Sir Berkeley Moynihan Ann Surg 1925

• “Acute Pancreatitis is the most terrible of all the calamities that occur in connection with the abdominal viscera.”

ACUTE PANCREATITIS

- Dr. Arkaprava

SinhaIntern

Malda medical college& Hospital

Clinical Features &

Diagnosis

Diagnosis

Clinical

Symptoms Signs

Investigation

For confirmation of diagnosis

For assessment of severity

For diagnosis of

complications

SymptomsPain • Onset : Acute• Site : Epigastrium or upper

abdomen ( mostly left)

• Character: Agonizing, burning,continuous, refractory

• Degree : excruciating

• Aggravating factor : Supine position

• Relieving factor : Sitting and leaning forward

• Radiation : Towards the back, chest, Lower abdomen

Other abdominal symptoms

• Severe nausea,vomiting & retching

• Abdominal distension• Haematemesis & malena

Symptoms of complications• Dyspnoea• Sudden blindness• Skin rashes• Decreased urine output

SignsGeneral features• Agonized look• Dehydration• Features of shock

TachycardiaHypotensionCold clammy extremitiesAltered mental status

• Hyperpyrexia• Jaundice• Skin changes

(Pancreatic panniculitis )

• Distension of abdomen• Features of peritonitis

Abdominal Tenderness

Rebound tendernessMuscle guard &

rigidity• Palpable pseudocyst• Ascites

Abdominal signs

Systemic signs

Cullen’s sign : Bluish discolouration around the umbilicusGrey Turner’s sign : Greenish brown discolouration of the flanks Fox’s sign : Bruising seen over the inguinal region

Other systems involvement

Respiratory system• ALI : Cyanosis

Widespread crepts

• Pleural Effusion : dullness

Decreased breathe

sounds• Basal

Atelectasis : Basal crepts

CVS

• Features of pericadialeffusion

Eye• Exudates and haemorrhages in

the region of optic disc & macula

CNS• Altered mental status

Recapitulation of Clinical Features

• P :• A :• N : • C : • R : • E : • A : • S :

Pain, PyrexiaAlimentary tract featuresNausea , Nervous system featuresCirculatory features , CVS featuresRespiratory featuresEye featuresAbdominal examination findingsSkin features

INVESTIGATIONSINVESTIGATIONS

For confirmationn of diagnosis

For assessment of severity

For diagnosis of complications

For confirmation of diagnosis

Serum amylase ( 23 – 140 U/L )Non specific elevation

Relation of amylase level with severityRelation with hyperlipidemiaUrinary amylase level

Serum lipase ( 0 – 160 U/L )More specific and sensitive ( 90% )

Pancreatic enzyme markers

Day0 Day1 Day2 Day3 Day4 Day50

1

2

3

4

5

6

AmylaseLipase

Folds of increase

• Serum ALT ( 7 – 56 U/L )• Serum AST ( 10 – 40 U/L)• Serum LDH (140 – 280 U/L)• Bilirubin level

LFT

Other Diagnostic marker• Trypsinogen activation peptide

For confirmation of diagnosis

• USG Abdomen• Shows increase in the size of pancreas• Any intra-abdominal fluid collection

For confirmation of diagnosisIMAGING

• Merits• GB stone ( 95% sensitivity)• Easily available• Cost effective• Portable• Pancr Enz + LFT + USG

= 97% sensitivity and 100% specificity

• Demerits• Obstruction of view• Choledocholithiasis

(50% sensitivity)

For confirmation of diagnosisIMAGING

– Rule out hollow viscus perforation

– Multiple air fluid levels– Colonic cut off sign

• X- Ray abdomen

• CT Scan Abdomen

For confirmation of diagnosisIMAGING

Normal abdomen Acute pancreatitis

– Acute interstitial oedematous pancreatitis

– Acute necrotising pancreatitis(CECT)

– Acute emphysematous pancreatitis

For confirmation of diagnosisIMAGING

Merits• 100% sensitivity after 4th day• Better delineation of inflammation,

fluid collection, viability• Wide availability• Ct guided FNAC

Demerits• Less sensitive before 24 hours• Contrast enhanced CT is

contraindicated in renal failure

• CT Scan Abdomen

• MRCP Indication:unexplained or recurrent pancreatitis

For confirmation of diagnosisIMAGING

• Merits :1. Can be used in patient with renal failure2. 90% sensitive and 95% specific for choledocholithiasis

• Demerits1. Can’t be used in patient with

pacemakersFerromagnetic aneurysm

clipsMetallic spinal fusion rods

• ERCP • EUS

For assessment of severity

• Scoring on pathophysiological basis

1. Ranson’s scoring

2. Modified Glassgow

scoring

Modified glasgow score• P - PaO2 < 8kPa (60 mm hg)

• A - Age > 55 years

• N - Neutrophils : WBC> 15x 10^9/L

• C – Calcium < 2 mmol/L

• R – Renal function(Urea > 16mmol/L

• E – Enzymes : (AST/ALT > 200 IU/ LLDH > 600 IU/ L )

• A – Albumin < 32 g/L

• S – Sugar ( Glucose > 10mmol/L)

• Phospholipase A• Trypsin• Trypsinogen activation peptide• IL-6 , IL - 8• Pancreatitis associated protein• CRP• Procalcitonin• Plasma Dimer

Markers of severity

For diagnosis of complications• CT scan abdomen

– Pancreatic pseudocyst– Pancreatic abscess– Pancreatic necrosis– Pancreatic phlegmon– Pancreatic ascites

• X- ray chest ( PA view)• Pleural effusion• Pericardial effusion

• ECG• Investigations for DIC • GI endoscopy• Serum Urea/Creatinine• Blood:

Sugar, calcium, albumin

Summarisation of investigations• Pancreas

:• Liver :• Show

:• Rapid

:

• Contrast:

• Material:

• Enhancement :in

• CT:

• Scan :

• Pancreatitis enzymes• Liver function tests• Sonography abdomen• Radiologic evidence( X-ray abdomen

and chest• CT scan abdomen• MRCP• EUS, ERCP

• For Dx of COMPLICATIONS• To assess SEVERITY

THANK YOU