Acute pancreatitis

• Gallstones (MC), etOH abuse, hypertriglycerides (genetic or acquired from things like DM/hypothyroid)

• Preggers/estrogen/tamoxifen, antiretrovirals, HCTZ, β-blockers

• Hypercalcemia, mumps, post ERCP

• Release of auto-digesting enzymes ➔ inflamed pancreas

  • Inflammation ➔ third spacing ➔ hypotension ➔ ↓ pancreas perfusion ➔ necrotic pancreas

  • Lipase breaks down fat ➔ fatty acid binding of calcium ➔ hypocalcemia

  • Can ➔ pleural effusion, ileus, sepsis

SSX:

• • Epigastric/ABD pain radiating to back, ↑ while supine and with meals

  • N/V, shocky ➔ anuria/oliguria

  • ± fever, jaundice (probably biliary in origin)

  • Retroperitoneal bleeding (2° to necrosis) ➔ ABD ecchymoses

    • CUllen's (periUmbilical), TURNer (turn onto flank)

DX:

• • 2/3 required (meaning you don't need CT if pain & ↑ lipase)

    • Epigastric pain

    • ↑ lipase (specific) or amylase (nonspecific) >3x normal

    • Imaging showing focal/diffuse enlarged pancreas

  • US best initial to assess for gallstones, CT not needed unless worsening

  • ABD X-Ray - Pancreatic inflammation ➔

    • Localized SB ileus ➔ dilation (sentinel loop)

    • Spasm of descending colon ➔ abrupt termination of gas at splenic flexure (colon cut off sign)

  • ↑ ALT means probably biliary in origin

  • Hypocalcemia, ↑ WBC, ↑ CRP, ↑ BUN

  • Ranson criteria (assessed after 48 hrs) assesses severity

TX:

• • NPO & Fluids (LR > NS) unless hypercalcemia (LR is contraindicated)

  • Pain control (demerol > morphine) morphine ➔ ↑ sphincter of Oddi pressure

  • ERCP and cholecystectomy if 2° to gallstones

  • Fenofibrates if 2° to hypertriglycerides

  • ABX if necrotic