Makindo Medical Notes

Related Subjects: | Acute Cholecystitis | Acute Appendicitis | Chronic Peritonitis | Abdominal Aortic Aneurysm | Ectopic Pregnancy | Acute Cholangitis | Acute Abdominal Pain/Peritonitis | Assessing Abdominal Pain | Penetrating Abdominal Trauma | Acute Pancreatitis | Acute Diverticulitis

Lipase is more useful than amylase as it is equally sensitive but more specific, and it remains elevated for longer. Higher lipase levels do not always correlate with the severity of pancreatitis. Lipase's longer half-life (8–14 days compared to 3–5 days for amylase) is especially useful for patients with delayed presentation.

Initial Management of Acute Pancreatitis
ABC, IV Fluids 3L+/day fluid resuscitation, Catheter, O₂ if hypoxic Effective Analgesia: Morphine 5-10 mg IV and antiemetics FBC, CRP, U&E, LFT, Amylase, Lipase, Ca, Lactate ABG, CXR, AXR, blood and urine cultures Consider Antibiotics if septic NG tube if vomiting, enteral feeding following assessment Consider ITU/HDU for severe disease

About

• Poor correlation between amylase level and severity of pancreatitis.
• Acute inflammation of the pancreas leads to the release of amylase and lipase.
• Significant morbidity and mortality rates.
• May be associated with systemic inflammatory syndrome.
• Increasing incidence due to improved detection and increased alcohol abuse.

Causes

• Gallstones, Alcoholism
• Pancreatic cancer, Post-ERCP complication
• Hereditary predisposition
• Hypertriglyceridaemia, Hyperparathyroidism
• Trauma, Snake bite, HIV, CMV, EBV
• Drugs: steroids, thiazides, azathioprine, sulphonamides
• Fibrates, Statins, ART drugs, Omega 3 fish oils
• Valproic acid, Cisplatin, Erythromycin

Diagnosis Criteria

• Abdominal pain
• ↑↑ amylase or lipase (>3 times upper limit of normal)
• Imaging suggesting pancreatitis (USS/CT/MRI)

Aetiology

• The release of activated proteases such as trypsin, lipase, and amylase causes local tissue injury and a marked inflammatory response, potentially leading to systemic inflammatory response syndrome (SIRS).

Clinical Features

• Epigastric pain radiating to the back, relieved by sitting up
• Tachycardia, tachypnea, hypotension, fever
• Peritonitis, gallstones, alcoholism
• Shocked appearance, Grey Turner's and Cullen's signs

Prognosis - Ranson's Criteria

• On admission: Age > 55, WCC > 16,000, Glucose > 11 mmol/L, LDH > 350 iu/L, AST > 600 iu/L
• First 48 hours: Hct fall > 10%, Calcium < 2 mmol/L, PaO₂ < 8 Kpa, BE > -4 mmol/L, Urea rise > 1.8 mmol/L, Fluid needs > 6L

Prognosis Based on Ranson's Criteria

• 0-2 criteria: <5% mortality
• 3-4 criteria: 20% mortality
• 5-6 criteria: 40% mortality
• 7-8 criteria: 100% mortality

Investigations

• FBC, U&E, Calcium (falls in severe cases)
• Lipids - increased Triglycerides
• Amylase - A raised amylase is not unique to pancreatitis
• Lipase - more specific than amylase
• Imaging: Erect CXR, AXR, USS abdomen within 24 hrs

Complications

• Pancreatic necrosis, pseudocyst, pancreatic abscess
• Ascites, Sepsis, ARDS
• Renal failure, hypocalcaemia
• Chronic pancreatitis

Management

• ABCs with IV fluid replacement and accurate fluid balance monitoring.
• Analgesia (Morphine) and enteral nutrition in severe cases.
• Antibiotics only if sepsis is suspected.
• ERCP and sphincterotomy within 72 hours if gallstones are present.
• Necrosectomy for infected necrosis or abscess.

References

• American College of Gastroenterology Guideline: Management of Acute Pancreatitis