Pancreas—Acute Pancreatitis
Concept
Life-threatening condition representing a massive retroperi- toneal burn with tremendous amounts of third-spacing.
May be secondary to alcoholism, gallstones, tumor, elevated triglycerides, medication, or even perforated ulcer.
Way Question May be Asked?
“Called down to the ER to evaluate a patient with severe epigastric pain, vomiting and history of recent alcohol use.
What do you want to do?” May or may not be given his- tory of gallstones or alcohol use. May be given elevated amylase. Need to rule out other causes of severe epigastric abdominal pain including gastritis, perforated ulcer, rup- ture of esophagus if history of emesis, AAA, ischemia, and gastric volvulus.
How to Answer?
Key parts: assessment of severity, determining etiology, aggressive volume resuscitation, appropriate support (nutrition/vent), operative intervention when appropriate, recognition of possible complications
History
Gallstones Alcohol use
Recent new medications
Timing of pain with retching/vomiting History of PUD/AAA
Physical Exam
Complete PE including:
Crepitus over chest/neck (r/o Boerhaave’s)
Abdominal exam (peritonitis, evidence of hemorrhagic pancreatitis)
Prior incisions
Hernias (could this be simply obstruction)
Diagnostic Tests
Complete laboratory panel including amylase, lipase, calcium, albumin, LDH, ABG (depending on sever- ity of illness)
CXR (r/o esophageal rupture)
AXR (look for ileus/sentinel loop/obstruction/aortic calcifications/free air/gallstones)
Ultrasound (look for gallstones, ductal dilatation, examine pancreas, r/o AAA)
Ranson’s criteria
On admission: age > 55 WBC > 16 Glucose > 200 SGOT > 250 LDG > 350 During first 48 h:
Hct fall by 10 BUN rise by 5 Calcium < 8
Fluid sequestration > 600 mL PO2 < 60
Surgical Treatment
(1) supportive care with:
IVF, NPO, NGT, serial labs, H2 blockers, IV anal- gesics
(2) CT scan to evaluate for complications, necrosis (3) Ventilatory/nutritional support where appropriate
(pt will likely deteriorate on Oral Boards and will need txfr to ICU, CVP, intubation, TPN)
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(4) Most pts should improve in next several days (on the exam, of course, your pt will not)
(5) If fails to improve, check repeat CT
(a) FNA if any necrosis present and pt having fever (can observe sterile necrosis)
(b) if FNA +, necrosectomy:
chevron incision open up lesser sac
debride all devitalized necrotic tissues large volume lavage of abdomen leave large drains in lesser sac jejunostomy
(6) Pt will develop epigastric mass (a) CT or U/S to confirm pseudocyst (b) Do not do FNA
(c) +/− ERCP to r/o ductal communication (d) feed past ampulla or TPN for 8 weeks and
reassess (allow wall to mature)
(e) various options for internal drainage depending on location
(7) Pt gets better and cause was gallstones
(a) need MRCP or ERCP pre-op if suspect choldecholithiasis, possible sphincterotomy and stone retrieval
(b) be prepared for intra-op cholangiogram and CBDE
(c) lap chole same admission
Common Curveballs
Pt will develop pancreatic necrosis Pt will develop pseudocyst
Pt will develop pancreatic ascites
Pt will develop ascending cholangitis (change scenario to discussion of how to drain dilated biliary tree) Pt will be pregnant
Pt will have gallstone pancreatitis
Pt will later present with symptoms of chronic pancre- atitis
Pt will develop UGIB related to splenic vein thrombosis
Asking you to discuss use of antibiotics/
somatostatin
Discussing Ranson’s criteria
Pt will have obstructing tumor/gallstone as cause for pancreatitis
Pt will need nutritional/respiratory support and asking you to discuss these modalities
Pt will develop DTs as result of alcohol withdrawl
Strikeouts
Trying to percutaneously drain infected necrosis Not recognizing/appropriately treating complications
of pancreatitis
Failing to rule out other possible causes of severe epi- gastric/abdominal pain
Not being aggressive in your supportive care for the pt Not trying to identify etiology of pancreatitis
Not performing MRCP/ERCP pre-op or IOC intra-op when doing lap chole after bout of pancreatitis
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