Acute Pancreatitis

The pancreas is a large gland located behind the stomach and next to the duodenum (the first section of the small intestine). The pancreas has two primary functions:

1. To secrete powerful digestive enzymes into the small intestine to aid the digestion of carbohydrates, proteins, and fat
2. To release the hormones insulin and glucagon into the bloodstream; these hormones are involved in blood glucose metabolism, regulating how the body stores and uses food for energy.

Pancreatitis is a disease in which the pancreas becomes inflamed. Pancreatic damage occurs when the digestive enzymes are activated before they are secreted into the duodenum and begin attacking the pancreas.In this serious disorder, pancreas is digested by its own enzymes Gland is swollen and oedematous in mild cases.Haemorrhagic necrosis occurs in more severe cases.

Aetiology of Pancreatitis

Biliary disease and alcoholism account for 80% cases, complication of renal transplantation, corticosteroids and oral contraceptives, mumps, hyper parathyoidism, hyper lipidemia. Thiazide, frusemide, valpronic acid rifampicin, azathioprin may also be responsible so also blunt abdominal trauma and ERCP.

Clinical features of Pancreatitis

1. Abdominal pain : Agonising, steady and boring character, in the epigastrium, periumbilical, or right hypochondrium region, radiates to the back and chest, flanks, lower abdomen; more intense in supine postion; pain within 12-24hours of consuming alcohol.

2. Nausea and vomiting, abdominal distension.

3. Physical signs : Anxious patient, tachycardia and hypotension, shock, slight jaundice, tender and rigid upper abdomen,erythematous skin nodules, basal rales, atlectasis, pleural effusion left side, absent bowl sounds, palpable pancreatic pseudocyst, a faint lue discoloration around umbilicus (culen’s sign), red purple or green brown discoloration of flanks (Turner’s sign).

Differential diagnosis of  Pancreatitis

Perforated peptic ulcer, acute cholecystitis with biliary colic, renal colic, mesenteric vascular occlusion, acute myocardial infarction, dissecting aortia aneurysm, Poly Arteritis Nodosa (PAN), porphyria, pneumonia.

Diagnosis of Pancreatitis

A.   Laboratory

Serum amylase > 200 Somogyi units

Leucocytosis 15-20,000 cmm.

Raised serum bilirubin (> 4mg/ dl)

Hyperlycemia, hypocalcemia, hypoxemia in 25% patients (PaO₂ < 60mm Hg)

B.     Plain X-Ray : abdomen

Absence of gas in the transverse colon.

C.     Plain X-RAY Chest study may reveals

Elevated Hemidiaphragm,Atelectasis/Consolidation,Pulmonary oedema(?Direct toxic effect/?Cardiosuppression)

Duodeno-jejunal ileus,Pleural effussion is more common

D.    Barium meal X-Ray :Displacement of stomach & duodenum.

E.    Ulterasonography-edematous, enlarged pancreas

F.    C.T.Scan – Most definitive and delineates the extent and nature of inflammation.

Treatment for Pancreatitis

Nasogastric suction, complete bowel rest

Treatment of shock : IV fluids, blood transfusion

IV calcium, treatment of hyperglycemia; antibiotics (Cefotaxime + gentamicin), trasylol, IV rantitidine, somatostatin infusion, IV              glucagons (hastns recovery)

Laparotomy, debridement and drainage of fluid.

Lexipafant, an antagonist of platelet activating factor may help.

Complications of Pancreatitis

Shock, ileus ARDS, DIC

Obstructions to duodenum and common bileduct.

Obstructions to duodenum and common bileduct

Upper G.I. Bleeding

Pancreatic abscess, phlegmon, Pseudocyst, Pancreatic ascites, left sided pleural effusion, Purtscher retinopathy.

Prognosis of Pancreatitis

The over all mortality is 10-20% which may go upto 50% in haemorrhagic pancreatitis. Pancreatitis secondary to gallstones is curable whereas alcoholic pancreatitis recurs if alcohol consumption continues. Poor prognostic factors are-advanced age, WBC above 16000/cmm, blood glucose above 200 mg / dl, LDH above 350 IU/IL, peritoneal bleed, hypoalbminemia and azotemia.