Which of the following does not correlate with severity of acute pancreatitis?
Ans. b. Serum amylase (Ref: Sabiston 19/e p1519-1526; Schwartz 9/e p1179-1185; Bailey 26th/1127-1129, 25th/1139-1144; Blumgart 5th/841-851; Shackelford 7/e p1123-1130)Level of amylase does not correlate with severity of acute pancreatitis.Assessment of Severity of Acute PancreatitisSevere pancreatitis is diagnosed if three or moreQ of the Ranson's criteria are fulfilled.The main disadvantage is that it does not predict the severity of disease at the time of the admission because six parameters are only assessed after 48 hours of admission.An APACHE II score of > 8Q defines severe pancreatitis. The main advantage is that it can be used on admission and repeated at any time.A CRP level > 130 mg/mLQ defines severe pancreatitis.Ranson's Prognostic Criteria for Non-Gallstone PancreatitisAt AdmissionDuring Initial 48 Hours* Age >55 yearsQ* WBC >16,000Q cells/mm* Blood glucose >200Q mg/dL* Serum LDH >350Q lU/L* AST >250Q U/L* Hematocrit fall >10Q percentage points* BUN elevation >5Q mg/ dL* Serum calcium fall to <8Q mg/ dL* Arterial PO2 <60Q mm Hg* Base deficit >4Q mEq/L* Estimated fluid sequestration >6Q Litres* Age >70 years* WBC >18,000 cells/mm* Glucose >220 mg/ dL* Serum LDH >400 IU/L* AST >250 U/L* Hematocrit fall >10 percentage points* BUN elevation >2 mg/ dL* Serum calcium fall to <8 mg/ dL* Base deficit >5 mEq/L* Arterial PO2 <60 mm Hg* Estimated fluid sequestration >4 LitresPatients with one or two criteria have a predicted mortality of less than 1%, with three criteria (10%) or four criteria (15%); with more than seven criteria 50%.Tools for Predicting Severity in Acute Pancreatitis Ready for Clinical UseOn AdmissionAt 24 HoursAt 48 Hours* APACHE-II Score > 8Q* IL-6* Urea >60 mmol/L* Polymorphonuclear elastase* Urinary trypsinogen 2* Urinary trypsinogen activation peptide* Ranson/Glasgow score > 3Q* CRP >130Q mg/mLModified Glasgow CriteriaThis system comprises eight factors. The presence of any 3 or more within 48 hours of admission defines the patient as having severe disease.Criteria During initial 48 Hours* Age >55 years* WBC count >15,000 cell/mm* Blood urea nitrogen >45 mg/dL* Arterial PO2 <60 mm Hg* Blood glucose >180 mg/dL* Serum LDH >600 IU/L* Serum calcium <8 mg/dL* Serum albumin <3.3 g/dLAcute Physiology and Chronic Health Evaluation (APACHE)-II Scoring SystemAPACHE-II scoring system incorporates 12Q physiological and laboratory parameters as well as age and comorbid conditions to estimate severity of any disease process.The 12 physiologic variables are* Temperature* Heart rate* Respiratory rate* Mean arterial blood pressureQ* Oxygenation* Arterial pHQ* Serum potassium* Sodium* Creatinine* Hematocrit* WBC countQ* Glasgow Coma ScaleQScore >_8 signifies severe, acute pancreatitisQIt can be determined on a daily basisQ.Recently modification of the APACHE-II scoring system with addition of obesity has been proposed.The APACHE-O scale, which adds one point for body mass index (BMI) between 25 and 30, and two points for BMI larger than 30.Balthazar Grading System for Acute Pancreatitis (CT scan based)Grade ANormal pancreasQGrade BFocal or diffuse pancreatic enlargementQGrade CIntrinsic pancreatic alterations with peripancreatic fat inflammatory changesQGrade DSingle fluid collection/or phlegmonQGrade ETwo or more fluid collections or gas, in or adjacent to the pancreasQComputed Tomography Severity Index (CTSI) for Acute PancreatitisCTSI (CT severity index scoring: system) = Balthazar grade score + necrosis scoreHighest attainable score = 10QPancreatic InflammationPancreatic Necrosis* Normal pancreas0* None0* Focal or diffuse pancreatic enlargement1* < 30%2* Intrinsic pancreatic alterations with peripancreatic fat inflammatory changes2* 30%-50%4* Single fluid collection/or phlegmon3* >50%6* Two or more fluid collections or gas, in or adjacent to the pancreas4 CTSI score:0-3: Mortality 3%, morbidity 8%4-6: Mortality 6%, morbidity 35%7-10: Mortality 17%, morbidity 92%Acute PancreatitisAP is mild and self-limited in most patientsQRapidly progressive inflammatory response associated with prolonged length of hospital stay and