Acute Pancreatitis Treatment We are going to talk about acute pancreatitis a 35 year old chronic alcoholic comes to emergency department with the VR epigastric pain the epigastric pain is very severe the patient has consumed large amount of alcohol in the last few years and now the patient has epigastric pain.

Which is associated with nause a and vomiting the epigastric pain is radiating towards the back of the patient patient cannot lie down straight on the bed because the pain worsens online down straight so the patient is holding that bigastric area and leaning forward like this when you perform serum amylase and lipase levels in this patient the serum amylase and lipase levels are highly elevated this is a classical presentation of acute pancreatitis.

Now what is acute pancreatitis how do you diagnose it how does it present and how do you manage it in emergency department today we will talk about it in detail first of all what is acute pancreatitis acute pancreatitis is an acute condition of diffuse pancreatic inflammation and auto digestion of pancreas which presents with abdominal pain and raised pancreatic.

Enzymes now remember pancreas produces enzymes that cause digestion of the food but in acute pancreatitis instead of digesting the food those enzymes are digesting the pancreas that is called as acute pancreatitis and it presents with raised pancreatic enzyme.

Since the there is auto digestion of pancreas going on that damage to the pancreas releases that enzymes and those enzymes are present in blood with amylase lipase levels elevated in blood raised pancreatic enzymes associated with auto digestion caused by Auto digestion and inflammation of the pancreas that is called as acutepancreatitis Acute Pancreatitis Treatment.

Acute Pancreatitis Treatment Now coming to the etiology of acute pancreatitis in the etiology of acute pancreatitis we want to know that what is causing the auto digestion of the pancreas from its very own enzymes to understand that the most common cause is gallstones in 40 percent of the cases you will see gallstones as the cause of acute pancreatitis to understand.

It you need to understand the Basic Energy that gall bladder opens into common bile duct gallbladder produces bile and that enters the common bile duct and common bile duct is joined by the pancreatic duct the pancreatic duct which is producing the pancreatic enzymes this is the pancreatic duct and the common bile duct join each other at ampulla of Veteran they have a common opening into the GI tract no.

If a person is suffering from gallstones that patient can have gallstones dislodged from the gallbladder and those gallstones can travel in the common bile duct and they get stuck at the Imperial of water now the path way of pancreatic enzymes is blocked the duct of pancreatic enzyme is blocked and the pancreatic enzymes are now backed up in the pancreas.

The pancreatic enzymes are backed up in the pancreas and they get activated within the pancreas and when they get activated within the pancreas they digest the pancreas they eat up the pancreas that causes acute pancreatitis gallstones is a common cause of acute pancreatitis second common cause is ethanol alcohol damages the pancreas and causes acute pancreatitis trauma is an important cause of acute pancreatitis especially in children.

Who are wearing seat bel tson their epig astrium and when if an accident takes place and that seat belt puts pressure on the epigastric area and puts pressure on the pancreas and damages the pancreas resulting in acute pancreatitis steroids can cause acute pancreatitis mumps auto immunedestruction of pancreas scorpions sting can cause acute pancreatitis hyper calcemia with calcium levels greater than 10.5 milligram per deciliter.

The calcium acts as a catalyst and detective which the pancreatic enzyme and results in Auto digestion of the pancreas hypertrigly ceridemia with triglyceride levels greater than 1000 milligram perdeciliter can cause acute pancreatitis ercp ercp is a diagnostic and therapeutic procedure done byg astroenterologists can cause acute pancreatitis important include exotherapy and sulfonamide’s Loop Diuretics thiazide diuretics steroids will provide the adenosone protease inhibitor estrogen.

These scan cause acute pancreatitis you can remember it with the simple mnemonic get smashed now coming to the patho physiology the patho physiology is just the same the pancreatic duct gets obstructed and when the pancreatic duct is obstructed the enzymes are backed up in the pancreas and they get activated within the pancreas and.

They result in Auto digestion and destruction of the pancreas and when ever there is auto digestion and destruction of the pancreas the immune system gets active immune system wants to clean Acute Pancreatitis Treatment up the debris clean up the digested material but in the process of cleaning up the digested material its releases inflammatory cytokines.

It releases inflammatory cells and sometimes this immune response also causes organ failure in these patients the inflammatory cells get attracted the release cytokines and results in inflammation of the pancreas and sometimes this inflammation is to such a severe extent that it results in organ dys function it results in acute respiratory distress syndrome.

