6.

3 Acute pancreatitis In the majority of cases, the diagnosis of acute pancreatitis can be made in the presence of consistent clinical picture and a serum amylase level more than 1200 iu/L or a value of 5 times more than normal upper limit A number of surgical conditions which may also give rise to abdominal pain associated with high serum amylase level are: 1. Perforated peptic ulcer 2. Perforated gall bladder 3. Afferent loop obstruction following gastrectomy 4. Ruptured abdominal aortic aneurysm 5. Mesenteric infarction 6. Ruptured ectopic pregnancy It is important to identify yhose who will have severe attack as they will require intensive supportive therapy and close monitoring for the development of complications. Scoring system for predicting severity of gallstone associated pancreatitis Glasgow(Imrie) score Within 48 hours of admission WBC > 15000/uL PaO2< 60mmH RBS>10 Se albumin<32g/L LDH>600iu/L AST>200SF u/L Blood urea>16mmol/L Se Ca2+<2 mmol/L

If patient has 3 or more of these parameters positive he is considered to be suffering from sever pancreatitis. Thus, for asessment of the severity of attack, the following tests are performed : WBC, RBS,blood urea, se albumin<AST,LDH,se Ca2+, ABG

Other useful investigations : AXR, ultrasound hepatobiliary-pancreas, CT scan CXR, ECG, serum electrolytes Management of acute pancreatitis: 1. Nil orally and nasogastric tube, hourly aspiration and free flow(in severe pancreatitis). Feeding can be started in mild pancreatitis. 2. Consider CVP line in sever cases. 3. Monitoring Hourly BP,PR initially Hourly urine output 4 hourly temperature CVP reading 2-4 hourly initially 4. Oxygen therapy may be required 5. Pain relief Use tramadol or Pethidine. Avoid morphine 6. Fluid replacement Shock is the principal of death in the first 48 hours , therefore fluid replacement is very crucial Choice of fluid: crystalloid, plasma, whole blood determined by the clinical signs, Hb/PCV and serum albumin Volume and rate of infusion must be adjusted according to CVP reading, urine output, and BP. Strict record of I/O chart is essential 7. Metabolic and electrolytes imbalance Hyperglycemia Hypocalcemia consider insulin therapy consider IV calcium gluconate

8. Suppression of pancreatic secretion Somatostatin/octreotide may be used Dose : octreotide s/c injection 0.1 mg tds for 5 days This should be given early upon admission

This efficacy of octreotide has not been proven 9. Antibiotics Consider when infectins is suspected, pancreatic or biliary, or severe pancreatitis 10.Nutrition TPN may be necessary in severe cases especially those with complications 11.Surgery Early surgical interventions Gallstone pancraetitis ERCP indicated Pancreatic necrosis(infected)

7.0 Deep vein thrombosis

- 1/3 of postoperative patient develop DVT(1/2 are occult) - 10% of patient with DVT develop pulmonary embolism

VIRCHOWS TRIAD 1. Intimal damage 2. stasis 3. hypercoagulable blood RISK FACTORS 1. Disseminated malignancy

2. multiple trauma 3. previous DVT 4. elderly patients going for surgery 5. non ambulant patients 6. hypercoagulable states postoperative - post splenectomy thrombocytosis -polycythemia -congenital deficiency of antithrombin 3 7. others obesity - age -pregnancy -smoking -dehydration -drugs (OCP, Stilboesterol) DIAGNOSIS: A) CLINICAL fever Tachycardia Swelling and wamth over limbs

B) NON INVASIVE doppler ultrasound C) INVASIVE venogram (gold standard) MANAGEMENT OF DVT PREVENTION

-identify the risk groups and institute prophylactic measures 1. general measures : - mobilisation and leg exercises (reduce venous stasis) - hydration, hemodilution and venesection ( increase blood viscosity and reduce blood flow) 2. mechanical methods : - increase mean blood flow velocity in leg veins and reduce venous stasis , which includes *graduated elastic compression stockings* 3. chemical methods : HEPARIN a) LMWH moderate risk :s/c clexane 20 u (12 hours pre op) High risk : s/c clexane 40u( 12 hours pre op) *continue for 7-10 days or until full ambulation*