内科学-消化系统教学课件：Acute Pancreatitis

1、Acute PancreatitisJ.H.JH is a 64-yr-old male admitted to an outside hospital with a 4 day history of progressively worsening epigastric pain without radiation. History What other points of the history do you want to know?History, J.H.Characterization of symptomsTemporal sequenceAlleviating / Exacerb

2、ating factors:Pertinent PMH, ROS, MEDS.Relevant family hx.Associated signs and symptoms Consider the FollowingHPI J.H.Pain is constant and unremitting, going through to his backPain started after beer and pizza 4 days prior, progressively worsening sinceNausea and vomiting x 3Some indigestion histor

3、y, never like thisNo relief with OTC Pepcid, Mylanta or AdvilHistory, J.H.No significant past medical or surgical historyNo medicationsNo allergies to medicationsSmokes 1ppd x 40 yrs, and drinks ethanol heavily. He denies drug use.Family history was noncontributory.What is your Differential Diagnosi

4、s?Differential DiagnosisBased on History and PresentationCholecystitisCholedocholithiasisPUDGastritisPancreatitisBowel obstructionMesenteric ischemiaGastroenteritis Appendicitis Hepatitis Diabetes Rectus hematoma Pneumonia Pyelonephritis Trauma w/ duodenal hematoma. Physical Examination What would y

5、ou look for on physical examination?Physical Examination, J.H.Vital Signs: T 38.5 BP 120/70 P 100 R18Appearance: lying still in moderate distress. Not jaundiced and sclera were anicteric. His mucous membranes were dry.Resp: His lungs were clear to auscultation.CV: heart was regular and without murmu

6、rs, rubs, or gallops.Physical Examination, J.H.Abdomen: soft, moderately distended, tender in the mid-epigastric region and right upper quadrant. No palpable masses. Bowel sounds were positive.Extremities: without cyanosis, clubbing, or edema.Rectal exam: no masses, guaiac neg.Would you like to revi

7、se your Differential Diagnosis?Revised DifferentialCholecystitisPUDPancreatitisBowel obstructionMesenteric ischemiaGastroenteritisHepatitisRectus hematomaPneumoniaLaboratory What would you obtain?LabsConsider the followingCBC, Electrolytes, LFTs, CMP, LDH, Amylase, Lipase, PT, PTT, Urinalysis, ABG,

8、Lab Results, J.H.CBC: Hb /HematocritWBC10/3017Electrolytes:Na 135, K3.0, Chloride 98, CO2 37, BUN 15, Cr 1.1, Glu 100, Calcium 8.1LFTs:AST 260, ALT 220, Total Bili 1.9, Alk phosphatase 110Amylase:Lipase:326245PT/PTT:NormalU/A:NormalOther: LDH375Lab Results, DiscussionThis patient has a hypokalemic h

9、ypochloremic metabolic alkalosis from vomiting.He has an elevated amylase and lipase consistent with pancreatitis.On admission he has 4 out of 5 of Ransons criteria and can be expected to become very sick.There are 6 more of Ransons criteria that should be tracked over the next 48 hours.Can you list

10、 Ransons criteria?Ransons Early Objective Prognostic Signs that Correlate with the Risk of Major Complications or DeathOn Admission Non-biliary BiliaryAge 55 70WBC 16 18Glucose 200 220LDH 350 400SGOT 250 250Ransons Early Objective Prognostic Signs that Correlate with the Risk of Major Complications

11、or DeathDuring the Initial 48 Hours Non-biliary BiliaryHematocrit decrease 10% 10%BUN increase 5 mg/dL 2 mg/dLCalcium 8 mg/dL 8 mg/dLArterial Po2 4 mEq/L 5 mEq/LFluid sequestration 6 L 4 L Ransons Prognostic Signs that Correlate with the Risk of Major Complications or DeathNumber of Prognostic Signs

12、0-23-45-67-8% spending 7 Days in ICU44090100Mortality (%)21540100Ransons Early Objective Prognostic Signs that Correlate with the Risk of Major Complications or DeathNote 1. The amylase and lipase levels are not prognostic signs and do not relate to the severity of the attack or prognosis.2. LDH mus

13、t usually be specifically ordered. It is not included with most comprehensive metabolic panels or with most liver function tests.Interventions at this point?Interventions at this pointIVF LR Bolus 1-2 liters then LR at 150cc/hr titrate to urine output/volume statusNPOFoley catheterNG TubeAdmission t

14、o ICUList common etiologies for PancreatitisPancreatitis Alcohol *Gallstones*HyperlipidemiaTraumaTumorIschemiaMedicationsInfectionPost-op/Post-procedureOtherIdiopathicStudiesWhat would you order ?Studies Obstruction Series/Acute Abdominal Series etc.CT Scan: Abd/PelvisCT Scan: OtherFlat/Upright Abdo

