Pancreatitis, Acute: Clinical Presentation

Pancreatitis, Acute
Clinical Presentation
Physical:
The following physical examination findings
vary with the severity of the disease:
■ fever (76%) and
■ tachycardia (65%)
are common abnormal vital signs
Pancreatitis, Acute
Physical:
abdominal tenderness
muscular guarding (68%) and
distension (65%)
► are observed in most patients
Pancreatitis, Acute
Physical:
Bowel sounds are often hypoactive due to:
gastric and
transverse colonic ileus
Guarding tends to be more pronounced in the

upper abdomen
A minority of patients exhibit jaundice (28%)

Physical:
Some patients experience dyspnea (10%),
which may be caused by irritation of the
diaphragm (resulting from inflammation)
►Pleural effusion, or a more serious condition,

such as acute ►respiratory distress
syndrome
• Illustration
Physical:
In severe cases
► hemodynamic instability (10%)
► hematemesis or melena (5%)
In addition, patients with severe acute pancreatitis

are often:
pale
diaphoretic and
listless
Physical:
► A few uncommon physical findings are associated with ► severe
necrotizing pancreatitis:
* The Cullen sign:
is a bluish discoloration around the umbilicus resulting from
hemoperitoneum
*The Grey-turney sign:

is a reddish-brown discolaration along the flanks resulting from
retroperitoneal blood
Pancreatitis, Acute
Differentials Diagnosis
Gastric Cancer
Gastric Ulcers
Duodenal Ulcers
Irritable Bowel Syndrome
Myocardial Infarction
Pancreatic Cancer
Pancreatitis, Chronic
Pneumonia, Bacterial
Pancreatitis, Acute
Differentials Diagnosis
Cholangitis
Cholecystitis
Choledocholithiasis
Cholelithiasis
Colon Cancer, Adenocarcinoma
Colonic Obstruction
Workup
Lab studies
► Hematocrit
May be elevated, or low
► WBCC:
There is usually a moderate leucocytosis
► Liver function studies are usually normal

* But there may be a mild elevation of the serum
bilirubin concentration
Pancreatitis, Acute
Workup
Lab studies
Elevated serum lipase is detectable early and
for several days after the acute attack
An elevated serum RNase correlates positively

with the development of:
► pancreatitis necrosis or
► abscess formation
Pancreatitis, Acute
Workup
Lab studies
Serum amylase
Concentration rises above 200IU/DL within 6 hours of the onset of an acute
episode
and generally remains elevated for about 2 days
Although it is the most valuable and most frequently performed diagnostic

study, it is not completely reliable for the following reasons:
Pancreatitis, Acute
Serum amylase
1) Elevate amylase levels also occur in other
acute abdominal conditions such as:
cholecystitis, small bowel obstruction, and
perforate ulcer
2) Episodes of acute pancreatitis may occur

unaccompanied by rise in serum amylase, this
the rule if hyperlipidemia is present
3) This high levels may have returned to normal

before the blood was drawn
Pancreatitis, Acute
Urine amylase excretion is a similar but somewhat more accurate test for pancreatitis
► Value above 5000 IU/24 hours are abnormal

Serum amylase
The ratio amylase clearance / creatinine clearance
► is increased in patients with acute pancreatitis

► but is normal in other causes of hyperamylasemia
►The clearance ratio is calculated as follows:

(Urinary amylase)/(Serum amylase) x (Serum
creatinine)/(Urine creatinine) x 100%
Imaging Studies
►The most frequent finding is isolated
dilatation of a segment of gut (sentinel
loop) consisting of:▼
jejunum
transverse colon or
duodenum adjacent to
pancreas
Pancreatitis, Acute
Imaging Studies
Gas distending the right colon that abruptly
stops in the mid or left transverse colon
(colon cutoff sign) is due to colonic
spasm adjacent to the pancreatic
inflammation
Pancreatitis, Acute
Imaging Studies
Chest films may reveal a pleural effusion
on the left side
Occasionally, a radiopaque gallstone will

be apparent on plain X-rays
An ultrasound study may demonstrate

gallstones early in the attack
Pancreatitis, Acute
Complications
1) The principal complications of acute pancreatitis
are:
► abscess and
► pseudocyst formation
2) Gastrointestinal bleeding may occur from:

► adjacent inflamed stomach or duodenum
► rupture pseudocyst, or peptic ulcer
Pancreatitis, Acute
Complications
3) Intraperitoneal bleeding may occur
spontaneously from the:
*celiac or *splenic artery
*or from the splenic vein thrombosis
4) Involvement of the transverse colon by the

inflammation process may result in colonic:
*obstruction
*hemorrhage
*necrosis or *fistula formation
Pancreatitis, Acute
Treatment
A) Medical treatment
The goals of medical therapy are reduction of:
1) pancreatic secretory stimuli and
2) correction of fluid and electrolyte derangements

Pancreatitis, Acute
Treatment
1) Gastric suction
2) Fluid replacement
3) Analgesic
4) Anticholinergics
5) Antibiotics
6) Calcium
7) Oxygenation
Pancreatitis, Acute
Treatment
8) Miscellaneous methods of treatment
a) Peritoneal lavage
b) Nutrition (total parenteral nutrition, TPN)
c) Other drugs:
e.g.: glucagon
Pancreatitis, Acute
Treatment
B) Surgery
Surgery is generally contraindicated in
uncomplicated acute pancreatitis
However, when the diagnosis is uncertain,

diagnosis laparotomy is not thought to
aggravate pancreatitis
Pancreatitis, Acute
Prognosis
The mortality rate in acute pancreatitis is about 10%
Respiratory insufficiency and hypocalcemia

indicate a poor prognosis
The mortality rate of acute hemorrhagic pancreatitis

exceeds 50%
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Pancreatitis, Acute

muscular guarding (68%) and

Guarding tends to be more pronounced in the

A minority of patients exhibit jaundice (28%)

►Pleural effusion, or a more serious condition,

In addition, patients with severe acute pancreatitis

*The Grey-turney sign:

► Liver function studies are usually normal

An elevated serum RNase correlates positively

and generally remains elevated for about 2 days

Although it is the most valuable and most frequently performed diagnostic

2) Episodes of acute pancreatitis may occur

3) This high levels may have returned to normal

► Value above 5000 IU/24 hours are abnormal

► is increased in patients with acute pancreatitis

►The clearance ratio is calculated as follows:

Occasionally, a radiopaque gallstone will

An ultrasound study may demonstrate

2) Gastrointestinal bleeding may occur from:

4) Involvement of the transverse colon by the

1) pancreatic secretory stimuli and

2) correction of fluid and electrolyte derangements

However, when the diagnosis is uncertain,

Respiratory insufficiency and hypocalcemia

The mortality rate of acute hemorrhagic pancreatitis

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