0071643192.pdf

ABDOMINAL AND GASTROINTESTINAL

EMERGENCIES

TABLE 11.14. Acute Versus Chronic Pancreatitis

VARIABLE ACUTEPANCREATITIS CHRONICPANCREATITIS

Pathophysiology Leakage of pancreatic enzymes into pancreatic Irreversible parenchymal destruction →pancreatic

and peripancreatic tissue, often secondary to dysfunction.

gallstone disease or alcoholism

Time course Abrupt onset of severe pain Persistent, recurrent episodes of severe pain

Risk factors Gallstones,alcoholism, hypercalcemia, Alcoholism(90%), gallstones, hyperparathyroidism,

hypertriglyceridemia, trauma, drug side effects congenital malformation (pancreas divisum); may

(thiazide diuretics, steroids), viral infections, also be idiopathic

post-ERCP, scorpion bites

History/PE Severe epigastric pain (radiating to the back), Recurrent episodes of persistent epigastric pain,

nausea, vomiting, weakness, fever, shock; anorexia, nausea, constipation, flatulence,

flank discoloration (Grey Turner sign) steatorrhea, DM

and periumbilical discoloration (Cullen sign)

may be evident on exam due to retroperitoneal

hemorrhage

Diagnosis Increased amylase, increased lipase, decreased Increased or normal amylase and lipase, glycosuria,

calciumif severe; “sentinel loop” or “colon pancreatic calcificationsand mild ileus on AXR

cutoff” signon AXR; ultrasound or CT may show and CT (chain of lakes)

enlarged pancreas with stranding, abscess,

hemorrhage, necrosis, or pseudocyst

Treatment Removal of offending agent if possible; Analgesia, exogenous lipase/trypsin and medium

standard supportive measures: IV fluids/ chain fatty-acid diet, avoidance of causative agents

electrolyte replacement, analgesia, bowel rest, (EtOH), celiac nerve block, surgery for intractable

NG suction, nutritional support, O 2. IV antibiotics, pain or structural causes

respiratory support and surgical debridement

if necrotizing pancreatitis is present

Prognosis 85–90% mild, self-limited; 10–15% severe, Can have chronic pain and pancreatic exocrine and

requiring ICU admission; mortality may endocrine dysfunction

approach 50% in severe cases

Complications Pancreatic pseudocyst, fistula formation,hypo- Chronic pain, malnutrition/weight loss, pancreatic

calcemia, renal failure, pleural effusion, chronic cancer

pancreatitis, sepsis; mortality secondary to acute

pancreatitis predicted with Ranson criteria

EXAM

■ Exam reveals upper abdominal tenderness with guarding and rebound.

■ Other findings include the following:

■ Severe cases: Distention, ileus, hypotension, tachycardia

■ Rare:Umbilical (Cullen sign) or flank (Grey Turner sign) ecchymosis

■ Other: Mild jaundice with stones or xanthomata with hyperlipidemia