Now when the immune system gets activated it releases cytokines and those cytokines cause capillary leakage they cause vasodilation and leakage Acute Pancreatitis Treatment of the capillaries When ever there is vasodilation there is hypotension and when there is hypotension the hearttries to pump more and more blood and there is tachycardia tachycardia with hypotension the skin of the hand and arms will be flushed and warm because of the vasodilation.

There is excessive vasodilation hypotension and tachycardia that is the classical presentation of distributive shock and multi-organ failure that’s why the immune response to clean up those digested materials of pancreas even results in multi organ failure of the patient now coming to the clinical presentation of acute pancreatitis the clinical presentation of acute pancreatitis is very simple the patient has constant severe epigastric pain epigastric pain.

That is radiating towards the back patient pain is worse after meals and it is worse when the patient lies down straight so the patient is holding the epigastric area patient is leaning forward like this and there is severe sharp epigastric pain which radiates towards the back it improves on leaning forward and it is associated with nause a vomiting and fever on examination.

What you will see is due to the immune response there will be tachycardia hypotension in urea only Euro since the kidneys are not receiving blood due to hypotension there will be in urea oliguria with or without jaundice when the liver gets damaged when the liver gets damaged it causes jaundiceon abdominal examination.

What you will see is that since an organ of the abdomen is getting damaged getting inflamed there will be tenderness guarding distension ileostasis of the gut ascites in on abdominal examination on the skin findings what you will see is that when these enzymes are released from the pancreas these enzymes will be traveling in the blood and they will bed amaging each and every organ and when they get into the skin in the abdominal skin.

They cause damage of the subcutaneous tissue they digest the subcutaneous tissue and they cause bleeds from the capillariesor those bleeds from the capillaries look as purplish discoloration of the skin in the flanks that is called as great Turner sign where there is purplish discoloration of the flanks due to the digestion of the subcutaneoustissues and micro bleeds.

If that digestion of subcutaneous tissues occur around the umbilicus thatis called as culin sign and if it occurs around the inguinal area that is calledas Forks Thyme and it occurs basically from these pancreatic enzyme digestionof the Acute Pancreatitis Treatment subcutaneous tissue now coming to the diagnosis of acute pancreatitis whenever the patientpresents.

To you with these signs and symptoms the first thing that you need to do is that you have to order thepancreatic enzyme level in serum the pancreatic enzyme levels will be elevated mlase lipase will be elevateddiagnosis is made if two out of these three things are fulfilled thecharacteristic abdominal pain epigastric pain radiating towards the back or with elevated pancreatic enzymes amylase.

And lipase and the third thing is characteristic finding on cross-sectional Imaging contrast enhanced CT now I’ll come to the thirdpoint in a while because CT is not needed in all the patients for diagnosis will reserve the CT for thecomplications we will use the above two characteristics to make the diagnosis of acute pancreatitis.

In most cases and will reserve the CT for the complications of acute pancreatitis andwhen you perform the serum lipase levels you will see that the serum levels are elevated three or more than three timesthe upper limit of normal this is a highly indicative of acute pancreatitis and it is very sensitive as well asspecific test for acute pancreatitis serum amylase is also performed and.

You will see that serum amylase is also elevated three times or more than three times of upper limit of normal butremember as compared to serum lipase serum amylase is less sensitive and less specific serum lipase is more specificfor acute pancreas because it is only produced from the ah a pancreas while serum amylase can be produced from manyother parts of the body.

So it is less specific to determine the severity when you havethe patient of acute pancreatitis you took the history you think that it is acute pancreatitis you perform the serumamylase and lipase levels with that you also to send the labs for CBC basalmetabolic profile electrolytes rfts lfts glucose levels.

You perform the abgs whydo you perform the abgs as I said when these enzymes are released from the pancreas and these enzymes travel in thebody they damage the organs and when they damage the lungs they cause acute respiratory distress syndrome so toassess the function of lungs.

Acute Pancreatitis Treatment We perform ABG is that the weather oxygenation of blood is normal or not whether the enzymes have now affected the lungs or not LDH is a inflammatory marker to assess the severity of acute pancreatitis inflammatory markers and serum calcium I’ll come to each one of them in detail with these tests to diagnose the cause of acute pancreatitis.

As I said gallstones is a very important cause of acute pancreatitis to diagnose the cause you perform the abdominal ultrasound to look for the stones so you perform serum amylase lipase levels you perform the abdominal ultrasound and you perform the other lab markers that I mentioned toassess the function of the body and whenever there is diagnostic un certainty.

