الفهرس 
ACUTE PANCREATITISOnly 14 pages are availabe for public view
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Abstract
A
cute pancreatitis refers to inflammation of the pancreas, causing sudden and severe abdominal pain. The pancreas is an organ that lies in the back of the mid-abdomen. It produces digestive juices and certain hormones, including insulin. Pancreatitis usually develops as a result of gallstones or moderate to heavy alcohol consumption over a period of years. Most attacks of acute pancreatitis do not lead to complications, and most people recover uneventfully with medical care. However, a small proportion of people have a more serious illness that requires intensive medical care. In all cases, it is essential to determine the underlying cause of acute pancreatitis and, if possible, to treat this condition to prevent a recurrence.
Pathogenesis:
The exocrine pancreas produces a variety of enzymes, such as proteases, lipases, and saccharidases. These enzymes contribute to food digestion by breaking down food tissues. In acute pancreatitis, the worst offender among these enzymes may well be the protease trypsinogen which converts to the active trypsin. Trypsin is most responsible for auto-digestion of the pancreas which in turn causes the pain and complications of pancreatitis.
Symptoms and Signs:
The acute attack frequently begins following a large meal and consists of severe epigastric pain that radiates through to the back. The pain is unrelenting and usually associated with vomiting and retching. In severe cases, the patient may collapse from shock.Depending on the severity of the disease, there may be profound dehydration, tachycardia, and postural hypotension. Myocardial function is depressed in severe pancreatitis, presumably because of circulating factors that affect cardiac performance. Examination of the abdomen reveals decreased or absent bowel sounds and tenderness that may be generalized but more often is localized to the epigastrium. Temperature is usually normal or slightly elevated in uncomplicated pancreatitis. Clinical evidence of pleural effusion may be present, especially on the left. If an abdominal mass is found, it probably represents a swollen pancreas (phlegmon) or, later in the illness, a pseudocyst or abscess. In 1–2% of patients, bluish discoloration is present in the flank (Grey Turner sign) or periumbilical area (Cullen sign), indicating hemorrhagic pancreatitis with dissection of blood retroperitoneally into these areas.
Pancreatitis diagnosis:
Diagnosing acute pancreatitis can be difficult because the signs and symptoms of pancreatitis are similar to other medical conditions. The diagnosis is usually based upon a medical history, physical examination, and the results of diagnostic tests.
Laboratory Tests-Because pancreatic acinar cells synthesize, store, and secrete a large number of digestive enzymes (e.g., amylase, lipase, trypsinogen, and elastase), the levels of these enzymes are elevated in the serum of most pancreatitis patients. Because of the ease of measurement, serum amylase levels are measured most often.
Imaging tests-Imaging tests provide information about the structure of the pancreas, the ducts that drain the pancreas and gallbladder, and the tissues surrounding the pancreas. Imaging tests may include an x-ray of the abdomen, chest, CT scan or MRI of the abdomen.
Assessment of disease severity:
Accurate prediction of severity early in the course of disease offers potential benefits in that complications can be anticipated and detected early through the use of intensive monitoring and frequent clinical assessment, and early and aggressive therapies can be instituted to attempt to prevent these complications. Routine clinical assessment at the time of admission is associated with low sensitivities (<50%) in identifying patients with SAP. Therefore, alternative methods for assessing disease severity based on scoring systems, CT scanning, and serum markers have been widely studied. In addition to these methods, hemoconcentration and obesity have been reported to be predictive of severe disease.
Complications:
Complications can be systemic or locoregional:
• Systemic complications include ARDS, multiple organ dysfunction syndrome, DIC, hypocalcemia (from fat saponification), hyperglycemia and insulin dependent diabetes mellitus (from pancreatic insulin producing beta cell damage)
• Locoregional complications include pancreatic pseudocyst and phlegmon / abscess formation, splenic artery pseudoaneurysms, hemorrhage from erosions into splenic artery and vein, thrombosis of the splenic vein, superior mesenteric vein and portal veins (in descending order of frequency), duodenal obstruction, common bile duct obstruction, progression to chronic pancreatitis.
Pancreatitis treatment:
The goals of treatment of acute pancreatitis are to alleviate pancreatic inflammation and to correct the underlying cause. Treatment usually requires hospitalization for at least a few days.
Mild pancreatitis - Mild pancreatitis usually resolves with simple supportive care.
Moderate to severe pancreatitis - Moderate to severe pancreatitis requires more extensive monitoring and supportive care.
During this time you may be given one or more of the following treatments:
• Adequate fluid resuscitation
• Pain control
• Early detection and treatment of additional organ failures
• Prophylactic antibiotics
• Antisecretory or anti-inflammatory treatment
• The indications and timing of surgical therapy or ERCP
Nutritional support during acute pancreatitis:
Early nutritional support plays an important role in preventing serious complications and ensuring optimal recovery in patients with acute pancreatitis and malnutrition
Patients who cannot tolerate oral feeding are given either enteral or parenteral nutrition. In enteral nutrition, nutritional formula is administered into a feeding tube placed into the stomach or small intestine. In parenteral nutrition, nutritional formula is delivered directly into the blood through a catheter in a vein.
For years, TPN has been considered the standard for nutritional support in SAP. The main argument favoring this practice was that intravenous nutritional support was a way of resting the pancreas by eliminating the hormonal stimulation and consequent exocrine secretion.
Nowadays, enteral nutrition (EN) is favored The rationale for the use of EN is based on the premise that enteral feeding maintains the barrier function of the intestinal tract, promotes gut motility, possibly reduces translocation of bacteria or endotoxins, and avoids the infectious complications associated with TPN.