View Full Version : ACUTE PANCREATITIS(Etiology-Pathology-Clinical picture-Complications-Investigations-Treatment)

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06-06-2008, 09:54 PM
(I) Bile irritation of the pancreas due to:
1- Obstruction at the ampulla of Vater: reflux of bile into pancreatic duct which causes activation of proteolytic enzymess which start inflammation "Common channel theory” so it is common with ch.calc. cholecystitis
2- Hypersecretion: Common in alcoholic individuals and those who suffer from vagal overactivity.
(II) Devitalization of panc. tissue by:
1- Trauma (postoperative pancreatitis).
2- Thrombosis of panc. vessels.
(III) Infection by:
- Blood or lymphatic born from septic focus.
- viral pancreatitis in cases of mumps.
Pathology: Two types:
1- Acute oedematous pancreatitis
Oedema & congestion. With minimal autodigestion.
2- Acute hemorrhagic pancreatitis:
· Marked autodigestion cause escape of proteolytic enzymes into peritoneum.
· Fat digestion Glycerine and fatty acids
· Erosion of vessels hgic. exudates.
· The fatty acids react with calcium present in hemorrhagic exudates giving Ca soap (white patches over peritoneum).
Clinical Picture:
1- Common in middle aged alcoholic patient and those with history of gall stones.
2- Sudden severe epigastric pain radiating to the back. The pain reach its maximum intensity in minutes and persist for hours and days and not respond to the ordinary analgesics.
3- Shock due to intense loss of protein rich fluids into peritoneal cavity. rapid pulse with low bl. pressure.
4- Vomiting and haematemesis due to gastric irritation.
5- Abd. examination:
· Tenderness and rigidity
· Shifting dullness due to fluid in peritoneum.
·Turner's sign: Ecchymosis and bluish discoloration in the flanks due to retroperitoneal hemorrhagic autolysis.
·Cullen’s sign: Ecchymosis and bluish discoloration around umbilicus.
·Silent abdomen: due to reflex paralysis of the intestine.
Differential Diagnosis:
Other causes of acute abdomen esp. of the chest and upper abdomen.
(See before)
Other causes of acute abdomen with shock:
1- Mesenteric vascular occlusion.
2- Leaking aortic aneurysm.
3- Abdominal injury with internal hemorrhage.
4- Myocardial infarction.
1.Serum amylase enzyme four times above normal (Normal level 80-150 Somugi unit, If more than 1000 it is highly suggestive.
2-Serum lipase (more diagnostic) ( normal < 1.5 cherry Candle unit)
3- Ca blood level due to soap formation.
4- Plain X ray:
· It may show manifestation of generalized ileus (Multiple fluid levels) or localized ileus (sentinel loop) .
· It may show helpful but not diagnostic findings e.g. gall stones or pancreatic calcifications.
5- Ultrasound scanning: It may show swollen pancreas, free peritoneal fluid, gall stones, or divert diagnosis to other pathology as leaking aortic aneurysm.
6- CT scan: If doubt remains.
1. Shock: Hypovolaemic and neurogenic due to severe pain.
2. Ascending cholangitis: ERCP and sphecterotomy may be needed to extract stone impacted in the ampulla of Vater.
3. Pleural effusion and pulmonary insufficiency: If not managed properly acute respiratory failure may follow.
4. Acute renal failure followed by multiple organ failure: The mortality in such situation is very high.
5. Pancreatic abscess: due to local necrosis and infection.
6. Pancreatic pseudocyst: due to encysted sac opened to pancreatic canaliculi.
7. Colonic stricture: due to extended infection and subsequent fibrosis.
If the diagnosis is sure surgery should be avoided. If the attack is severe the patient should be admitted to intensive care unit and the patient should be monitored invasively to ensure homeostasis of the cardiovascular, respiratory and renal systems. The patient should be made comfortable and adequately sedated. The following usually needed:
1- Aspiration of gastric secretion by N / G tube.
2- Analgesics: Pethidine Not morphin as it increase the spasm of sphincter of Oddi which increase reflux of bile.
3- Antibiotics.
4- Atropine inhibit pancreatic secretion.
5- Rarely Ca and insuline may be given to correct deficiency.

Surgery is indicated when:
1- Doubtful cases Fluid is evacuated. Lesser sac is drained.
2- Residual abscess in the lesser sac: Drainage of with Continuous postoperative closed lavage of the lesser sac is advised.
3-Pancreatic pseudocyst: Closed drainage into stomach by cystogastrostomy.
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