When you have performed the serum Mis lipase level end of serum amylase lipase levels are normal but you are quite sure that that patient is suffering from acute pancreatitis in their diagnostic uncertainty you can go for contrast enhanced CT scan but remember contrast and our state skin is not of first line investigation that you perform for the diagnosis of acute pancreatitis.

Because contrast enhanced CT scan does not show changes in the morphology of pancreas in the initial few days when the patient is having acute pancreatitis it takes almost five to seven days for those changes to appear on CT scan so till that time wehave already managed the patient but for academic purposes you can remember.

That contrast and our cities can can be used in diagnostic uncertainty but remember that contrast an acetic skin is usually reserved for the complications of acute pancreatitis because when we will study the complications of acute pancreatitis in that you will see that whenever there those complications of acute pancreatitis can be easily diagnosed on CT scanon CT scan.

What you will see is that there will be pancreatic swelling on the pancreas and damage to the pancreas will be evident on CT scan if the patient cannot have contrast Acute Pancreatitis Treatment and has CD scan or if there is any contraindication to contrast like patients with renal failure in those patients you can perform MRI now coming to the investigation the supporting investigations.

We had the patient of acute pancreatitis we did mla’s lipase levels we did abdominal ultrasound and we did certain Labs now the labs are back in the labs what you will see is that the CBC will show increased hematocrit why would there be increased hematocrit the increase hematocrat shows that there is third space laws of fluid as.

I said the inflammatory mediators are released in pen in acute pancreatitis and those inflammatory cytokines will causevasodilations and increase capillary permeability and the fluid will move out into the third space that will cause the hemoconcentration and increased hematocrit the WBC count will be elevated.

it is a marker of severity of acute pancreatitis the basal metabolic profile will be deranged the most important one is blood urea nitrogen the Bon level blood urea nitrogen will be elevated and it shows the damage to the kidneys and it is an important marker of severity in patient with acute pancreatitis creatinine levels lactate levels will be elevated because.

There will be St doses blood glucose levels will be elevated because it is astressful condition and there will be hyper glycemia and with that when ever there is damage to the pancreas the insulin production the insulin control is also damaged the endocrine function endocrine part of the pancreas is also damaged that will result in hyperglycemia LDH levels will be elevated.

It is a marker of severity of acute pancreatitis serum triglyceride levels are also performed because as I said serum triglyceride levels if theyare elevated they can cause acute pancreatitis so you do the fasting levels and you mail promptly after of the patient because if the patient goes into Acute Pancreatitis Treatment the fasting stage then the serum triglyceride will levels will normalize so you do it initially as soon as the patient presents Acute Pancreatitis Treatment.

You perform the lfts and in lfts what you will see is that if it is the biliary cause if there is cholestasis then the Alp level and Gamma glutamyl transferase levels will be elevated and if the alt is greater than 150 and ASTis greater than 3 times upper limit of normal it suggests most likely it’s the biliary cause it’s the gallstones that are causing acute pancreatitis and you also send serum calcium levels and.

When you receive the calcium levels report Acute Pancreatitis Treatment you will see that there will be hypocalcemia where does hypocalcemia occurs because the serum amylase that was Acute Pancreatitis Treatment released from the pancreas that amylase digested the the fats in the body and fatty acids were formed the fatty acids are circulating in the blood and those fatty acids love calcium.

They love calcium and they bind calcium and they reduce the calcium levels and there is a hypocalcemia due to saponification combination of fatty acids with the calcium and when there is a hypocalcema you should also measure the magnesium levels because a hypocalcemia is associated associated with hypo magnesemia other than that you also Meyer serum calcium levels to see.

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That whether serum elevated serum calcium is causing acute pancreatitis or not Acute Pancreatitis Treatment because as I said sometimes a hypercalcemia can cause acute pancreatitis so for that purpose you also measure serum calcium the second purpose is that acute pancreatitis Acute Pancreatitis Treatment beat any cause it usually causes saponification and lowers the calcium level so.

You measure the calcium level in acute pancreatitis you alsosend inflammatory markers and CRP will be elevated Pro calcitonin levels will be elevated interleukin-6 will be elevated these are all the inflammatory markers that show that there is inflammation going on in the body Acute Pancreatitis Treatment an important point to remember is that elevated level of serum amylase lipase are useful for.

