Updated: 5/16/2018

Acute Pancreatitis

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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 radiograph shows localized dilation of the upper duodenum and a small collection of fluid in the left pleural cavity.
Introduction
  • Damage to the pancreas causing release of pancreatic enzymes that autodigest surrounding tissue
    • enzymes normally stored/secreted as proenzymes
      • are activated by enzymes in the bowel lumen
    • can be actived pathologically in acute pancreatitis by (PANCREATITIS)
      • Posterior perforation of peptic ulcer
      • Alcohol (most common cause in adults)
      • Neoplasm
      • Cholelithiasis, Cholecystectomy, increased Calcium
        • biliary tract obstruction
      • Renal disease
      • ERCP
      • Anorexia
      • Trauma (seatbelt injury most common cause in children)
      • Infections (mumps)
      • Toxins / drugs (thiazides, AZT, protease inhibitors)
      • Incineration
      • Stings (Scorpion)
  • More common in males and in younger age groups
Presentation
  • Symptoms
    • severe epigastric pain
      • described as steady and boring
      • radiates to the back
        • due to retroperitoneal location of pancreas
      • relieved by leaning forward
    • nausea/vomiting
    • weakness
    • low grade fever
    • shock 
      • due to loss of fluid in peripancreatic third space
        • defined as nonfunctional extracellular fluid
    • tetany
      • hypocalcemia secondary to free digested fats binding ionized calcium 
  • Physical exam
    • abdominal tenderness with guarding or rebound tenderness
    • 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 serum amylase
      • initially increases 2-6 hours after onset of pain
      • also increased in mumps
    • elevated serum lipase
      • has higher sensitivity
    • hypocalcemia (see above)
    • hyperglycemia
      • due to decreased insulin release
  • Imaging
    • AXR
      • sentinel loop
        • isolated, dilated loop of bowel seen in inflammatory conditions
        • caused by inflammation irritating adjacent bowel
      • colon cutoff
    • CXR
      • may show left sided exudative pleural effusion
    • CT and ultrasound
      • CT is gold standard
      • 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 (NPO)
    • NG decompression
    • antibiotics
    • oxygen
  • Pain control
    • meperidine
Prognosis, Prevention, and Complications
  • Patients often require ICU admission and the condition may be fatal
  • Pulmonary complications
    • pleural effusions
    • atelectasis
    • mediastinal abscess
    • ARDS
      • released phospholipase destroys pulmonary surfactant and increases intrapulmonary shunting
  • Pancreatic complications
    • pseudocysts
    • abcess
      • often results in E.coli and Pseudomonas sepsis
    • chronic pancreatitis
  • DIC
  • Splenic vein thrombosis
    • gastric varices in absence of esophageal varices
 

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Questions (1)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
Calculator

(M1.GI.69) A 29-year-old female is hospitalized 1 day after an endoscopic retrograde cholangiopancreatography (ERCP) because of vomiting, weakness, and severe abdominal pain. Physical examination findings include abdominal tenderness and diminished bowel sounds. A CT scan demonstrates fluid around the pancreas. Serum levels of which of the following are likely to be low in this patient? Review Topic

QID: 101126
1

Calcium

48%

(51/106)

2

Glucose

10%

(11/106)

3

Amylase

12%

(13/106)

4

Lipase

15%

(16/106)

5

Triglycerides

14%

(15/106)

M1

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