significant morbidity and mortality occur in 10-20%deg of patientsMortality rate: Mild pancreatitis <1%; Severe pancreatitis 10-30%Q.MC cause of death in this group of patients is multiorgan dysfunction syndromeQ.First sign of Multi-system organ failure in AP commonly is impaired lung function caused by ARDSQ.Mortality in the first 2 weeks (early phase; Due to multiorgan dysfunctionQMortality after 2 weeks (late period; Caused by septic complicationsQPathophysiology:AP is the final result of abnormal pancreatic enzyme activation inside acinar cellsQ.Colocalization hypothesis: Cathepsin B-mediated intra-acinar cell activation of the digestive enzymes leads to acinar cell injury and triggers an inflammatory response.Intra-acinar pancreatic enzyme activation induces autodigestion of normal pancreatic parenchyma.Acinar cells release proinflammatory cytokines, which propagate the response locally and systemically.The local inflammatory response further aggravates the pancreatitis because it increases the permeability and damages the microcirculation of the pancreas.In severe cases, the inflammatory response causes local hemorrhage and pancreatic necrosisQ.Inflammatory cascade is self-limited in 80-90% of patientsQ.The mortality seen in the early phase of pancreatitis is the result of persistent inflammatory response.Risk factors:Gallstones (MC) and ethanol abuse (2nd MC) account for 70-80% of AP casesQ.In pediatric patients, abdominal blunt trauma and systemic diseasesQ are the two most common conditions that lead to pancreatitis.Clinical Features:Cardinal symptom: Epigastric and/or periumbilical pain that radiates to the back, relieved by sitting and leaning forwardQ.Up to 90% of patients have nausea and/or vomiting that typically does not relieve the pain.The nature of the pain is constantQ.Dehydration, poor skin turgor, tachycardia, hypotension, and dry mucous membranes are commonly seen in patients with AP.Mild pancreatitis: Abdomen may be normal or reveal only mild epigastric tenderness.Severe pancreatitis: Significant abdominal distention, associated with generalized rebound tenderness and abdominal rigidityFlank (Grey Turner)Q, periumbilical (Cullen's sign)Q and inguinal ecchymosis (Fox sign)Q are indicative of retroperitoneal bleeding associated with severe pancreatitis.Dullness to percussion and decreased breathing sounds in the left or, less commonly, in the right hemithorax suggest pleural effusionQ secondary to AP.Diagnosis:Cornerstone of the diagnosis of AP: Clinical findings + elevation of pancreatic enzyme levels in the plasmaQ.Pancreatic EnzymesA threefold or higher elevation of amylase and lipase levels confirms the diagnosisQ.Amylase's serum half-life is shorter as compared with lipase.Lipase is also a more specific marker of APQ because serum amylase levels can be elevated in a number of conditions, such as peptic ulcer disease, mesenteric ischemia, salpingitis, and macroamylasemia.Patients with AP are typically hyperglycemic; they can also have leukocytosis and abnormal elevation of liver enzyme levels.Elevation of ALT levels in the serum in the context of AP has a positive predictive value of 95% in the diagnosis of acute biliary pancreatitisQ.X-ray Abdomen; Localized ileus of duodenum and proximal jejunum (sentinel loop)Q or that of transverse colon up to its mid point (colon cut off sign)Q.IOC for acute pancreatitis: CECTTreatment:Cornerstone of the treatment: Aggressive fluid resuscitationQ using isotonic crystalloid solution with supplementary oxygenNarcotics are usually preferred, especially Buprenorphine >morphineQ as analgesics.In Acute PancreatitisNSAIDs of choiceMetamizoleQOpiate of choiceBuprenorphineQNutritional support: Enteral nutritionQ is associated with less infectious complications and reduces the need for pancreatic surgery as compared to TPN.ERCP: Beneficial for patients with severe acute biliary pancreatitis and cholangitisQ.Laparoscopic cholecystectomy: Indicated for all patients with mild acute biliary pancreatitisQ with the exception of older patients and those with poor performance statusQ
Serum glucose
Serum amylase
Serum calcium
AST
Pathophysiology - Acute Pancreatitis