We have something called Ranson?s
criteria for acute pancreatitis.
I?ve given you a bunch of criteria in
medicine, especially with the GI system,
but what?s most important about the
criteria is that you understand
the concepts and at least know the name
and what type of disease and
what organ system that you?re in,
and that will help you out tremendously.
For example, if you talk about MELD
and that will be the model for end-stage
liver disease. If we say Duke, you?re
thinking about GI system.
If you?re thinking about Gleason,
the prostate system.
You?re thinking Ann Arbor classification,
Hodgkin. Remember all these, right?
Now, some of these you have to know
a little bit more detail than others,
but nonetheless, know what organ system.
The other one that comes to mind is
Jones criteria for rheumatic fever.
On admission, older patient, acute
pancreatitis, -itis means inflammation.
It should be of no surprise that
you found leukocytosis.
-itis of whom? The pancreas.
There?s every possibility
that the insulin might be affected.
Then what happens to glucose?
Hyperglycemia. Don?t just memorize it,
analyze everything that I'm saying here.
Because you have the understanding now,
okay? That?s the power that you have now.
It?s the fact that you have all these
information in your head and everything
that?s being presented here, you?re
actually understanding what?s going on.
It?s beautiful, it really is.
You have lactate dehydrogenase and
AST that might be elevated, meaning to say
that now, you start involving your liver
and company, especially AST.
On admission, within two days, 48 hours,
now at this point hematocrit drops
greater than 10% and now, you're
thinking about anemia kicking in,
kidneys might be affected with BUN
rising. Calcium is going to diminish.
Diminish. The more this calcium
starts dropping or it starts depositing
on your damaged tissue, what kind
of calcification is this?
Good. Dystrophic calcification.
Also with these enzymes causing
damage to the lung, two days later,
you find that your PO2 - What?s your
normal PO2 in the artery?
Approximately 100, right? About 95 to 100.
It dropped down to 60.
This is not good. You have damage
to the lung and base defect,
and you have fluid deficit of greater
than 6 liters, that?s important,
something they call third
Fluid deficit of greater than 6 liters.
You?ve heard of third spacing?
Give me some examples oft hird spacing.
How about third degree burns?
Severe burns in which now the
fluid is escaping into your tissue.
Pancreatitis, there?s every possibility
that third spacing might be a possibility.
So your patient is actually
hypovolemic and is therefore
presenting with hypotension.
So therefore, why are we looking at this?
Greater than three risk factors,
mortality rate 15%. You double this
and you have six of these risk factors,
mortality rate-- it doesn?t get any
worse than this -- 100%.
Acute pancreatitis. What is your
management? Supportive care. Step by step.
Bowel rest. IV fluid, your patient is
hypovolemic. Your patient?s in pain,
so much so that your patient might
actually become addicted on narcotics.
When?s the last time you?ve heard of that?
Let's see this patient.
Young African American boy, playing quite
a bit, and complains of pain in the chest,
pain in the hands, sickle cell disease,
dactylitis. Pain, pain, pain, pain.
Analgesia there as well. Almost
100% of those patients with
sickle cell disease will also
be addicted to narcotics.
Antibiotics. Pancreatitis. You?re
worried about abscess formation.
Antibiotics often empirically given
and definitely reserved for your
necrotizing type of pancreatitis.
You absolutely worry about
infection setting in. This is not good.
Continue here with the pancreas,
it?s the organ for proper digestion.
My goodness. Every food group that
we consume, pancreas plays a role.
Trypsin and company, protein. Lipase,
lipid. Insulin, glucagon, all that?s
carbohydrates granted some as
endocrine and some as exocrine,
but it plays a huge role. So therefore
acute pancreatitis, you?re definitely
worried about proper nutrition. Parenteral
nutrition. ERCP for duct disruption,
meaning to say there might be
a need to remove a stone,
but be careful with that,
you might cause damage.
And if there is going to be abscesses
and pseudocysts that we?ll talk about
in a little bit, then drainage of infected
pancreatic collection is definitely
something that you want
to think of in doing.
At some point, perhaps surgery
is required and you start thinking
about necrosectomy. In other words,
you need to get in there and make sure
that you prevent any further damage
and surgery might be the last resort.
Complications of acute pancreatitis
locally? Something called phlegmon.
Illl-defined fluid collection, usually
sterile locally, acute pancreatitis.
So think about where you are in
the pancreas and pancreatic region
and all the different things that
could occur locally as complications.
The pseudocyst we talked about.
I mean this is pseudocyst,
meaning to say that it?s not a true cyst.
And the reason for that is because
it?s a non-epithelial wall. By definition,
a cyst has a pure or true epithelial wall.
That's not whatever is a pseudocyst.
If infection sets in, your worried about
pancreatic abscess and you might have
pseudoaneurysm of splenic artery.
This is known as hemosuccus pancreaticus
and meaning to say that you have hemorrhage
taking place into it. These are local
complications that you want to keep
in mind for acute pancreatitis.
Systemically, we?ve talked about
a few of these already.
If these enzymes and such then start
getting into the respiratory system or
pulmonary circulation, there?s every
possibility that ARDS might kick in.
Next, kidney damage, renal failure
and with such severe volume deficit
may actually result in shock and
you?re absolutely worried about DIC.
Remember, keep this in mind
I can only give you so many
different angles for DIC, okay?
And by that I mean DIC is an
interesting beast. It really is.
For example, we?ve talked about M3,
acute myelogenous leukemia type 3,
that being DIC, amniotic fluid emboli,
venom, sepsis being a common.
What I?m saying is anything in which
to the bodythere has been pretty massive
alterations or even during pregnancy.
Remember with pregnancy,
especially if we start getting into
the point of what's known as
pre-eclampsia or eclampsia and such,
you might be worried about DIC as well.
What you're paying attention to truly is
what is that major stress the patient
might be then suffering or experiencing
that all of a sudden
triggers DIC and it?s dangerous.