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Acute pancreatitis - define and treat.
- Define: Acute inflammation, varies from mild edema to severe hemorrhagic necrosis
- Causes: 1) Gallbladder disease, gallstones, 2) chronic alcohol intake; less common include trauma, viral infections (mumps, coxsackievirus B, HIV), duodenal ulcer, cysts, abscess, cystic fibrosis, Kaposi sarcoma, drugs, metabolic disorders, vascular disease, idiopathic
- What happens: Autodigestion of pancreas by pancreatic enzymes
- How: Trypsinogen (inactive proteolytic enzyme produced by pancreas) + enterokinase = trypsin; this should occur in the intestines; if it occurs in pancreas, trypsin causes autodigestion and activates other proteolytic enzymes such as elastase and phospholipase A, which result in further pancreatic autodigestion
- Clinical manifestations: LUQ to mid abdominal pain; sudden onset, severe, deep piercing, continuous or steady; aggravated by eating or recumbent position; not relieved by vomiting; may have flushing, cyanosis, dyspnea, nausea and vomiting, low-grade fever, leukocytosis, hypotension, tachycardia, jaundice
- Lab tests: Elevated serum amylase (24-72 hours), elevated lipase (elevates and stays elevated)
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Grey-Turner's sign.
- Areas of ecchymosis, bluish flank discoloration
- Takes 24-48 hours to appear
- Can predict severe attack of acute pancreatitis
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Cullen's sign.
- Ecchymosis, bluish periumbilical discoloration
- Takes 24-48 hours to appear
- Can predict acute pancreatitis
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Pancreatic pseudocyst.
- Cavity continuous with or surrounding the outside of the pancreas
- Fills with necrotic products and liquid secretions (plasma, pancreatic enzymes, inflammatory exudates)
- Manifestations include abdominal pain, palpable epigastric mass, nausea, vomiting, anorexia
- Elevated serum amylase
- Usually resolves spontaneously within a few weeks, but may perforate, causing peritonitis, or rupture into stomach or duodenum
- Treatment includes internal drainage procedure with anastomosis between pancreatic duct and jejunum
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Pancreatic abscess.
- Large fluid-containing cavity within the pancreas
- Results from extensive necrosis in the pancreas
- Manifestations include upper abdominal pain, abdominal mass, high fever, leukocytosis
- Requires prompt surgical drainage to prevent sepsis
- Complications include pleural effusion, atelectasis, pneumonia, hypotension, and tetany (hypocalcemia)
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Pancreatitis - collaborative care.
- Relief of pain
- Prevention or alleviation of shock - IV fluids, volume expanders (dextran, albumin); vasoactive drugs (dopamine/Intropin) to reduce hypotension
- Reduction of pancreatic secretions and stimulation - NPO, NG suction to reduce stomach acids
- Control of fluid and electrolyte imbalances - Lactated Ringers, other electrolyte solutions
- Prevention or treatment of infection
- Removal of precipitating cause (if possible)
- Aggressive rehydrationPain management - IV morphine, spasmolytics (nitroglycerine, papaverine)
- Management of metabolic complications
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Chronic pancreatitis, obstructive and calcifying.
- Continuous, prolonged, inflammatory and fibrosing process of the pancreas; pancreas becomes progressively destroyed and replaced by fibrotic tissue
- Chronic obstructive pancreatitis: Associated with biliary disease, most commonly caused by inflammation of the sphincter of Oddi associated with cholelithiasis; other causes include cancer of ampulla of Vater, duodenum, or pancreas
- Chronic calcifying pancreatitis: Inflammation and sclerosis mainly in the head of the pancreas and around pancreatic duct; also called alcohol-induced pancreatitis
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Cholelithiasis.
- Gallstones (stones in the gallbladder), predominantly made from cholesterol
- Develop r/t imbalance between cholesterol, bile salts, and calcium
- Treatment includes sphincterotomy and mechanical removal, extracorporeal shock-wave lithotripsy (ESWL), and cholecystectomy (gallbladder removal)
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Cholecystitis.
- Inflammation of the gallbladder
- Usually associated with gallstones (cholelithiasis) or biliary sludge
- Acalculous (without gallstones) cholecystitis can occur from prolonged immobility and fasting, prolonged parenteral nutrition, diabetes mellitus, bacteria (E. coli), or chemical irritant
- Manifestations include RUQ to mid abdominal pain, nausea, vomiting, restlessness, diaphoresis, right shoulder blade pain
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Gallbladder cancer.
- Primary cancer of gallbladder is uncommon
- Majority are adenocarcinomas (cancer of epithelium that originates in glandular tissue)
- Relationship between gallbladder cancer and chronic cholecystitis and cholelithiasis
- Symptoms similar to cholecystitis
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