General data. Age: 31 y/o Gender: male Occupation: electronic worker Admission: 92/10/27~92/11/07, total 11 days
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1 General data Age: 31 y/o Gender: male Occupation: electronic worker Admission: 92/10/27~92/11/07, total 11 days
2 Chief Complaint Abdominal pain and vomiting since this morning (92/10/27)
3 Brief Illness 1 31 y/o male Denied all systemic illnesses 2 wks ago, yellow discoloration of skin 92/10/26, abdominal fullness 92/10/27 morning, post-prandial vomiting induced by hiccups
4 Brief Illness 2 Periumbilical pain and left lumber pain Pain was relieved by sitting up Tea colored urine Denied HBV & HCV history, fever Multiple gallstones observed at OPD abd echo on 10/24 ED, elevated amylase and lipase (1332/215) elevated GOT/GPT (96/363)
5 Family History Mother: DM
6 Personal History Smoking: ½ pack for 8 days Alcohol: denied Food allergy: denied Drug allergy: denied Betel nut eating: denied
7 Past History Medical history:denied Surgical history:denied
8 Physical Examination Body weight: 76 Kg Body height: 172 cm TPR: 36.8 / 87bpm/ 18/min BP: 139/96 mmhg Sclera: icteric Abdomen: flat and soft Hypoactive bowel sounds Tenderness (+) Murphy s sign (+)
9 Laboratory Data 1 WBC x10 3 /ul Neut 86.8% RBC 5.74 x10 6 /ul Hb 18.5 g/dl PLT 304 x10 3 /ul
10 Laboratory Data 2 Hemolysis ++ Jaundice + Sugar AC( 血 ) 112 mg/dl Albumin( 血 ) 4.2 g/dl ALK-P( 血 ) 479 IU/L GOT( 血 ) 350 IU/L GPT( 血 ) 949 IU/L γ -GT( 血 ) 734 IU/L Bilirubin D/T( 血 ) 6.9/10.7mg/dl Amylase 414 IU/L Lipase 118 U/L
11 Radiography CXR KUB Ultrasound (US) CT of abdomen
12 CXR No definite active lung lesion No significant abnormality in heart and diaphragm Intact bony thoracic cage
13 KUB 10/27 Negative finding of the abdomen Well visible of bil. psoas outlines
14 KUB 11/09 Gastric gas Bowel gas in T-colon
15 Ultrasound Liver : Increased brightness of parenchyma No space-occupying lesion Fatty metamorphosis, Liver Mild dilatation of IHD
16 Stones, Gallbladder, Multiple, R/O chronic cholecystitis Chronic inflamamatory change of gallbladder wall Multiple GB stone Acoustic shadow
17 Pancreas tail obscured by bowel gas
18 CT of Abdomen 1 Pre-contrast Swollen pancreas Increased density of peripancreatic fat
19 CT of Abdomen 2 Pre-contrast GB stones Swollen pancreas
20 CT of Abdomen 3 Post-contrast Enhanced swollen pancreas GB stones Abdominal aorta
21 CT of Abdomen 4 Post-contrast Enhanced swollen pancreas GB stones Abdominal aorta
22 Differential Diagnosis for Abdominal Pain Acute pancreatitis Pancreatic abscess/necrosis Mesenteric ischemia Visceral perforation Leaking abdominal aortic aneurysm
23 Pancreatic abscess Pancreatic abscess
24 Mesenteric ischemia Ischemic bowel with intramural pneumatosis Bowel wall thickening
25 Visceral perforation free air under right hemidiaphragm Large pneumoperitoneum (arrow) Falciform ligament (arrowhead)
26 Leaking abdominal aortic aneurysm (AAA) AAA Leaking AAA
27 Discussion for Acute Pancreatitis
28 Etiology 1 A. Cholelithiasis Most common cause (45%) B. Chronic alcohol ingestion (35%) C. "Traumatic" causes postoperative stress, ERCP, direct trauma, manometry of the sphincter of Oddi, endoscopic sphincter-otomy, and perforation of a duodenal ulcer
29 Etiology 2 D. Metabolic insults hypertriglyceridemia hypercalcemia (e.g., hyperparathyroidism) renal failure. E. Drugs DDI, DDC, azathioprine, mercaptopurine, valproic acid, acetaminophen, and others
30 Etiology 3 F. Infectious causes viruses (mumps, rubella, CMV, adenovirus, HIV, coxsackievirus B) bacteria (mycoplasma, Campylo- bacter, legionella, Mycobacterium tuberculosis, M. avium complex) parasitic (ascariasis, clonorchiasis) G. Connective tissue disorders (SLE, polyarteritis nodosa, Sarcoidosis) H. Idiopathic causes
31 Symptoms & Signs 1 Mild to severe epigastric pain, with radiation to flank, back, or both: 50 ~ 90 % Characteristics: constant, dull and boring worse in supine position sitting or fetal position heavy meal or drinking Nausea and nonfeculent vomiting: 75 ~ 90 % Retroperitoneal bleeding (hemorrhagic pancreatitis) Cullen s sign (periumbilicus) Grey-Tunner s sign (flank)
32 Symptoms & Signs 2 Tachycardia Tachypnea Hypotension Fever Mild jaundice Diminished or absent bowel sounds Basilar rales, especially in the left lung Muscular spasm hypocalcemia
33 History Alcohol-related pancreatitis Early 30s: secondary to alcohol consumption Estimated consumption of alcohol 150 g/day On average, it develops after four to seven years of drinking Biliary pancreatitis Older adults History of cholelithiasis or intermittent, postprandial RUQ pain
