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ACUTE PANCREATITIS

Any severe acute pain in the abdomen or back should suggest the possibility of acute pancreatitis. The diagnosis is established by two of the following three criteria: (1) typical abdominal pain in the epigastrium that may radiate to the back, (2) threefold or greater elevation in serum lipase and/or amylase, and (3) confirmatory findings of acute pancreatitis on cross-sectional abdominal imaging. Pathologically, acute pancreatitis varies from interstitial pancreatitis, which is usually a mild and self-limited disorder, to necrotizing pancreatitis, in which the degree of necrosis may correlate 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 154-1.

TABLE 154-1Causes of Acute Pancreatitis

CLINICAL FEATURES

Can vary from mild abdominal pain to shock. Common symptoms: (1) steady, boring pain in the epigastric and periumbilical region may radiate to the back, chest, flanks, and lower abdomen; (2) nausea, vomiting, abdominal distention.

Physical examination: (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 and lipase values threefold or more above normal almost always secure the diagnosis if gut perforation, ischemia, and infarction are excluded. Serum lipase is the preferred test. There is no correlation between the severity of pancreatitis and the degree of serum lipase and amylase elevations. After 3–7 days, amylase values tend to return toward normal; however, pancreatic lipase levels may remain elevated for 7–14 days.

  2. Other tests: Hypocalcemia occurs in ∼25% of pts. Leukocytosis (15,000–20,000/µL) occurs frequently. ...

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