Definition and classification
Acute pancreatitis is an acute syndrome of self-destruction triggered by the activity of pancreatic and peripancreatic intraglandulară own enzymes .
Fundamental lesions of acute pancreatitis are interstitial inflammation , hemorrhage and necrosis . Combining these lesions , topography and their extension are extremely varied making to distinguish three main forms of acute pancreatitis :
– Edematous form , considered mild and potentially reversible and consists of interstitial – edematous acute inflammation . The pancreas is enlarged , easily endured with gelatinous edema and lobulaţie evident;
– Necrotic hemorrhagic form when large haemorrhages leading to the formation of intra- and peripancreatic hematoma . The pancreas is enlarged , with blackish spots or bay bleeding and necrotic areas gray or purplish , soft and friable consistency ;
– Form is characterized by the presence of necrotic glandular necrosis solitary without macroscopic bleeding .
• Alcohol ( 80 % of cases) ;
• gallstones that cause transient obstruction of the duodenum by removing stones ;
• Iatrogenic that occurs when certain medications (steroids , diuretics, chemotherapy , tetracycline , estrogen ) after diagnostic investigations (paragraph pancreatic endoscopy, cholangiography ) or during power -tion with excess parenteral lipid emulsions .
• trauma that occurs after abdominal trauma ( contusions , wounds ) ;
• Metabolic diseases ( hyperlipidemia ) ;
• Endocrine disorders ( hyperparathyroidism ) ;
• Viral infections ;
• idiopathic .
Clinical and laboratory diagnosis
The clinical presentation of acute pancreatitis has multiple choices between two extremes : form with easy abdominal discomfort and severe form , dramatic , patented shock and hypoxemia .
Clinical onset is brutal in a patient with a history of biliary , alcohol and occurs in 1-4 hours after a high fat meal or after heavy drinking . Clinical symptoms are:
– Abdominal pain in a bar ( in 90% of cases) , high intensity ;
– Nausea and vomiting ;
– Constipation due to paralytic ileus ;
– Mild fever , anxiety , tachycardia and shortness of breath ;
– In severe patient is agitated, confused or comatose, the flushing, dyspnoea and asthmatic signs hypervolemic shock .
Laboratory diagnosis is established by :
– Bioassays : amilazemia and amilazuria ( increase of 3-4 times higher than normal within 2 -12h ) , lipazemia ( over 20 to 30 times normal) ;
– Ultrasonography and computed tomography (CT ) or MRI are the methods with high accuracy ;
– Empty abdominal radiography is a routine indication to exclude visceral perforation and intestinal obstruction ;
– Chest X-ray may reveal pleural effusion , alveolar infiltrates and others
– Endoscopic retrograde cholangiopancreatography is indicated at 48-72 hours after onset of acute pancreatitis treatment for papillary obstruction .
– Diagnostic laparoscopy to visualize lesions ;
– Paracentesis .
Positive diagnosis of acute pancreatitis is based on suggestive clinical syndrome in conjunction with a significant increase in amylase , lipase and pancreatic changes highlighted the existence of imaging or intraoperative laparoscopic .
Evolution and complications
Acute pancreatitis ( AP ) is evolving whimsical . 80 % of patients with PA edematous forms are submitted.
Early phase is dominated by failure and multiple organ systems : respiratory and renal failure , stress ulcers , encephalopathy . Complications that can occur in PA are:
Seizure pancreatic necrosis demarcation means retro – peritoneal glands and in the second week of illness . Diagnosis is suggested clinically and imaging confirmed .
Extra pancreatic pseudocyst is a collection or intrapancreatic initially without proper wall containing pancreatic fluid and necrotic debris . The diagnosis is suggested by clinical 2-3 weeks after the onset of necrotizing pancreatitis .
Pancreatic abscesses are encysted purulent collections , based intra- glandular , peripancreatic or retroperitoneal . Clinical manifestations occur 3-6 weeks after the onset of AP .
Other complications of PA that occur less frequently : pancreatic hemorrhage , vascular thrombosis ( Spen , portal , mesenteric ) , bile duct necrosis , pancreatic fistula , gastrointestinal fistulas , duodenal stenosis .
PA is one of the major emergencies . Treatment is complex and requires strict individualization and continuous adaptation to the clinical , physiological and evolutionary . Primary therapy of all forms is conservative , patients with severe ( Ranson score above 3 ) must be hospitalized in intensive care .
Drug treatment applied aims to ensure :
– Analgesia , given the severity of the pain . Indicated : iv procaine , xilocaina , petidinicile ;
– Restoring and maintaining blood volume is through large amounts of crystalloid solution , administered through the venous catheter PVC control . Decreased hematocrit and hypoalbuminemia requires administration of albumin, plasma and blood transfusions ;
– Respiratory failure is treated with nasal oxygen under monitoring ;
– Acute renal failure treated by adequate volume replacement , adding dopamine infusion ;
Stress – ulcer prophylaxis is achieved by Admin parenteral H2 receptor blockers ;
– Treatment of metabolic disorders include electrolyte and acid-base balancing ;
– Putting at rest the pancreas is achieved by abstention Food and nasogastric suction continues. Will resume oral nutrition with caution ( hipolipidic regime and hypoproteic ) and only after pain remission ;
– Inhibition of exocrine pancreatic secretion can be achieved by administration of anticholinergics ( atropine, probantin ) ;
– Treatment is performed antienzimatic Trasylol or Gordox .
Surgical treatment is different in the two main exports of PA :
1 ) PA by gallstones when emergency response is delayed. Performed laparoscopic intervention will increase diagnostic accuracy by allowing avoiding laparotomy with a potentially aggravating . It consists of : cholecystectomy , cholangiography , drainage tube choledochal Kehr ;
2 ) PA alcoholic when surgery is only at the stage of complications . The intervention consists of capsulotomy , and necretomii pancreatic drainage .