Acute Pancreatitis ICD-9CM Code 577.0 Acute Pancreatitis 1. Etiologic Factors: A. Metabolic: 1. Alcohol 2. Hyperlipoproteinemia 3.

Drugs eg Thiazide Diuretics 4. Genetic B. Mechanical: 1. Gallstones blocking the Sphincter of Oddi 2. Traumatic Injury 3. Perioperative Injury C. Vascular: D. Shock E. Atheroembolism F. Polyarteritis Nodosa G. Infections: 1 .Mumps 2. Coxsackie Virus 3. Mycoplasma Pneumonia

2. Etiology and Pathogenesis: A. The Anatomic Changes Of Acute Pancreatitis Reflect Two Fundamental Events 1. Autodigestion Of The Pancreatic Substance By Inappropriately Activated Pancreatic Enzymes 2. Cellular Injury Response Mediated By Proinflammatory Cytokines B. Among Many Possible Activators Of The Pancreatic Enzymes A Major Role Is Played By Trypsin Which Itself Is Synthesized As A Proenzyme In The Acinar Cells Of The Pancreas. Here The Proenzymes Are Activated And Escape From The Zymogen Granule Within The Acinar Cell.The Activated Enzymes Cause Disintegration Of The Acinar Cells And Fatty Tissue Around The Pancreas Damaging The Blood Vessel Walls and Causing Vascular Leakage C. The Other Result Of Premature Enzyme Activation Is The Acinar Cell Injury Response. Damaged Acinar Cells Release Potent Cytokines And Attract PMNLs And Macrophages. These Inflammatory Cells Release More Cytokines Such As TNF, IL 1 Nitric Oxide And Platelet Activating Factor, Amplifying The Local And Systemic Response. D. Acute Pancreatitis Occurs In Two Settings: 1. Pancreatic Duct Obstruction By Gallstones or Intrahepatic Stones That Develop In Alcoholism 2. Bile Reflux or Duodenal Juice Reflux Do Not Appear To Be A Factor In Acute Pancreatitis As Was Once Thought 3. The Degree Of Pancreatic Injury Appears To Be Proportional To The Duration Of Ampullary Obstruction By An Impacted Gallstone 4. Primary Acinar Cell Injury is Most Clearly Involved In The Pathogenesis Of Acute Pancreatitis Caused by Certain Viruses eg Mumps, Drugs And After Trauma.

3. Clinical Features: A. Localized Epigastric Pain Radiating To The Back B. Shock Caused By : 1. Pancreatic Hemorrhage 2. Release of Bradykinin and PGs C. In the DD of Shock R/O 1. Perforated Peptic Ulcer 2. Acute Cholecystitis 3. Bowel Infarction 4. Laboratory Features: A. Elevated Serum Amylase: 1. Rises Within The First 12 Hours And Drops To Normal Within 48-72 Hours 2. DD : Hyperamylasemia: A. Perforated Peptic Ulcer B. Carcinoma of the Pancreas C. Intestinal Obstruction D. Peritonitis E. Any Disease Impinging On The Pancreas B. Elevated Serum Lipase: 1. Remains Elevated 7-10 Days C. Hypocalcemia: 1. Calcium Is Depleted As It Binds With Fatty Acids Released From Hydrolyzed Fat In the Abdomen. D. Jaundice E. Hyperglycemia F. Glycosuria

5. Course of Disease: A. Mortality Rate : 20-40% B. Causes Of Death: 1. Shock 2. Sepsis 3. Acute Respiratory Distress Syndrome C. Patients Who Recover Must Be Re-Evaluated For Cholecystectomy Because Of The Possible Presence Of Gallstones 6. Rx: A. NPO B. IV Fluids: D5 1/2 NS Or D5 Normal Saline C. Nasogastric Suction D. Pain Medication: Meperidine E. Correct Electrolyte Abnormalities: 1. Replace Caclium and Magnesium As Necessary F.IV Antibiotics: 1. B. Fragilis or Other Anaerobes Cefoxitin, Metronidazole or Clindamycin Plus Aminoglycoside 2. Enterococcus: Ampicillin G. Possible TPN H. Possible Surgical Therapy For: 1. Cholecystectomy For Gallstone Induced Pancreatitis When Acute Pancreatitis Subsides 2. Surgery For Perforated Peptic Ulcer 3. Surgery For Excision and Drainage of Necrotic Or Infected Foci

I. Complications: 1. Pseudocyst: CT Scan Or Ultrasound Guided Drainage 2. Phlegmon: Pancreatic Edema: Supportive Therapy 3. Pancreatic Abscess: A. Gram Stain And Cultures From Guided Percutaneous Aspiration B. Catheter Drainage and IV Antibiotics: Imipenem (Primaxin) 4. Pancreatic Ascites: A. Paracentesis 1. High Amylase Levels 5. GI Bleeding Due To A. Alcoholic Gastritis B. Bleeding Varices C. Stress Ulceration D DIC 6. Renal Failure: A. Hypovolemia Resulting In Oliguria Or Anuria, Cortical Or Tubular Necrosis Or Thrombosis Of Renal Artery Or Vein 7. Hypoxia: A. Caused By ARDS, Pleural Effusion Or Atelectasis J. Surgical Consultation J. Differential Diagnosis: 1. PUD 2. Acute Cholangitis, Biliary Colic 3. High Intestinal Obstruction 4. Early Acute Appendicitis 5. Mesenteric Vascular Obstruction 6. DKA 7. Pneumonia (Basilar) 8. Myocardial Infarction (Inferior Wall) 9. Renal Colic 10.Ruptured or Dissecting Aortic Aneurysm 11.Mesenteric Ischemia