The diagnosis of acute pancreatitis but their elevated level does not correlate with the severity that you say that they are elevated in the Thousand so it is more severe and if they are in 800 or 900 then this is less severe no its not like that they do not correlate with the severity they are only used for the diagnosis another important point is that you measure serum triglyceride levels promptly after you make the diagnosis of acute pancreatitis because as I said we need the fasting Acute Pancreatitis Treatment sample of triglycerides.

Acute Pancreatitis Treatment Because hyper trigly ceridemia can cause acute pancreatitis and we want to catch hyper trigly ceridemia and for that you have to take the sample before the patient is NPO nilp by mouth in before putting the patient on fasting State you take the sample and send it to the lab because once.

Once the patient has started the fasting period the triglyceride levels will normalize hypercalcemia can cause acute pancreatitis but once the acute pancreatitis has taken place the hypercalcemia will be converted to hypocalcemia because of the saponification because of The Acute Pancreatitis Treatment Binding of fatty acids with the calcium so you take the calcium levels initially as soon as possible.

Because in the later stages there will be hypocalcemia due to the saponification process as I explained now once you have the patient of acute pancreatitis you did all these Labs you diagnosed that that patient has acute pancreatitis now you classify the patient that what kind of care is needed whether that patient needs an ICU admission whether.

That patient needs to be treated in the emergency department or that patient needs to be treated inthe ward for the severity assessment there are certain criterias revised Atlanta Acute Pancreatitis Treatment grades of severity Rems andcriteria Apache 2 criteria bicep criteria these are certain criteria that you don’t need to memorize the most important one among these is and most commonly used in the words is Ranson.

Criteria so you need to know a little bit about the rents and criteria and what are the markers that are used you don’t need to exactly memorize each and everything out of itah Acute Pancreatitis Treatment coming to revised Atlanta grading criteria divides the patient into mild moderate and severe catering category ifthere is no organ failure no local or systemic complication.

It is mild if there is persistent organ failure even after 48 hours that is severe acute pancreatitis and moderate is the one where there is transient organ failureless than 48 Acute Pancreatitis Treatment hours with local art systemic complications an important point to remember is that at the time of presentation if the patient is having organ failure if you check the blood pressure and the blood pressure is down.

If the labs are highly elevated all if there is organ dys function how do you see organ dys function when you get the lab reports all the labs will be deranged it shows that there is Acute Pancreatitis Treatment severe organ dys function going on and if at the time of presentation the patient has already developed organ dys function that patientis a severe case of acute pancreatitis patient presenting with organ failure are within.

The first 24 hours of admission should be classified as aiming Acute Pancreatitis Treatment severe pancreatitis no Ransom criteriais the most important criteria which is most commonly used at admission you check the age WBC count blood glucose level serum LDH and serum AST and if these things are elevated like this you score you give the points to this patient each one carries.

One point after 48 Hours you again repeat the labs and you take the data and you apply the ransom criteria if the hematocrit decrease is greater than 10 percent bun increase Acute Pancreatitis Treatment serum calcium is low hypocalcemia fluid sequestration fluid sequestration means the fluid losses you are administering fluids to the patient and the output is very low the there areincreased fluid losses a serum base deficit the bases aredeficient because there is SC doses increased Assets in the body.

Acute Pancreatitis Treatment

You score the patient and if the score is greater than or equal to 3 then Acute Pancreatitis Treatment there is higher risk of acute severe pancreatitis in that patient that patient is classified as having severe pancreatitis bed side index of severity of acute pancreatitis uses all these things remember the single most important investigation is the BUN blood urea Nitro.

If you do not have any other investigations you can simply use blood Acute Pancreatitis Treatment urea nitrogen to assess the severity of acute pancreatitis because the kidneys are the ones that get affected first and the bun changes will appear earlier and it can be used to guide the treatment ofthe patient biceps score greater than or equal to 2 indicates severe pancreatitis now coming to the treatment of acute pancreatitis.

You received the patient with severe epigastric pain in the emergency Acute Pancreatitis Treatment department by pain radiating towards the back you thought that this is acute pancreatitis you send the serum amylase lipase levels and the amylase lipase levels are elevated and you diagnose the patient as the case of acute pancreatitis now the next thing that you do is that you urge.

The patient to stop any oral food in take you make the patient nil per orally nil by mouth the patient stops any oral food intake and what you do is that you give fluids just imagine acute Acute Pancreatitis Treatment pancreatitis as if the pancreas ison fire the pancreas is burning and what you do is that you throw water on something that is burning the only treatment.

