Acute Pancreatitis: Clinical Presentation and Diagnosis

Surgeons and General Practitioners often encounter patients of Acute pancreatitis who are shouting in severe pain in emergency. But how do you diagnose Acute pancreatitis from a wide range of diseases that can exhibit similar presentation? Why not Cholelithiasis? Why not Acid Peptic Disease (APD) or Cholangitis? Let’s find out the basics of Acute Pancreatitis, explaining the concepts in following segments:

Etiology

1. Biliary Colic: Small Gall Stones that tend to pass to Common Bile Duct (CBD) and block sphincter of oddi. Occurs in 50-70% cases.
2. Alcohol abuse: Ethanol causes intra-cellular accumulation of digestive enzymes and their premature activation and release. Additionally, it increases the permeability of ductules, allowing enzymes to reach the parenchyma and cause pancreatic damage. Occurs in 25% cases.
3. Post-ERCP
4. Abdominal trauma
5. Following biliary, upper GI or cardiothoracic surgery
6. Ampullary tumor
7. Drugs: Corticosteroids, Azathioprine, Valproic acid, Thiazides, Oestrogen
8. Hyperparathyroidism
9. Hypercalcemia
10. Pancreas Divisum: is a congenital anomaly in the anatomy of the ducts of the pancreas in which a single pancreatic duct is not formed, but rather remains as two distinct dorsal and ventral ducts
11. Autoimmune pancreatitis
12. Hereditary pancreatitis
13. Viral infections like Mumps, Coxsackie B
14. Malnutrition
15. Scorpion bite
16. Idiopathic

Clinical Presentation

1. Pain: Sudden in onset, severe in intensity, constant in nature, refractory to usual doses of analgesics. Usually, first in epigastrium but may be localized to ether upper quadrant or felt diffusely whole abdomen. Radiates to back in 50% cases.
2. Pain aggregated on lying supine and relieved on leaning forward (retro-peritoneal organ)
3. Nausea, vomiting, and retching (sound of vomiting)
4. Physical Signs include:

• Tachycardia, Tachypnea and Hypotension
• If with mild icterus: Biliary obstruction in gall stone pancreatitis
• If Acute swinging pyrexia: Cholangitis
• If bluish discoloration due to bleeding:

a. Flank: Grey turner’s sign

b. Umblicus: Cullen’s sign: A.P/Ectopic pregnancy/Trauma to liver

4. Per Abdomen:

• Distension due to ileus
• Ascites with shifting dullness (rarely)
• Guarding in upper abdomen
• Pleural effusion: 10-20% cases

Investigations: Diagnosis Criteria

The diagnosis criteria of Acute Pancreatitis can be made if:

1. Clinical presentation with 3-4 times of normal Serum Amylase, i.e, greater than 200 U/L (Normal: 23-85 U/L)
2. Serum Lipase greater than 200 U/L (normal 0-160 U/L)
3. CT Scan

Management of Severe Acute Pancreatitis

1. Admission to HDU/ICU
2. Analgesics
3. Aggressive fluid re-hydration guided with vitals, urine output and central venous pressure and blood gases (ABG)
4. Frequent monitoring of hematological and biochemical parameters (including liver and renal functions, i.e, LFT and KFT), Clotting (PT-INR), Serum Calcium and Blood Glucose (RBS).
5. Antibiotic Prophylaxis (Meropenam, Cefuroxime)
6. Nasogastric Tube, i.e, RT if patient is vomiting
7. CT Scan essential if organ failure, clinical deterioration or signs of sepsis develop
8. ERCP within 72 hours for sever gall stone induced pancreatitis or signs of cholangitis
9. Supportive therapy for organ failure if it develops (inotropes, ventilatory support, hemofiltration, etc.)
10. If nutritional support is required, consider external (nasogastric) feeding

Complications

1. Systemic- More common in first week:

• Cardiovascular- Shock
• Arrhythmia
• Pulmonary: ARDS
• Renal failure
• Hematological- DIC
• Metabolic- Hypocalcemia, Hyperglycemia, Hyperlipidemia
• GIT- Ileus
• Neurological- Visual disturbances, confusion, irritability, encephalopathy
• Miscellaneous- Subcutaneous fat necrosis, arthralgia

2. Local- Usually develop after first week:

• Acute fluid collection
• Sterile pancreatic necrosis
• Infected pancreatic necrosis
• Pancreatic abscess
• Pseudocyst
• Pancreatic ascites
• Pleural effusion
• Portal/Spelnic vein thrombosis
• Pseudoaneurysm

We hope these notes help you correctly predict your diagnosis next time and create a better differential diagnosis when patient comes with these features.