Pancreatitis

Both acute and chronic pancreatitis are not uncommon in India, but are seldom seen in Africa. You you may have to treat them, or to drain a pancreatic abscess (5.10b), or a pancreatic pseudocyst.

Pathologically, acute pancreatitis varies from oedema and congestion of a patient's pancreas to its complete autodigestion, with necrosis, haemorrhage, and suppuration. Less severe forms may go on to form a tender, ill-defined mass in his epigastrium.

His main symptom is pain, which can vary from moderate epigastric discomfort to an excruciating, penetrating agony, which bores through to his back, and needs high doses of pethidine to relieve it. He is tender in his epigastrium, perhaps with guarding. Later, his abdomen distends, and he vomits. Vomiting, and the outpouring of fluid into his retroperitoneum, sends him into shock and his gut into ileus.

You may diagnose pancreatitis clinically, or you may only find it when you do a laparotomy for an acute abdomen. Estimating the serum amylase is not difficult, and your laboratory should be able to do it.

Chronic relapsing or recurrent pancreatitis is one of the causes of a severe chronic upper abdominal pain. It is quite common in the states of Kerala and Orissa in India, and in alcoholics anywhere. It only needs surgery if the pain is debilitating, or if it constricts the common bile-duct, so that it causes jaundice and produces a syndrome which resembles carcinoma (13.8). A bypass (cholecystojejunostomy) will relieve a patient's jaundice, but this is not common.

ACUTE PANCREATITIS THE DIFFERENTIAL DIAGNOSIS includes perforated peptic ulcer (11.2), acute cholecystitis (13.3), biliary colic (13.2), rupture of an amoebic abscess (31.12), and strangulating upper small gut obstruction (10.3).

SPECIAL TESTS. The patient's serum amylase rises within a few hours of the start of his pain, and remains high for about 2 days. A level of more than 1000 Somogyi units is almost diagnostic. A peritoneal tap in his right lower quadrant will confirm the diagnosis[md]the aspirate may be straw-coloured, or reddish-brown, but its amylase is always high. In the severest haemorrhagic form of the disease the serum calcium is low.

X-RAYS may show pancreatic calcification, if he has had previous attacks; gallstones, a left pleural effusion, or distended loops of gut (ileus).

TREATMENT. Treat his shock energetically with large volumes of 0.9% saline, Ringer's lactate, or a plasma expander. Monitor his urinary output, his haematocrit, and if posssible, his central venous pressure (A 19.2).

His pain may be overwhelming. Give him large doses of pethidine, supplemented by diazepam or promethazine. Keep his stomach empty with nasogastric suction. Antibiotics are useless.

If you are reasonably sure of the diagnosis, don't operate; but it is better to operate unnecessarily, than not to operate on a case of strangulated gut, for example.

If you do open his peritoneum, you will know that he has pancreatitis, because you will see areas of whitish-red fat necrosis on his transverse mesocolon, or omentum, and the exudate described above. His pancreas feels swollen and oedematous, and may contain greenish-grey necrotic areas.

Don't insert drains: there is no evidence that they help.

DIFFICULTIES [s7]WITH ACUTE PANCREATITIS If you find that he also has GALLSTONES, consider doing a choledochostomy (13-2). Don't be tempted to remove his gall-bladder, or a stone in his common bile duct, which may have precipitated the attack. Theoretically, this might be beneficial; but practically it is very difficult.

If, during the course of 2 or 3 weeks, he develops the signs of SEPTICAEMIA, suspect that he is developing a pancreatic abscess.

If his pancreatitis has progressed to form an ABSCESS (uncommon, 5.10b), you will need to do a laparotomy to drain it, and a jejunostomy (9.7) to feed him while ''resting' his pancreas.

If he develops RESPIRATORY OR RENAL FAILURE, usually in the first 48 hours (5-10% chance), he will probably die. There is little you can do except give him oxygen, plenty of intravenous fluids, and plasma expanders, together with frusemide to stimulate his urine flow. If necessary, ventilate him (A 19.4).