The only management is fluid resuscitation in the patients with acute pancreatitis in the first 24 to 48 hours the only effective treatment is fluid resuscitation when something is burning you put water on it you never put more food onto it so you put the patient on nil per oral the patient is not taking any food now the patient is receiving fluids to put away.

The fire so the only effective treatment in the first 24 hours is fluid Acute Pancreatitis Treatment replacement you give ringer lactate solution 1.5 ml per kg per hour with 10 ml per kg bolus in the patients who present to be the hypovolemia now remember when you are giving.

These IV fluids you do not need to be over regressively giving IV hydration because Acute Pancreatitis Treatment remember as I said these patients are usually having capillary their capillary permeability is increased due to the inflammatory process in the body and when the capillary permeability is increased there is increased chance that the more fluid.

You are giving that fluid and is entering the third spaces of the body so while you are giving the fluid replacement you must be cautious that that fluid should a replacement Acute Pancreatitis Treatment should not be so aggressive that that fluid is getting out into the third spaces of the body so the fluid replacement must be targeted and you keep examining the patient that fluid is not developing edema.

The patient is not developing pulmonary edema edema in the feet you keep examining the patient to keep looking for the signs of fluid over load because you do not want to Acute Pancreatitis Treatment overly aggressively treat the patient with fluid replacement that patient goes into ah fluid overload States you give the targeted fluid therapy so that you maintain the normal vitals.

You limit fluid resuscitation after 48 hours and you Monitor and when you are giving the fluid replacement therapy you monitor the heart rate and you keep the Acute Pancreatitis Treatment heart rate below 120 beats per minute you keep the mean arterial pressure between 65 to 85 mm of HG and you try to bring the urine output to 0.5 to 1 cc per kg per hour in the process of fluid replacement.

This is your target but do not overly aggressively rehydrate the patient that that patient goes into a fluid over load state now when the patient is nil per Acute Pancreatitis Treatment oral patient is not taking any oral food and the you have started the oral rehydration therapy now repeatedly you have to perform certain labs to see that whether the patient is improving or not whether the hematocrit.

Is now normalizing or Acute Pancreatitis Treatment not the hematocrit was over concentrated you see that bun levelis the most important levels whether BUN levels are normalizing or not the creatinine Acute Pancreatitis Treatment levels the electrolytes and electrolytes you look for hypocalcemia you there is where hypocalcemia you treat that and you see the serum glucoselevels hourly so you you are hydrating.

The patient and with that you are also keep checking thelabs that whether the patient is responding to fluid resuscitation or notif the patient is having hypocalcemia if the ionized calcium is low and the patient or if the patient develops the signs of neuromuscular irritability which is the Chop stick science the spasm of the mouth the spasm of the arm.

When you are checking the blood pressure these are the hypocalcemia signs in that case you replace calcium because as I said in acute pancreatitis there is saponification Acute Pancreatitis Treatment and hypocalcemia the patient is nil per mouth the patientis getting fluid replacement but the patient is in pain you need to control the pain of the patient and in the pain control we prefer opioids.

M cells can be used but you have to look that whether the bun level are the renal function tests are normal or not usually these patients of acute pancreatitis are having Acute Pancreatitis Treatment organ dys function and the renal function tests are deranged in that condition NSAIDs can worsen the renal problems so NSAIDs are avoided and we prefer opioids because opioids will not affect the kidneys NSAIDs can affect the kidneys so opiates are used IV hydroxomorphone.

0.2 to 1 mg IV every 2 to 3 early or IV phenetenyl bolus dose 20 to 50 micro gram can be used meperidine is favored over morphine you never give morphine in acute Acute Pancreatitis Treatment pancreatitis because it is always the wrong answer in acute pancreatitis because morphine causes contraction of sphincter or for dye and it further blocks the passage of the pancreatic duct.

The pancreatic duct path way is already blocked and it further causes contraction of the sprinkler of Huda and further blocks it and it Aggregates acute penetrated assume Acute Pancreatitis Treatment pyridine is preferred those of 50 to 150 mg IM every three to four hourly is given the patient is nil per oral not taking oral food we gave the fluid resistation we’ve controlled the pain with opiates now we control the nausea and vomiting with antimetics if the patient is having nausea and vomiting.

