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Diagnosis
Algorithm for managing Acute Pancreatitis
CONFIRMATION OF DIAGNOSIS(Clinical symptoms, Lipase/Amylase, Ultrasound)
ASSESSMENT OF SEVERITY(Clinical Signs, Scoring Systems, Biochemical Markers, contrast CT scan)
MILD SEVERE
ICU
antibioticsimprove FNA
Supportive care InfectionSepsisSurgical debridement
CONFIRMATION OF DIAGNOSIS
CLINICAL SYMPTOMSAND HISTORY
SEVERE ABDOMINAL PAIN NON-ALCOHOLIC
History and PE
• Severe pain, following a substantial meal
• Vomiting does not relieve pain
• Epigastric pain – Knifing or boring
through the back – Relieved with leaning
forward
• Tachycardia, tachypnea hypotension, hyperthermia
• Temp: mildly elevated • Involuntary guarding
over epigastric area • Bowel sounds are
decreased or absent
Laboratory tests – on admission
Normal Values• CBC
– Hgb: 120-160 g/dl– WBC: 5,000-10,000/cumm– PMN: 60-70%
• Serum amylase: 60-180 units• FBS: 70-110 mg/dl• Serum ALP: 9-35 IU• Serum Creatinine: 0.5-1.2 mg/dl • Serum Sodium: 135-145 meq/L• Serum Potassium: 3.5-5 meq/L• Serum Calcium: 8.5-11 mg/dl
Patient’s Results• CBC
– Hgb: 130g/dl– WBC: 16,000/cumm– PMN: 75%
• Serum amylase: 850 units• FBS: 120 mg/dl• Serum ALP: 250 IU• Serum Creatinine: 1.3 mg/dl• Serum Sodium: 145 meq/L• Serum Potassium: 4 meq/L• Serum Calcium: 9 mg/dl
Laboratory tests – on admission
Normal Values• ABG
– PaO2: 90 mmHg– PaCO2: 35-45 mmHg– pH: 7.35-7.45– HCO3: 22-26
• Serum Bilirubin– TB: 0.2-1.0 mg%– DB: 0-0.2 mg%– IB: 0-0.8 mg%
Patient’s Results• ABG
– PaO2: 90 mmHg– PaCO2: 38 mmHg– pH: 7.4– HCO3: 20
• Serum Bilirubin– TB: 2.0 mg%– DB: 1.5 mg%– IB: 0.5 mg%
Laboratory tests – 3rd hospital day
Normal Values• CBC
– Hgb: 120-160 g/dl– Hct: (Adult males) 42%-54% – WBC: 5,000-10,000/cumm– PMN: 60-70%
• Serum amylase: 60-180 units• Serum Sodium: 135-145 meq/L• Serum Potassium: 3.5-5 meq/L• Serum Calcium: 8.5-11 mg/dl
Patient’s Results• CBC
– Hgb: 130g/dl– Hct: 40%– WBC: 19,000/cumm– PMN: 80%
• Serum amylase: 800 units• Serum Sodium: 145 meq/L• Serum Potassium: 3 meq/L• Serum Calcium: 5 mg/dl
Laboratory tests – 3rd hospital day
Normal Values• ABG
– PaO2: 90 mmHg
– PaCO2: 35-45 mmHg– pH: 7.35-7.45– HCO3: 22-26 meq
Patient’s Results• ABG
– PaO2: 95 mmHg @ 5L O2 inhalation
– PaCO2: 40 mmHg– pH: 7.2– HCO3: 15 meq
Serum Markers• Elevated because inflammation of pancreas pancreatic
acinar cells synthesize, store and secrete a large number of digestive enzyme
• LIPASE– Serum indicator of highest probablity of disease
• AMYLASE– Increase almost immediately with onset and peak w/in hours – Remain elevated for 3-5 days – No correlation between magnitude of amylase elevation and disease
severity – False (+): small bowel obstruction, Perforated ulcer, intraabdominal
inflammatory condition– Can also be false (-) in pancreatitis
Radiographic Procedures
• CT Scan - “gold standard”
• Ultrasonography – presence of gallstones
– Endoscopic Ultrasound
• ERCP
Computed Tomography Scan• CT scan is more commonly used to diagnose pancreatitis• Gold standard for detecting and assessing severity of
pancreatitis• CT scan findings:
mild: interstitial edema• Microcirculation of pancreas remain intact• uniform enhancement
Necrotizing:• Microcirculation of pancreas is disrupted• Gland enhancement is decreased
infected necrosis/pancreatic abscess: associated with necrosis and presence of air bubbles
CT Scan
Ultrasound• Best way to confirm gallstone• Detects:
• extrapancreatic ductal dilatation
• Pancreatic edema, swelling• Peripancreatic fluid collection
GYG
• US RESULT:– Liver normal– Gallbladder with
multiple stones; wall not thickened
– CBD 0.8 cm – Pancreas not visualized
Scout film
ERCP• Early ERCP (endoscopic retrograde cholangiopancreatography),
performed within 24 hours of presentation, is known to reduce morbidity and mortality.
• The indications for early ERCP are as follows :– Clinical deterioration or lack of improvement after 24 hours – Detection of common bile duct stones or dilated intrahepatic or extrahepatic
ducts on CT abdomen
• The disadvantages of ERCP are as follows :– ERCP precipitates pancreatitis, and can introduce infection to sterile
pancreatitis – The inherent risks of ERCP i.e. bleeding – It is worth noting that ERCP itself can be a cause of pancreatitis.
ERCP done 3rd hospital day
Assessment of Severity
I. Early prognostic signs - Ranson’s Criteria- APACHE II
I. CT scan findings
Ranson’s Criteria
Ranson’s Criteria – acute gallstone pancreatitis
• Patient – 3rd day hospital admission– Base deficit = 7 meq/L– Serum calcium = 5 mg/dl
• Ranson’s
– Base deficit = 5 meq/L– Serum Ca < 8 mg/dl
Early Prognostic Signs• Prognostic Implications of Ranson’s Criteria:
# of (+) signs Mortality
</=2 0%
3-5 10-20%
>7 up to >50%
Apache II score
Age in yearsHistory of severe organ insufficiency or
immunocompromisedRectal Temperature (Celsius)Mean arterial pressure (mmHg)Heart rate (ventricular response)Respiratory Rate (non-ventilated or ventilated)Oxygenation (use PaO2 if FiO2 < 50%,
otherwise use A-a gradient)Arterial pHSerum sodium (mMol/L)Serum potassium (mMol/L)Serum Creatinine (mg/100 mL)Hematocrit (%)White blood count (total/cubic mm in 1000's)15 minus the Glasgow Coma
APACHE II
Score Interpretation 0-4 ~4% death rate 5-9 ~8% death rate10-14 ~15% death rate15-19 ~25% death rate20-24 ~40% death rate25-29 ~55% death rate30-34 ~75% death rateover 34 ~85% death rate