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Cullen and Grey Turner signs indicate retroperitoneal hemorrhage and warrant careful history-taking and investigations, including coagulation studies, serum lipase and amylase, and imaging.

 Cullen sign: in acute pancreatitis, rectus sheath hematoma, splenic rupture, perforated ulcer, intra-abdominal cancer, and ruptured ectopic pregnancy, and as a complication of anticoagulation

 Grey Turner sign:Pancreatic hemorrhage.Retroperitoneal hemorrhage.Blunt abdominal trauma Ruptured abdominal aortic aneurysm.Ruptured / hemorrhagic ectopic pregnancy.Spontaneous bleeding secondary to coagulopathy

pancreatitis

CT scanning with bolus IV contrast has become the gold standard for detecting and assessing the severity of pancreatitis.

MARKER NEED FOR DIAGNOSIS

serum amylase levels are measured most often. It remains elevated for 3 to 5 days before returning to normal. In many cases, urinary clearance of pancreatic enzymes from the circulation increases during pancreatitis; therefore, urinary levels may be more sensitive than serum levels. For these reasons, it is recommended that amylase concentrations also be measured in the urine. Urinary amylase levels usually remain elevated for several days after serum levels have returned to normal.

 In patients with severe pancreatitis associated with significant necrotic damage, the pancreas may not release large amounts of enzymes into the circulation. It is important to recognize that, in patients with severe pancreatitis, frequent measurement of serum enzymes is not needed. Patients with alcoholic pancreatitis, in general, have a smaller increase in serum amylase levels.

Specificity of these markers ranges from 77 to 96%, the highest being for lipase. Measurements of many digestive enzymes also have methodologic limitations and cannot be easily adapted for quantitation in emergency labs. Because serum levels of lipase remain elevated for a longer time than total or p-amylase, it is the serum indicator of highest probability of the disease.

PT.PTT.INR .for coagulation studies(use anti coagulation agent)

  

Biochemical Markers for Assessment of Severity

Ranson's Criteria for acute pancreatitis not due to gallstones

At admission

During the initial 48 h

Age >55 y

Hematocrit fall >10 points

WBC >16,000/mm3

BUN elevation >5 mg/dL

Blood glucose >200 mg/dL

Serum calcium <8 mg/dL

Serum LDH >350 IU/L

Arterial PO2 <60 mm Hg

Serum AST >250 U/dL

Base deficit >4 mEq/L

Estimated fluid sequestration >6 L

Criteria for acute gallstone pancreatitis

At admission

During the initial 48 h

Age >70 y

Hematocrit fall >10 points

WBC >18,000/mm3

BUN elevation >2 mg/dL

Blood glucose >220 mg/dL

Serum calcium <8 mg/dL

Serum LDH >400 IU/L

Base deficit >5 mEq/L

Serum AST >250 U/dL

Estimated fluid sequestration >4 L

 

CBC . BS . LDH .LFT . BUN/CR . ABG . CHAART INTAKE/OUT PUT.  For Ranson's criteria

Although serum enzymes such as amylase and lipase are helpful in the diagnosis of pancreatitis, these have no prognostic value

Several recent research studies have suggested additional markers that may have prognostic value, including acute phase proteins such as C-reactive protein (CRP), alpha2-macroglobulin, polymorphonuclear neutrophil–elastase, alpha1-antitrypsin, and phospholipase A2. Although CRP measurement is commonly available

Severe Pancreatitis

Pancreatitis can be classified as severe based on predictors such as APACHE-II scores and Ranson's signs, and any evidence that the condition is severe mandates care of the patient in the intensive care unit. Such evidence may take various forms, such as the onset of encephalopathy, a hematocrit >50%, urine output <50 mL/h, hypotension, fever, or peritonitis. Elderly patients with three or more Ranson's criteria should also be monitored carefully despite the absence of severe pain.

Treatment :

Encephalopathy    =  severe disease

1- transferred to the intensive care unit for observation and maximal support

2-  NPO. Nasogastric suction. replacement of fluids and electrolytes parenterally as assessed by central venous pressure and urinary excretion,

3-pain management is of great importance. Administration of buprenorphine, pentazocine, procaine hydrochloride, and meperidine are all of value in controlling abdominal pain

4- In severe acute pancreatitis, most experts recommend broad-spectrum antibiotics (e.g., imipenem) and careful surveillance for complications of the disease

5- if develop ARDS . ventilation with positive end-expiratory pressure

6- cardiovascular events and other complication. Appropriate treatment

7- H2-blockers have routinely been used

8-  Treatment of sterile necrotic pancreatitis falls into three degrees of aggressiveness. The last and most serious condition is that of the patient who appears to be very ill, has high APACHE-II and Ranson's scores, and shows evidence of systemic toxicity, including shock  likes this patient. Patients in this category have a poor chance of survival without aggressive debridement, and a decision may be made to proceed with exploration simply due to a relentless course of deterioration despite maximal medical therapy


 

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