You give odensetron four to eight mg IV as needed metoclopramide Acute Pancreatitis Treatment 10 mg IV or im as needed now coming to the nutrition in the nutrition you ask the patient to stop taking any oral food the patient is nil by mouth the patient is not taking any food the moment you realize that that patient is having acute pancreatitis the first thing that you.

You should do is that you ask the patient to stop taking any oral food you tell him that your pancreas is on fire and that fire needs water to put away that fire you throw Acute Pancreatitis Treatment water onto it you never put more food onto it so that it burns more so you stop the oral food and you put water onto it with fluid replacement that is the only management of acute pancreatitis.

Now you have stopped the patient from taking the oral diet but that patient asks you the doctor when can I restart my oral food it depends upon the severity in the absence of Ilias nause a vomiting and if the patient is saying that he is hungry that is the biggest point that you restart the oral food because previously the guide lines said.

That you keep the patient NPO for a longer period of time but now the newer guide lines say that if if there is if it is less severe if there is no Alias if there is no nause a Acute Pancreatitis Treatment vomiting if the patient is hungry you give the food because if you keep the gut NPO for a longer period of time that gut can go into stasis and when the gut is in stasis.

When the gut movements are stopped due to absence of food in it there is increased chances that infections will grow and those infections will further spread to the body so to prevent the complications the newer guidelines recommend that as soon as the patient is hungry and as soon as fish you feel that that the pancreatitisis less severe you restart.

The food you can initiate within 24 hours you give low residue Acute Pancreatitis Treatment low fat diet and you can start from clear fluid and you can shift the patient to solid food if the patient is hungry or if the patient is not having any nausea vomiting earliest when the patient feels hungry that’s the biggest start point that you should start giving food early enteral feeding decreases.

The risk of infectious complication as I said when the gut is Acute Pancreatitis Treatment empty for a long period of time the motility of gut stops the gut goes into stasis and when the gut goes into stresses there is increased chances that infections will grow.

So you keep the gut running after 24 hours what you do is that you start giving food to the patient if the patient is not having any nausea vomiting you start giving food Acute Pancreatitis Treatment so that the gut starts running and there is less chances of infection in the patient complete bowel rest no longer recommended.

If the patient is having severe pancreatitis severe nausea vomiting post prandial pain in that patient you cannot start oral food as soon as possible in such patients you keep the Acute Pancreatitis Treatment patient nil by mouth for at least four to five days but after five days you give an attempt you ask the patient that whether you are feeling hungry now or not whether.

Do you want food or not because after five days Acute Pancreatitis Treatment there are so many days have passed and that patient has not eaten anything in that patient after five days overall diet should be started and if patient can not tolerate oral diet what you can do is that you can start enteral Acute Pancreatitis Treatment feeding through NG tube through enteral tube directly into the stomach in that patient.

You after five days you start giving food because you do not want stasis of the gut for a longer period of time after the fifth day you should start what if the patient cannot take oral food you give the food by NG tube or you give the food directly into the stomach by internal tube reading high protein low fat formulas are present peptide and such formulas are given to these patients antibiotics are not indicated they are only indicated.

If there is any evidence of infection in these patients 20 percent of the patients develop infection in the complications will study that the patients develop infection in those Acute Pancreatitis Treatment patients only antibiotics are needed if there is deterioration in the clinical status after 72 hours you must go for contrast enhanced CT skin because as I said contrast in her CT skin was not the first line of Investigation.

We diagnosed the patient with serum amylase lipase and the clinical presentation and if after 72 hours the patient is deteriorating in that patient you go for CT scan and Acute Pancreatitis Treatment you look with that what is the status of pancreas now this was the management of acute pancreatitis but you also need to investigate the cause you need to treat the cause which resulted in acute pancreatitis.

If it was it was the gallstones that were obstructed in them pillar whether you go for the rapeutic ercp in which you get inside the ampule of water you have to take the stones Acute Pancreatitis Treatment out through an endo scope that is the ercp procedure urgent ercp is only needed if cholangitis is present otherwise you let the fire stop you treat the patient in the acute inflammatory stage in acute pancreatitis and.

You wait for some period till the time patient is stable and then you go for the treatments of under lying causes cholecystectomy is done after the patient has recovered from acute pancreatitis almost after six weeks you go for ah cholecystectomy if the patient is having hyper triglyceridemia you treat it with insulin therapy insulin pushes the triglycerides into the fats and itreduces.

