Snap Shot A 35-year-old man complains of rapid onset of midepigastric pain with radiation to the back after eating a large meal. Physical exam shows low grade fever, epigastric tenderness, and decreased bowel sounds. Abdominal CT scan shows localized dilation of the upper duodenum and a small collection of fluid in the left pleural cavity. Introduction Life threatening disease Caused by leakage of pancreatic enzymes that autodigest the pancreas More common in males and in a younger age group 70% related to gallstone disease alcohol Etiologies include (PANCREATITIS) Posterior perforation of peptic ulcer Alcohol Neoplasm Cholelithiasis, cholecystectomy, increased calcium biliary tract obstruction Renal disease ERCP Anorexia Trauma Infections Toxins / drugs (thiazides, AZT, protease inhibitors) Incineration Stings (Scorpion) hypertriglyceridemia Presentation Symptoms severe epigastric pain described as steady and boring radiates to the back relieved by leaning forward nausea vomiting weakness low fever (70-85%) shock (20-40%, due to loss of fluid in peripancreatic third space) Physical exam abdominal tenderness without guarding or rebound diminished bowel sounds from a localized ileus Hemorrhagic pancreatitis indicated by Grey Turner's sign (purple discoloration of the flank) Cullen's sign (periumbilical purple discoloration) Jaundice is rare Evaluation Labs: elevated amylase: elevated in 95% of acute attacks during the first 12-24hrs initially increases 2-6 hours after onset of pain elevated lipase Imaging AXR shows sentinel loop isolated, dilated loop of bowel seen in inflammatory conditions caused by inflammation irritating adjacent bowel colon cutoff CXR may shows left sided exudative pleural effusion (present in 10%) CT and ultrasound show peripancreatic fluid pancreatic calcifications Ranson criteria used to determine prognosis examines age, WBC count, glucose, LDH, AST, hematocrit, BUN, and calcium Treatment Acute management includes IV fluids bowel rest NG decompression Abx (controversial) Pain control Surgical debridement if peripancreatic fluid Prognosis, Prevention, and Complications Prognosis is typically determined by CT scan Some sources determine prognosis based on Ranson's 11 criteria: Ranson's Criteria On Admission Within 24-48 hours Age > 55 years HCT drops > 10% BUN increase by 5 mg/dL after resuscitation Serum Ca < 8mg/dL Arterial PaO2 < 60mmHg > 6 L fluid deficit Base deficit > 4 mEq/L Note: amylase and lipase not prognostic WBC > 16,000/μL AST > 250 IU/dL LDH > 350 IU/L Blood glucose > 200 mg/dL Risk of Mortality 3-4 signs 20% 5-6 signs 40% > 7 signs 100% Patients often require ICU and the condition may be fatal Pulmonary complications pleural effusions atelectasis mediastinal abscess ARDS Pseudocyst Chronic pancreatitis Splenic vein throbosis gastric varices in absence of esophageal varices Multiple episodes increase risk of pancreatic cancer