Clinical Features

The major symptom of acute pancreatitis is mid-epigastric or left upper quadrant pain. It is most commonly described as a constant, boring pain that often radiates to the back as well as the flanks, chest, or lower abdomen. Although usually described as severe, the intensity can be extremely variable and does not correlate with the severity of the disease.1 The pain is exacerbated in the supine position and can be relieved when sitting with the trunk and knees flexed. Colicky discomfort is atypical and suggests another etiology. Nausea and vomiting are common, and abdominal bloating from gastric and intestinal hypomotility is a frequent complaint.

Physical examination usually reveals a patient in moderate distress. Low-grade fevers and tachycardia are frequently present, and hypotension is not unusual. 1 About 10 percent of patients have respiratory symptoms secondary to atelectasis, pleural effusion (usually left sided) and, rarely, ARDS. Abdominal examination is notable for epigastric tenderness. Peritonitis is a late finding, presumably due to the retroperitoneal location of the organ. Bowel sounds may be diminished from an associated ileus. Cullen sign, a bluish discoloration around the umbilicus, and Grey Turner sign, a bluish discoloration of the flanks are characteristic but rare signs of hemorrhagic pancreatitis.

Patients with pancreatitis may present in hypovolemic shock and multisystem organ failure. Hypotension can result from fluid third-spacing, hemorrhage, increased vascular permeability, vasodilatation, cardiac depression, and vomiting.2 Diagnosis

The absence of a pathognomonic clinical syndrome often precludes a diagnosis based solely on presentation. Unfortunately, the only diagnostic gold standard is pathologic examination of the pancreas. Laboratory and radiographic investigations can be helpful in the diagnosis of acute pancreatitis, but both suffer from limited diagnostic accuracy.

LABORATORY TESTS Serum amylase and lipase are the most widely used laboratory tests used in the evaluation of acute pancreatitis (Iable 83.:3). Both enzyme markers, released during pancreatic inflammation, lack the sensitivity and specificity to be the sole indicators of disease and must be interpreted in the context of the clinical setting.67

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