Ebook Decision making in emergency critical care: Part 2
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Ebook Decision making in emergency critical care: Part 2
26PancreatitisSusan Y. Quan and Walter G. Park BACKGROUNDThe pancreas is approximately 6 to 10 inches long, is located directly behind the stomach, an Ebook Decision making in emergency critical care: Part 2nd has distinct endocrine and exocrine functions. The endocrine portion of the pancreas is composed of islets of Langerhans cells that constitute about 2% of the organ. These cells produce and secrete hormones including insulin, glucagon, and somatostatin. The exocrine portion of the pancreas is com Ebook Decision making in emergency critical care: Part 2posed of acinar cells (80% of the organ) and ductal cells (18% of the organ). Acinar cells produce digestive enzymes that are sequestered until physioEbook Decision making in emergency critical care: Part 2
logic impulses stimulate their release into the pancreatic ductal system where they are transported to the small intestine. The digestive enzymes are 26PancreatitisSusan Y. Quan and Walter G. Park BACKGROUNDThe pancreas is approximately 6 to 10 inches long, is located directly behind the stomach, an Ebook Decision making in emergency critical care: Part 2ies, is the basis for our current understanding of acute and chronic pancreatitis. This chapter primarily focuses on acute pancreatitis, which is more commonly seen in emergency care. Pertinent aspects of chronic pancreatitis are also addressed.ACUTE PANCREATITISThe incidence of acute pancreatitis i Ebook Decision making in emergency critical care: Part 2s estimated to be as high as 38 per 100.000 patients and accounts for more than 220,000 hospital admissions in the United States annually.1 Most casesEbook Decision making in emergency critical care: Part 2
are clinically mild and self-limited; a minority of cases are severe and are associated with critical illness, prolonged hospitalization, infection, 26PancreatitisSusan Y. Quan and Walter G. Park BACKGROUNDThe pancreas is approximately 6 to 10 inches long, is located directly behind the stomach, an Ebook Decision making in emergency critical care: Part 2igestive and inflammatory process. Evolution into a life-threatening systemic process begins when acinar cell injury leads to expression of endothelial adhesion molecules that further potentiates the inflammatory response. Local microcirculator}' failure and ischemia-reperfusion injury ensue, with s Ebook Decision making in emergency critical care: Part 2ome patients developing systemiccomplications such as systemic inflammatory response syndrome (SIRS), acute respirator}' distress syndrome, and multioEbook Decision making in emergency critical care: Part 2
rgan failure.The most common causes of acute pancreatitis are gallstones and excess alcohol ingestion. These account for about 45% and 35% of cases, r26PancreatitisSusan Y. Quan and Walter G. Park BACKGROUNDThe pancreas is approximately 6 to 10 inches long, is located directly behind the stomach, an Ebook Decision making in emergency critical care: Part 2 trauma, and complications after endoscopic retrograde cholangiopancreatography (ERCP) (Table 26.1). Controversial etiologies include pancreatic divisum and sphincter of Oddi dysfunction. Idiopathic pancreatitis occurs in up to 20% of patients, and by definition, the cause is not established by hist Ebook Decision making in emergency critical care: Part 2ory, physical exam, routine laboratory tests, or imaging.TABLE26.1CausesofAcutePancreatitisObstructiveGallstones, tumors, altered ductal anatomyToxinsEbook Decision making in emergency critical care: Part 2
/drugsAlcohol, insecticides, drugsMetabolicHypertriglyceridemia, hypercalcemiaInlectionsMumps,Coxsackie, HBV, cytomegalovirus, zosterVascularVasculiti26PancreatitisSusan Y. Quan and Walter G. Park BACKGROUNDThe pancreas is approximately 6 to 10 inches long, is located directly behind the stomach, an Ebook Decision making in emergency critical care: Part 2cal presentation includes a constant (as opposed to waxing and waning) upper abdominal pain located primarily in the epigastric area with radiation to the back. The onset of pain is rapid and typically reaches maximum intensity within 10 to 20 minutes. Pain that lasts only a few hours is unlikely to Ebook Decision making in emergency critical care: Part 2 be pancreatitis. About 90% of patients will also complain of nausea and vomiting.Mild pancreatitis may involve minimal abdominal tenderness without gEbook Decision making in emergency critical care: Part 2
uarding. In severe disease, abdominal tenderness can be elicited with superficial palpation. Abdominal distention and reduced bowel sounds can occurse26PancreatitisSusan Y. Quan and Walter G. Park BACKGROUNDThe pancreas is approximately 6 to 10 inches long, is located directly behind the stomach, an Ebook Decision making in emergency critical care: Part 2ons (Cullen sign). Severe disease should be suspected with abnormal vital signs that can include fever, tachycardia, tachypnea, and hypotension. These signs represent a transition from localized retroperitoneal inflammation to one of systemic inflammation. Pleural effusions and mental status changes Ebook Decision making in emergency critical care: Part 2 are also hallmarks of severe disease. The presence of jaundice may suggest an underlying alcoholism or choledocholilhiasis.Diagnostic EvaluationAcuteEbook Decision making in emergency critical care: Part 2
