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home - Pancreas - Pancreatitis - Acute Pancreatitis Diagnosis Written by Dr Sebastian Zeki
Knowledge


Knows the aetiology of acute pancreatitis Understands the means by
which the condition is diagnosed

Is aware of the risk stratification and prognostic scoring systems such
as Glasgow and Ranson; can apply this to the
management plan for individual patients

Knows the complications of severe attacks and the indications for
intervention

Knows how to initiate investigation of patients with recurrent
unexplained attacks of pancreatitis

Skills
Shows ability to make early risk stratification and involve multidisciplinary team and/or intensive care staff when appropriate

Behaviours
Collaborates closely with radiological and surgical colleagues where
appropriate

Transfers patient to a specialist centre in accordance with guidelines

Also...

Knowledge


Understands the causes presentation investigation and
management of chronic pancreatitis

Knows the potential value of the various imaging modalities
Recognises the potential of blood and stool tests

Aware of the exocrine and endocrine consequences of the condition
Recognises complications

Knows the value of endoscopic non-invasive (ESWL) and surgical
intervention

Skills
Can diagnose the condition promptly
Knows possible avenues of treatment both to treat the consequences
of pancreatic insufficiency and to control pain where appropriate

Can recognise complications
Behaviours
Works within multi-disciplinary team and liaises with colleagues in
pain management

Shows empathy with patient and relatives

Also..

Acute Pancreatitis Diagnosis

Causes:Gallstones (3-7%).ETOH (10%).Trauma.Steroids.Mumps.Autoimmune.Scorpion.Hy/lipid/Hy/calcaemia.ERCP/Postoperative (when manipulating pancreas or during hypotension).Drugs( aza/6-MP/thiazid/sulphonamide).FH (hereditary pancreatitis/SPINK 1).Idiopathic.Structural (Pancreas divism/CA/CABG).SOD. INITIAL BLOODS-LFT/amylase/lipaseUSSERCPRECOVERY PHASE- LipidsViral serologyCalciumRECURRENT IDIOPATHICUSS/EUSAutoimmune screenERCP + cytologySOD measurementPancreatic function testsGenetic testing for PRSS1 RadiologyCT is indicatedwith persisting organ failure or sepsis 6-10 days post admission (80% sensitive for necrosis).Repeat CT is indicated if the initial index is 3-10 as routine before discharge.USS Findings include Hypoechoic, diffusely enlarged pancreas.USS cant diagnose pancreatic necrosis.USS is good for pseudocyst follow-up.CT: Can be normal in mild pancreatitis. Diagnostic Criteria for autoim-mune pancreatitis1.Diffuse narrowing of pancreatic duct with irregular wall (>1/3rd length of pancreas)2. Inc IgG/gamma globulin/autoantibodies3. Fibrotic change of pancreas with lymphocytosis and plasma cell infiltrateCT-Diffusely enlarged and hy/choic and low density capsule-like ring around focal massMRI Diffuse narrowing pancreatic duct and bile duct strictureTreatmentsteroidsAssociations: PBC/PSC/RPF/RA/Sjogrens/Sarcoid Grading based upon findings on unenhanced CTGrade/Findings/Score A Normal pancreas - normal size, sharply defined, smooth contour, homogeneous enhancement, retro/itoneal/ipancreatic fat without enhancement - 0 B Focal or diffuse enlargement of the pancreas, irregular contour, enhancement inhomogeneous but no/ipancreatic inflammation -1 C /ipancreatic inflammation with intrinsic pancreatic abnormalities 2 D Intrapancreatic or extrapancreatic fluid collections 3 E >2 large collections of gas in the pancreas or retro/itoneum 4 Necrosis score based upon contrast enhanced CT Necrosis(%) Score 0 0 <33 2 33-50 4 50 6 Amylase ALT Phos-pholi-pase A1 IL6 CRP Lipase IL-8 48 24 12 2 Diagnostic Predict severity Acute pancreatitis- Causes and Investigations PredictorsInitial assessment @24hours @48 hoursClinical impression Clinical impression Clinical impressionBMI >20 CRP > 150 CRP> 150Apache II> 8 Apache ii>8 MOFPleural effusion Persisting organ failure APACHE II scaleIncludes: age, rectal temp, mean arterial pressure, heart rate, PaO2, arterial pH, [K], [Na], serum creatinine, Hct, WCC, GCS, chronic health status Imrie scoring system Age > 55 yearsWCC> 15,000/mm3 (15.0 × 109/L)BG > 180 mg/dL (10 mmol/L) in patients without diabetesLDH > 600 U/LAST or ALT > 100 U/LCa< 8 mg/dLPaO2 < 60 mm Hg Albumin < 3.2 g/dL (32 g/L)Urea > 45 mg/dL (16.0 mmol/L)1 point for each criterion met 48 hours after admission Ranson's criteriaAt admission or diagnosis:Age > 55 yearsWhite blood cell count > 16,000/mm3 (16.0 × 109/L)Blood glucose > 200 mg/dL (11.1 mmol/L)LDH > 350 U/LAST > 250 U/LDuring initial 48 hours:Hct decrease > 10%Urea > 5 mg/dL (1.8 mmol/L)Ca < 2 mmol/LBase deficit > 4 mmol/L (4 mEq/L)Fluid sequestration > 6,000 mLPaO2 < 60 mm Hg Scoring: 1point for each criterion met Severity: Ranson's score of >3 and/or an APACHE II score of >8 within the first 48 hours, organ failure (respiratory, circulatory, renal, and/or gastrointestinal bleeding), and/or local complications (pancreatic necrosis, abscess, or pseudocyst). Most attacks of acute pancreatitis are mild with recovery occurring within five to seven days-Death is unusual (< 3 %) in such patients.15 to 20 % of all cases are severe. Severity Scores Investigations Severity Written by Dr Sebastian Zeki

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