-IBIS-1.5.0-
tx
digestive system
pancreatitis
diagnoses
definition and etiology
definition: inflammation of the pancreas
etiology: The condition may be either acute or chronic. Common causes are biliary tract disease (about half of all patients), alcoholism (especially in chronic disease), stomach/biliary tract surgery, hypolipoproteinemia, trauma, viral and bacterial infections, especially S. typhi, streptococcus, coxsackie.
signs and symptoms
signs and symptoms:
acute:
severe abdominal pain: may radiate to the back, flank, chest, etc.; it increases over hours and lasts until the inflammation disappears (days to weeks); the pain is worse supine and better sitting flexed forward with knees up
nausea and vomiting
abdominal distention
fever of 100-102° F
abdominal guarding and rigidity: in a third of patients
occasional rebound tenderness, diminished or absent bowel sounds
patient is distressed and anxious
tachycardia, hypotension
shock may occur
Grey Turner's sign or Cullen's sign may appear after a couple of days: (ecchymosis on the flanks or around the umbilicus, respectively)
abscesses are common 2-5 weeks after the attack
chronic:
upper abdominal pain may be persistent or intermittent; it may be worse after eating, often radiates to the back and is described as aching, gnawing, burning or stabbing; it typically lasts for days or weeks.
nausea and vomiting
progression to insufficiency
steatorrhea may occur when the pancreas has been severely damaged
weight loss
abdominal masses may be palpated
lab findings:
acute:
serum amylase concentration begins to rise at 3-6 hr, peaks at 20-30 hours, then declines (> 500 Somogyi units/ml characteristic)
increased urine amylase lags 6-10 hours behind serum amylase
increased amylase/creatinine clearance ratio above 5%
increased serum triglyceride concentration
increased serum lipase remains elevated 14 days after amylase normalizes
bilirubin may be increased
blood sugar and glycosuria
LDH over 700 u.; AST/SGOT over 250 S-F units; and/or PaO2 less than 60 mmHg indicates a poor prognosis
hemoconcentration occurs
X-ray of abdomen and chest
IV cholangiography, ultrasound, CT scan
serum Ca may decrease 1-9 days after onset; may cause tetany
elevated WBCs
chronic:
(+) secretin test measuring decreased pancreas exocrine function
pancreas x-ray shows calcific pancreas (usually in patients with alcoholic history)
abdominal ultrasound, CT scan, angiography
may see increase in serum amylase or lipase (10%)
glucose tolerance test mimics diabetic pattern
steatorrhea present
course and prognosis
Most patients recover in 5-7 days in cases of mild, uncomplicated acute conditions. Mortality is about 5%. Complications include progression to chronicity, abscesses, jaundice, respiratory failure and acute renal failure. The prognosis in acute hemorrhagic or suppurative pancreatitis is very unfavorable, with a mortality rate of 50-90%. Acute pancreatitis must be treated with utmost urgency to avoid complications.
In chronic pancreatitis, the pancreatic acinar cells decrease, and the patient develops steatorrhea and creatorrhea. If islet cell destruction occurs, the patient may develop glucose intolerance and diabetes mellitus. The course is gradual and progressive. Conventional treatment includes use of pancreatic enzymes, antacids and provision of pain relief.
differential diagnosis
acute:
acute cholelithiasis
perforated viscus
acute intestinal obstruction
mesenteric infarction
ectopic pregnancy
diabetic coma
other causes of acute abdomen
chronic:
peptic ulcer
gastritis
biliary tract disease
pancreatic cancer
malabsorption
Crohn's disease
footnotes