pancreatitis is diagnosed when two of the following three criteria are met: (1) characteristic abdominal pain, (2) scrum amylase or lipase greater th26PancreatitisSusan Y. Quan and Walter G. Park BACKGROUNDThe pancreas is approximately 6 to 10 inches long, is located directly behind the stomach, an Ebook Decision making in emergency critical care: Part 2ently used serumbased tests for pancreatitis. The most common source of amylase is not the pancreas, but salivary glands. In contrast, 90% of lipase is made from the pancreas, making it a more specific marker. Amylase rises within 6 to 24 hours of acute pancreatitis and peaks in 48 hours, normalizin Ebook Decision making in emergency critical care: Part 2g in 3 to 7 days. Lipase has a longer half-life than amylase, with levels increasing within 4 to 8 hours, peaking at 24 hours, and falling over 8 to 1Ebook Decision making in emergency critical care: Part 2
4 days. ’ The degree of elevation is not a marker of disease severity, and mild elevation of these serum markers— less than three times the upper limi26PancreatitisSusan Y. Quan and Walter G. Park BACKGROUNDThe pancreas is approximately 6 to 10 inches long, is located directly behind the stomach, an Ebook Decision making in emergency critical care: Part 2e first two diagnostic criteria are not met and (1) the pretest probability for pancreatitis remains high or (2) there is a high pretest probability for another abdominal process. Otherwise, CT and MRI have no role and may exacerbate renal injury from use of intravenous contrast.6 Such imaging can b Ebook Decision making in emergency critical care: Part 2e considered 7 days later should the diagnosis remain uncertain or to assess disease severity and identify’ complications related to severe pancreatitEbook Decision making in emergency critical care: Part 2
is. Following clinical and laboratory parameters allows adequate initial assessment of disease severity. For patients with an established history of c26PancreatitisSusan Y. Quan and Walter G. Park BACKGROUNDThe pancreas is approximately 6 to 10 inches long, is located directly behind the stomach, an Ebook Decision making in emergency critical care: Part 2ble complications of pancreatitis including, but not limited to, enlarging pseudocysts, arterial pseudoaneurysms, and/or new common bile stones.Differential DiagnosisThe differential diagnosis includes biliary colic, acute cholecystitis, acutecholangitis, biliary dyskinesia, peptic ulcer disease, dy Ebook Decision making in emergency critical care: Part 2spepsia, acute mesenteric ischemic, and bowel obstruction. Nongastrointestinal disorders, including acute myocardial infarction, aortic dissection, puEbook Decision making in emergency critical care: Part 2
lmonary embolism, acute spinal disorders, and renal calculi, should also be considered.ComplicationsThe majority of cases (80% to 90%) of pancreatitis26PancreatitisSusan Y. Quan and Walter G. Park BACKGROUNDThe pancreas is approximately 6 to 10 inches long, is located directly behind the stomach, an Ebook Decision making in emergency critical care: Part 2ications including abscess formation, infected necrosis, and/or extrapancreatic organ failure. These patients typically exhibit SIRS or sepsis physiology.Fluid collections around the pancreas affect over half of patients. Most will resolve, but for those that persist, a fibrogenic anti-inflammatory Ebook Decision making in emergency critical care: Part 2response will lead to containment of these fluid collections, resulting in the formation of a pseudocyst. A pancreatic pseudocyst is a fluid collectioEbook Decision making in emergency critical care: Part 2
n that persists beyond 4 weeks. Other complications include infections (arising from pancreatic necrosis or within pseudocysts), thrombosis (splenic, 26PancreatitisSusan Y. Quan and Walter G. Park BACKGROUNDThe pancreas is approximately 6 to 10 inches long, is located directly behind the stomach, an Ebook Decision making in emergency critical care: Part 2titis is approximately 30%. Death within the first 2 weeks of illness is usually due to multiorgan failure. Death after 2 weeks typically stems from infection.Management GuidelinesOnce a diagnosis of acute pancreatitis is made, a risk stratification calculation should be performed. Clinical risk sco Ebook Decision making in emergency critical care: Part 2ring systems, such as Ranson's and APACHE II, have traditionally been used. However, both are cumbersome and require 48 hours before a meaningful inteEbook Decision making in emergency critical care: Part 2
rpretation can be made. The Bedside Index for Severity in Acute Pancreatitis (BISAP) score is a newer validated scoring system that requires five data26PancreatitisSusan Y. Quan and Walter G. Park BACKGROUNDThe pancreas is approximately 6 to 10 inches long, is located directly behind the stomach, an Ebook Decision making in emergency critical care: Part 2esence of a pleural effusion (Table 26.2). The presence of three or more features at admission is associated with a 7- to 12-fold increase in organ failure. Such patients should be managed in the intensive care unit.TABLE 26.2 Risk Stratification Scoring System for Severity of Acute Pancreatitis Ebook Decision making in emergency critical care: Part 2Gọi ngay
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