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