34 Diagnostic Laboratory Factors Amylase Lipase Trypsin Elastase
35 Laboratory data 1 Amylase Increase from 2 ~ 12 hours after the onset of symptoms Peak at 12 to 72 hours Return to normal within 1 week 4X high limit of normal range Urinary amylase activity
36 Laboratory data 2 Lipase Increase within 4 ~ 8 hours after the onset of symptoms Peak at about 24 hours Decrease within 8 to 14 days Specificity (50 ~ 99%) Sensitivity (86 ~ 100%) particularly in alcoholic pancreatitis 2X high limit of normal range
37 Laboratory data 3 Trypsin/Elastase Elevated trypsin level: most accurate Serum trypsin assay: not widely available Urinary trypsin activity: new Elastase level: not better
38 Prognosis Glasgow scoring system APACHE II scoring system Ranson/Imrie criteria
39 Glasgow Scoring System
40 APACHE II Scoring System Acute physiology and chronic health evaluation scoring system
41 Ranson/Imrie Criteria
42 Prognosis According to Ranson/Imrie Criteria Score of Criteria Mortality 2 < 5% 3~4 15~20% 5~6 40% 7 > 99%
43 Management
44 Radiologic Studies of Acute Pancreatitis Chest x ray films Plain radiography Ultrasound Computed tomography (CT) Endoscopic Retrograde Cholangiopancreatography (ERCP)
45 Radiologic studies 1 Chest x ray films Pleural effusion Diffuse alveolar interstitial shadowing ARDS Pleural effusion
46 Radiologic studies 2 Plain Radiographs None for specific diagnostic purposes Gas-filled duodenum (sentinel loop) Colon cut off Renal halo sign Retroperitoneal gas: infection GB stones Calcification
47 Cut off sign Gaseous distention of colon from right colon with an abrupt termination at the level of splenic flexure No gas below this point in colon or in small bowel
48 Retroperitoneal gas mottled gas to left of spine large gas collection in lesser sac with fluid laterally
49 Pancreatic calcification Calcification of pancreas
50 Radiologic studies 3 Ultrasound Swollen pancreas Peritoneal fluid Pancreatic calcification GB stones Dilatation of bile duct
51 Radiologic studies 4 Computed Tomography (CT) Pancreatic glandular edema Peripancreatic fat stranding Pancreatic/peripancreatic fluid collections Necrosis Pseudocyst Advantage severe symptoms, fever or persistent leukocytosis assess complications
52 Peripancreatic fat stranding Peripancreatic fat (arrows) Pancreas: relatively normal Pancreas
53 Necrosis Peripancreatic and retroperitoneal edema Large non-enhancing areas of necrosis in the body and neck of the pancreas (arrows).
54 Pancreatic pseudocyst A well defined fluid collection (arrow) in retroperitoneum just below pancreas
55 Radiologic studies 5 Endoscopic Retrograde Cholangiopancreatography (ERCP) Primarily indicated in biliary obstruction Enable endoscopic sphincterotomy and remove impacted stones Risks: precipitating an acute episode of pancreatitis infection hemorrhage and perforation
56 ERCP
57 CT Severity Index (CTSI) Balthazar et al Grade of pancreatitis with the extent of pancreatic necrosis
58
59 Prognosis According to CTSI CTSI Mortality Complication rate 0-3 3% 8% 4-6 6% 35% % 92%
60 Degree of Confidence Clavien et al Prospective study of 202 patients Sensitivity 92% and specificity 100% Balthazar et al Overall accuracy of 80-90% (pancreatic necrosis) Block et al Positive predictive value 92% (CECT for pancreatic necrosis)
61 Reference Matthew Freedman: Clinical imaging: an introduction to the role of imaging in clinical practice, pp , 1998 Dr. 葉偉成 : 基礎腹部影像學 (3 rd ed.), 2002, 中華中西醫學影像研究中心 Peter Armstrong, Martin L. Wastie: Diagnostic imaging (4 th ed.) 1998, Blackwell Science Ltd., pp United Kingdom guideline for the management of acute pancreatitis. Gut 1998; 42 (suppl 2): S1-S13 Braunwald, Fauci, Kasper, Hauser, Longo, Jameson. Harrison s principles of internal medicine, sec. 3 Disorder of the pancreas (15 th ed.), pp , 2001, McGraw-Hill Co., Inc. American family physician Diagnosis and management of acute pancreatitis ( Ghattas Khoury, MD: emedicine Pancreatitis (
62 Glenda Romero-Urquhart, MD: emedicine Acute pancreatitis ( Pancreas.org patients>pancreas test>ercp ( CUHK Department of diagnostic radiology & organ imaging gastrointestinal imaging: acute pancreatitis ( CT is us ( Balthazar EJ, Ranson JH, Naidich DP, Megibow AJ, Caccavale R, Cooper MM. Acute pancreatitis: prognostic value of CT. Radiology 1985; 156(3): Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis. Radiology 1990; 174(2): Balthazar EJ: Acute pancreatitis: assessment of severity with clinical and CT evaluation. Radiology 2002; 223:
63 Thanks for your attention!!
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