-Psudocyst.
-Abscess & hemorrhage.
-Presence of gas bubbles in CT scan indicate
pancreatic abscess.
MRI
• Particularly magnetic resonance

pancreatography (MRP), is being used for the
evaluation of pancreatic carcinoma and
chronic pancreatitis.
• MRP may be used as an alternative to ERCP

Predicting The Severity Of Acute
Pancreatitis
• Clinical Predictors
• Clinical, age, obesity, comorbidity, organ failure, alcohol and onset
• Laboratory And Radiologic Predictors

HCT, c-reactive protein, BUN, creatinine, X-RAY, CT and MRI
• Scoring Systems
Ranson's criteria
The APACHE II score
Ranson criteria
0 hours
Age >55
White blood cell count >16,000/mm3
Blood glucose >200 mg/dL (11.1 mmol/L)
Lactate dehydrogenase >350 U/L
Aspartate aminotransferase (AST) >250 U/L
48 hours
Hematocrit Fall by ≥10 percent
Blood urea nitrogen Increase by ≥5 mg/dL (1.8 mmol/L) despite

fluids
Serum calcium <8 mg/dL (2 mmol/L)
pO2 <60 mmHg
Base deficit >4 MEq/L
Fluid sequestration >6000 mL

APACHE II
Principles Of Managing
• The first step is determining the severity.
• In Mild acute pancreatitis recover without

complications and require supportive
measures only.
• In severe acute pancreatitis, intensive care

unit monitoring and support of pulmonary,
renal, circulatory, and hepatobiliary function
REST THE PANCREAS
• NPO
Supportive Care
• Close attention to volume status and electrolyte balance
Mild acute pancreatitis is treated with supportive care

including
• Pain control
• Intravenous fluids and correction of electrolyte and

metabolic abnormalities.
• The majority of patients require no further therapy, and

recover and eat within three to seven days.
Pain Management
• Include parenteral narcotics and antiemetic.
• Pethidine (75-100 mg) for 3-4 hr to control

pain
NUTRITION
• Patients with mild pancreatitis can often be :-
• Managed with intravenous hydration alone since
recovery often occurs rapidly, allowing patients to
resume an oral diet within a week.
• ENTERAL — Enteral feeding is recommended in
patients with severe acute pancreatitis
• PARENTERAL — Parenteral nutrition should be
initiated in patients who do not tolerate enteral feeding.
ANTIBITICS
•Prophylactic broad-spectrum antibiotics for

patients with predicted severe pancreatitis
•Ciprofloxacin in combination with

metronidazole are recommended
Initiation Of Oral Feeding
• In mild pancreatitis, in the absence of ileus,
nausea or vomiting, oral feeds can be initiated
as soon as the pain starts improving and
narcotic requirements are decreasing.
• Traditionally, patients have been advanced

from a clear liquid diet to solid food as
tolerated.
• In severe pancreatitis, oral feeding is
frequently not tolerated due to
Postprandial pain,
Nausea, or vomiting
• When the local complications start

improving, oral feeds are initiated and
advanced as tolerated.
Treatment Of Associated Conditions
• Gallstone pancreatitis
• Endoscopic retrograde
cholangiopancreatography(ERCP)
• Hypertriglyceridemia pancreatitis
• Hypercalcemia
Peritoneal Lavage
• May provide short-term clinical improvement but

does not appear to alter clinical outcome.
• Acute fluid collections are rarely symptomatic and
frequently resolve spontaneously.
LAPAROTOMY
Is indicated for hemorrhage control and abscess
drainage.
• Abscesses and pseudocysts also may be drained
radiologically or endoscopically, if indicated.
SUMMERY
•Acute pancreatitis can be divided into two broad categories:

•Mild acute pancreatitis and severe acute pancreatitis.
•Mild pancreatitis is treated With supportive care and nothing by
mouth.
•In severe pancreatitis, Intensive care unit monitoring and support
Adequate pain control
•In patients with severe pancreatitis, Provide early enteral
nutrition in the first 72 hours
•Health education
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ACUTE PANCREATITIS

Acute pancreatitis is an acute inflammatory process of

•It is usually associated with severe acute upper abdominal

•Premature activation of pancreatic zymogens within the pancreas

•Activation proteolytic enzymes,

• Activated pancreatic enzymes, microcirculatory impairment,

• Cause edema, interstitial hemorrhage, vascular damage,

• Rapidly causes a local inflammatory reaction that further

• Particularly magnetic resonance

• MRP may be used as an alternative to ERCP

• Laboratory And Radiologic Predictors

White blood cell count >16,000/mm3

Blood glucose >200 mg/dL (11.1 mmol/L)

Lactate dehydrogenase >350 U/L

Aspartate aminotransferase (AST) >250 U/L

Hematocrit Fall by ≥10 percent

Blood urea nitrogen Increase by ≥5 mg/dL (1.8 mmol/L) despite

pO2 <60 mmHg

Base deficit >4 MEq/L

Fluid sequestration >6000 mL

• The first step is determining the severity.

• In Mild acute pancreatitis recover without

• In severe acute pancreatitis, intensive care

Mild acute pancreatitis is treated with supportive care

• Intravenous fluids and correction of electrolyte and

• The majority of patients require no further therapy, and

• Include parenteral narcotics and antiemetic.

• Pethidine (75-100 mg) for 3-4 hr to control

•Prophylactic broad-spectrum antibiotics for

•Ciprofloxacin in combination with

• Traditionally, patients have been advanced

• When the local complications start

• May provide short-term clinical improvement but

•Acute pancreatitis can be divided into two broad categories:

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