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  • • Abrupt onset of epigastric pain, frequently with back pain

    • Nausea and vomiting

    • Elevated serum or urinary amylase

    • Cholelithiasis or excessive alcohol consumption

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Epidemiology

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  • • A nonbacterial inflammatory disease caused by activation, interstitial liberation, and autodigestion of the pancreas by its own enzymes

    Biliary: 40% of cases; if untreated, high risk of additional acute attacks

    Alcoholic: 40% of cases

    Hypercalcemia

    Hyperlipidemia

    Familial: Usually begins in childhood; chronic pancreatitis often develops

    Iatrogenic: Postoperative; cardiopulmonary bypass, ERCP

    Drug-induced: Corticosteroids, estrogen contraceptives, azathioprine, thiazide diuretics, tetracyclines

    Obstructive: Congenital (pancreas divisum) or after injury or inflammation

    Idiopathic: 15% of patients; there is no identifiable cause of the condition

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Symptoms and Signs

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  • • Severe epigastric pain that radiates through to the back

    • Nausea and vomiting

    • Tachycardia and postural hypotension

    • Normal or slightly elevated temperature

    • Distention and generalized or epigastric tenderness

    • Decreased or absent bowel sounds

    • Abdominal mass due to pancreatic phlegmon, pseudocyst, or abscess

    • Bluish discoloration in the flank (Grey Turner sign) or periumbilical area (Cullen sign), indicating retroperitoneal dissection of blood

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Laboratory Findings

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  • • Either elevated Hct (dehydration) or decreased (hemorrhagic pancreatitis)

    • Moderate leukocytosis

    • Mild elevation of serum bilirubin; greater with choledocholithiasis

    • Elevated serum amylase

    • Elevated serum lipase

    • Increased urine amylase excretion (> 5000 U/24 h)

    • Decreased serum calcium

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Imaging Findings

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  • Abdominal x-ray

    • -Isolated dilation of a segment of gut (sentinel loop) adjacent to the pancreas

      -Distended right colon that abruptly stops in the mid or left transverse colon (colon cutoff sign)due to colonic spasm adjacent to the pancreatic inflammation

      -Calcification suggesting chronic pancreatitis

    Chest film: Left-sided pleural effusion

    CT scan

    • -Perform if no improvement after 48-72 hours

      -May demonstrate phlegmon, necrosis, pseudocyst or abscess formation

    Abdominal US: Gallstones, dilated common bile duct or choledocholithiasis (biliary pancreatitis)

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  • • Elevated amylase levels may occur with gangrenous cholecystitis, small bowel obstruction, mesenteric infarction, and perforated ulcer (rarely > 500 IU/dL)

    • Leukocytosis > 12,000/µL is unusual in the absence of abscess

    • Hemorrhagic pancreatitis: Bleeding into the parenchyma and retroperitoneal structures with extensive necrosis

    • Severe acute pancreatitis

    • -Shock

      -Multiple organ failure

      -Acute respiratory distress syndrome

      -Myocardial depression

      -Renal insufficiency

      -Gastric stress ulceration

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Rule Out

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  • • Acute cholecystitis

    • Penetrating or perforated duodenal ulcer

    • High small bowel obstruction

    • Acute appendicitis

    • Mesenteric infarction

    • Chronic hyperamylasemia

    • Necrotizing pancreatitis

    • Infected necrotizing pancreatitis

    • Pancreatic abscess

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  • • Serum amylase

    • Serum lipase

    • Aspartate transaminase (AST), alanine transaminase (ALT), bilirubin

    • Serum electrolytes

    • CBC

    • Abdominal x-ray

    • Chest x-ray

    • Abdominal US (if biliary source suspected)

    • Abdominal CT scan if no improvement within 48-72 hrs

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When to Admit

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  • • All cases should be ...

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