The triglyceride levels plasmapheresis can be done hypercalcemia must be Acute Pancreatitis Treatment treated if it is alcohol induced alcohol must be stopped and you also check magnesium and phosphorus level and vitamin supplementation must be given to these alcohol equations because usually these chronic alcoholic patients have low magnesium levels.

Low phosphorus level and low vitamins like thi amine when the patient is in the ER the check list that you can follow for the management of acute pancreatitis you start oxygen therapy of the patient is hypoxic you start give IV access and you send the labs you perform abgs you give the targeted IV fluid you do not over aggressively resuscitate the patient.

You give electrolytes as needed especially the calcium levels you give analgesics antimetics you obtain ultrasound and CT scan only if there is diagnostic uncertainty and Acute Pancreatitis Treatment you assess the severity you you apply those criterias urgent concerns are taken if they are needed from gastroenterology and ears P if there is cholangit is and you consider the general surgery Department only if there is severe acute necrotizing pancreatitis.

Where there is so much necrotic tissue and that General surgical department will open up the abdomen and take out the necrotic material but remember that is as that Acute Pancreatitis Treatment procedure is associated with high mortalitya conservative approach is a better approach in patients with acute pancreatitis you admit the patient to hospital you consider ICU admission.

If there is severe organ dys function so this is all a checklist that you can follow in patients with acute pancreatitis indications of ICU include patients with severe acute pancreatitis with all these things these patients are unstable these patients have organ failure and these Acute Pancreatitis Treatment patients must be admitted to ICU coming to local complications in the local complications acute pancreatic fluid collection can occur but that pancreatic fluid.

That is visible on CT scan resolves spontaneously it does not need an international necrotizing pancreatitis is also a sterile fluid collection and that also can be treated conservatively if the that fluid gets infected and there is bacteria in it then CT scan will show Acute Pancreatitis Treatment gas with in the pancreas in that case antibiotics are needed carbop and a miropenum are the main that are used a one gram IV TDS are given and.

If the further you further the patient deteriorates you send them to General Surgery department for necrosectomy and preferred things that you stabilize the patient first and then you send for acute necroceptomy because if the patient is unstable and if the patient is having severe acute pancreatitis in that case if you open up the belly.

There is high mortality associated with it world of necrosis occurs after four weeks and you diagnose it with CT scan with IV contrast now remember in all these Acute Pancreatitis Treatment complications we are using CT scan so you reserve the seed scan only forthe complications ah world of necrosis is drained with percutaneous drain age or transmural endoscopic necrosectomy.

You drain out the fluid if there is a world Acute Pancreatitis Treatment of cavity containing fluid in it systemic complications of acute pancreatitis include shock surge sepsis DIC due to the inflammation and inflammatory mediators present in the blood pneumonia respiratory failure ards and is an important complication plural effusion pre-renal failure volume depletion hypocalcemia paralytic.

Alias and pancreatic ascitis every thing makes sense now when you know the pathology and patho physiology of acute pancreatitis coming to the prognosis mortality without organ failure if the patient is having no organ failure the mortality is less than one percent and if the Acute Pancreatitis Treatment patientis having organ failure the mortality is almost 30 percent important predictors of severity age greater.

Than 55 GI bleeding fall in hematocorate hypocalcemia hyper glycemia elevated inflammatory markers evidence of organ failure if these things are present it indicates that it is more severe these are the same things that we used in those ah criterias the rents and criterias Acute Pancreatitis Treatment Apache criteria they also use these markers and if these things are elevated.

It means that the patient is having severe pancreatitis before going into the summary gastroenterology lectures and emergency medicine lectures we discussed that what is acute pancreatitis what is the etiology of acute pancreatitis the path ophysiology and the multi-organ failures that occurs due to acute pancreatitis the symptoms of and presentation examination finding.

Show do you diagnose it how do you determine the severity the labs are that Acute Pancreatitis Treatment are performed CT scan only for the complications the labs of acute pancreatitis inflammatory markers important points how do you assess the severity with these all grading criterias in which direction criteria is the most important one fluid replacement being the most important.

One you keep monitoring the patient with these Labs you correct the calcium levels you for pain control you give opiates you give antimetics you keep the patient NPO but you start the oral diet as soon as possible as soon as the patient feels hungry you start the oral diet antibiotics are not needed under lying causes must be treated a checklist for the management local complications systemic complications and the prognosis of acute pancreatitis Acute Pancreatitis Treatment.