Welcome back. Thanks for joining me in this discussion of pancreas under the section of general surgery.
Our discussion of pancreas starts with pancreatitis. Most common etiologies of pancreatitis
in the United States include alcohol and biliary diseases specifically gallstones disease.
The chronicity of pancreatitis is incredibly important. In the acute setting, pancreatitis can quickly
deteriorate into something that causes severe sepsis and hemodynamic instability. Patients with chronic
pancreatitis may develop chronic changes to the pancreas and destruction of the duct system.
That leads to chronic exocrine and endocrine pathologies. It is not completely understood why alcohol
causes acute pancreatitis. For biliary diseases specifically gallstones, the gallstones can escape
the gallbladder, obstruct the common bile duct and specifically at the confluence of the pancreatic
duct and the common bile duct. This leads to obstruction of the pancreatic ducts and autodigestion
and just destruction of the pancreas. There’s also an association of smoking, hypertriglyceridemia,
and of course post procedural. In this image, you see an ERCP as discussed previously in other lectures.
Another risk-factor is the usage of different drugs, such as Didanosine, Tetracyclines or 5-ASA.
What are some common findings for patients who present with pancreatitis? The vast majority of patients
experience abdominal pain specifically in the epigastrium and very classically described
as radiating to the back. Patients may present with nausea or vomiting, although it’s not 100%.
Oftentimes, patient lack appetite. Epigastric tenderness is the classic location for pain. But remember
especially with severe pancreatitis, the pain can be diffuse in nature when the entire peritoneum is irritated.
Laboratory values may be of assistance. The chemistries may actually be normal. Particularly in acute
necrotizing pancreatitis, one may see an elevation of the white blood cell count or leukocytosis.
Liver function tests are commonly obtained for patients who come in with abdominal pain.
You may see a normal or elevated total bilirubin depending on whether or not the common bile duct
is obstructed. Amylase and lipase are typically elevated as is alkaline phosphatase
particularly in the setting of obstruction. It’s important to note Ranson's criteria as a prognostic value
for how the patient will do in the hospital with acute pancreatitis. Ranson's criteria is broken down
into two parts. The first set of Ranson's criteria is determined on admission. These parameters
include leukocytosis greater than 16,000, age greater than 55, glucose greater than 200,
AST greater than 250, and LDH greater than 350. Within 48 hours, Ranson’s criteria is reassessed
on patients with acute pancreatitis. In this setting, we’re specifically looking for how much
resuscitation the patient has gotten. We might see a hematocrit drop greater than 10% as a sign
of fluid retention and potentially marker of more severe disease; a BUN rise greater than 5;
calcium less than 8; arterial pO2 as obtained by an arterial blood gas or ABG less than 60mmHg;
and lastly and very importantly, a base deficit greater than 4 or greater than 6L of fluid resuscitation.
The common thing through all of these Ranson’s criteria is to suggest to you that if a patient
with acute pancreatitis receives a very aggressive resuscitation or extensive resuscitation,
they may have more severe disease and may lead to complications. Are there any imaging studies
that we can use to diagnose pancreatitis? Ultrasound is often used when patients present
with epigastric or right upper quadrant abdominal pain specifically to evaluate for gallstones.
What’s more commonly used as you see in this image is a CT scan or cross sectional imaging
of the abdomen and pelvis to evaluate for pancreas. It’s important to know however, that obtaining
a CT scan of the abdomen and pelvis should not be routinely done for a diagnosis of acute pancreatitis
unless there are two scenarios. One, the diagnosis of the epigastric abdominal pain is uncertain.
You’re looking for other potential etiologies of abdominal pain. Two, the patient looks quite ill
and you’re concerned for severe necrotizing or severe acute pancreatitis.