15、menHIDA ScanPA/Lat ChestMRCPRUQ USOTHER: EKGUS GBDiscussion of Studies Ultrasound of right upper quadrant is indicated to evaluate gallbladder and bile duct for stones.CT scan should be done after initial stabilization. IV contrast is useful to assess pancreatic viability. Use of IV contrast on pres

16、entation is debated. His initial CT Scan is shown below:Discussion of imaging studyThis is a CT scan of the abdomen done with both oral and IV contrast. It demonstrates edema surrounding the pancreas and is consistent with the laboratory results suggesting pancreatitis. No significant pancreatic nec

17、rosis is noted.My preference is to not use IV contrast on admission if pancreatitis is suspected due to the toxic nature of the dye and the rarity of finding infection on presentation. I do use IV contrast later on in the hospitalization to better discern the amount of necrosis that has resulted as

18、long as the patients renal function is acceptable.Would you like to revise your differential diagnosis?Revised Differential Diagnosis Acute Pancreatitis Choledocholithiasis Cholecystitis Perforated ulcerWhat next?Supportive measuresNothing by mouthearly oral feedings may increase the severity of pan

19、creatic inflammation. Oral feedings should be withheld until resolution of abdominal pain, fever, and leukocytosisFluid and electrolyte repletion and resuscitationRespiratory supportNutritional supportProton pump inhibitorsDVT prophylaxisAntibiotics (debated)AnalgesicsTiming of cholecystectomyGallst

20、ones are present in 60% of non-alcoholic patients with pancreatitis and if allowed to persist, 36 - 63% will develop recurrent bouts of pancreatitis. Cholecystectomy reduces this risk to 2 - 8%. Timing of cholecystectomy75% of patients with acute abdominal pain, gallstones, and elevated amylase have

21、 no gross evidence of significant pancreatitis. Cholecystectomy is safe in this group.In patients with gross evidence of pancreatitis, 80% have mild disease and cholecystectomy is safe but does not alter the course of the pancreatitisIntra-Operative Cholagiogram (IOC) during Laparoscopic Cholecystec

22、tomyThe timing of cholecystectomyIn patients with severe pancreatitis there is an 82.6% morbidity and 47.8% mortality from cholecystectomy if performed within the initial 48 hours. If deferred until the signs of pancreatitis have subsided, morbidity and mortality fall to 17.8% and 11.8% respectively

23、.Timing of cholecystectomyIn patients with severe pancreatitis and an obstructed biliary tree secondary to choledocholithiasis, ERCP and sphincterotomy significantly reduce morbidity related to biliary complications but do not alter the course of the pancreatic inflammation.ERCPHospital CourseThis p

24、atient deteriorates with non-operative treatment. He develops high fevers and hypotension. What could be happening? What would you do next? Repeat CT Scan is shown belowWhat do you see?CT Findings CT scan now shows air in the lesser sac. This is diagnostic of infected pancreatic necrosis. What next?

25、What next?Supportive TreatmentElective Cholecystectomy if caused by gallstones. Endoscopy with ERCP if obstructing stone is identified in the common bile duct.OR if infectedManagement The patient was started on broad spectrum antibiotics and taken to the operating room for pancreatic debridement, ch

26、olecystectomy, and placement of large axiom sump drains. A jejunal feeding tube was also placed at this time.Temporary Abdominal ClosureSump DrainManagementThis patient was slowly weaned from his vasopressor agents and ventilator. Tube feedings were started two days after his debridement. The patien

27、t eventually made a full recovery and was discharged from the hospital approximately 4 months after presentation.ManagementOperative Options includeDebridement and drainage-Mortality 13.9%. 58.3% of patients can be treated with one surgical procedure.Debridement & packing, and dressing changes every

28、 2 - 3 days. Mortality 10.7%.My preference is to debride and drain if all necrotic debris can be easily removed. Otherwise I pack and return to the operating room every 48 hours until the necrotic tissue is fully debrided. At that time, I place drains and close the patient.ManagementPatients who are

29、 not infected should not be operated on.Bradley - Neither the existence nor the extent of necrosis can be used as an indication for surgery. (90.4% survival in patients treated conservatively with over 50% necrosis of the gland and no infection).ManagementThe use of antibiotics in patients with necr

30、osis without infection is debated. Overall mortality does not seem to change significantly, but there is a lengthening of time to develop infection with the use of antibiotics. Antibiotic use, however, has been suggested to increase the risk of infection with resistant organisms.ManagementThe number one determinant of survival is whether infection of the necrotic tissue occurs.Infection is demonstrated by air in the lesser sac/retroperi