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ACUTE PANCREATITIS

The pathologic spectrum of acute pancreatitis varies from interstitial pancreatitis, which is usually a mild and self-limited disorder, to necrotizing pancreatitis, in which the degree of pancreatic necrosis correlates with the severity of the attack and its systemic manifestations.

ETIOLOGY

Most common causes in the United States are cholelithiasis and alcohol. Others are listed in Table 162-1.

TABLE 162-1CAUSES OF ACUTE PANCREATITIS

CLINICAL FEATURES

Can vary from mild abdominal pain to shock. Common symptoms: (1) steady, boring midepigastric pain radiating to the back that is frequently increased in the supine position; (2) nausea, vomiting.

Physical exam: (1) low-grade fever, tachycardia, hypotension; (2) erythematous skin nodules due to subcutaneous fat necrosis; (3) basilar rales, pleural effusion (often on the left); (4) abdominal tenderness and rigidity, diminished bowel sounds, palpable upper abdominal mass; (5) Cullen's sign: blue discoloration in the periumbilical area due to hemoperitoneum; (6) Turner's sign: blue-red-purple or green-brown discoloration of the flanks due to tissue catabolism of hemoglobin.

LABORATORY

  1. Serum amylase: Large elevations (>3 × normal) virtually assure the diagnosis if salivary gland disease and intestinal perforation/infarction are excluded. However, normal serum amylase does not exclude the diagnosis of acute pancreatitis, and the degree of elevation does not predict severity of pancreatitis. Amylase levels typically return to normal in 48–72 h.

  2. Urinary amylasecreatinine clearance ratio: no more sensitive or specific than blood amylase levels.

  3. Serum lipase level: increases in parallel with amylase level and measurement of both tests increases the diagnostic yield.

  4. Other tests: Hypocalcemia occurs in ~25% of pts. Leukocytosis (15,000–20,000/μL) occurs frequently. Hypertriglyceridemia occurs in 15–20% of cases and can cause a spuriously normal serum amylase level. Hyperglycemia is common. Serum bilirubin, alkaline phosphatase, and aspartame aminotransferase can be transiently elevated. Hypoalbuminemia and marked elevations of serum lactic dehydrogenase (LDH) are associated with an increased mortality rate. Hypoxemia is present in 25% of pts. ...

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