Clinical symptomatology and diagnosis of acute pancreatitis

A severe form of acute pancreatitis is often characterized by a rough beginning, attacks of severe pain in the upper abdomen, sometimes so intense that a patient is not able to pinpoint their location. Immediately creates a view about terrible abdominal disaster with the development of deep shock. Most often felt pain in the epigastric region and give in the back, the left half of the body, often wear a belt-like character. However, as the localization of pain and their irradiation may be different. Pain attacks sometimes remind severe angina, renal or hepatic colic. In some cases the pain may be continuous, as in acute cholecystitis, in others it paroxysmal in nature, reminding pain when gallstones or kidney stones.
Along with pains in the abdomen, develops flatulence, nausea, excessive vomiting, often resistant salivation. Presence in emetic liquid admixture of bile has diagnostic value, suggesting patency of the common bile duct. Bloody vomiting occurs at extremely severe forms of the disease and, as a rule, defines a poor prognosis. This fecal vomiting does not happen.
Noteworthy is the fact that, despite the severity of pain, abdominal wall remains soft, and only in epigastralna area is usually found moderate muscle tension in contrast to the well-known pattern of acute abdomen. This discrepancy between the severity of subjective sensations and data fingering / research of the abdominal cavity in the first hours of the disease is an important diagnostic feature that allow to suspect acute pancreatitis.
Shock, which is in acute pancreatitis develops more often than any other disease of the abdomen, usually accompanied aetiology and high blood pressure; blood pressure falls, tachycardia occurs, the pulse becomes filiform, develops collapse, which may be a direct cause of death in the initial period of the disease.
In connection with shock and kidney trypsin the amount of the urine reduces, and in very severe cases come anuria and uremia fatal. For less severe forms of the disease, the amount of urine is reduced due to fluid loss, vomiting and exudate. Urine contains a small amount of protein, moderate amount of red blood cells and cylinders in the sediment. The defeat of the biliary tract and tropicheskie necrosis of the liver can lead to jaundice.
In severe forms of the disease often observed effusion in the abdominal cavity (in 70-75% of cases) and less frequently - in the left pleural cavity. These exudates, as a rule, contain pancreatic enzymes.
Haemorrhagic ascites on the skin of the abdomen, around the belly button, you can find petechiae and blue-green pigmentation (symptom Cullen) or hemorrhage on the lateral surface of the abdomen (symptom Gray Turner). Facial flushing with small cyanotic shade, often celebrated in most of these cases, explain the influence released into the blood of kallikrein (Gulzow, 1967).
Temperature, subnormal in the period of shock, in the future may increase; high fever happen at extensive necrosis of the authority, purulent pancreatitis, complications, sepsis, pneumonia, cholangitis, etc. Should be borne in mind that acute pancreatitis may develop on the background of infectious diseases occurring with increasing temperature.
Acute pancreatitis can be accompanied coronary insufficiency and be combined with myocardial infarction. Changes in the electrocardiogram in an acute initial period of the disease may sometimes remind changes in myocardial infarction; in these cases, only the subsequent electrocardiographic monitoring allow to finally establish or eliminate the defeat of coronary arteries. Usually electrocardiographically in acute pancreatitis are revealed diffuse lesions of the heart muscle.
The disorder of the intestine is manifested constipation or diarrhea. Blood tests often find neutrophilic leucocytosis with a shift to the left, limfopenia, the disappearance of eosinophils, accelerated ROHE. In the period of dehydration there is a thickening of the blood and increase the number of red blood cells. Sometimes even in severe forms of the disease changes in the blood may be low.
Electrophoretic study of protein fractions of blood in the first days of the disease reveals an increase of alpha and beta globulins, and in the subsequent period has increased only gamma-globulin. The General content of the plasma proteins is reduced through albumin and alpha-globulin.
Suspected acute pancreatitis important diagnostic significance also laboratory tests, the performance of which does not require a long time and doesn't burden of patients in serious condition. First of all concern the determination of amylase in the blood and urine and the establishment of glycosuria.
For acute pancreatitis is characterized by early (in the first day) improve the maintenance of enzymes in the blood and urine, is many times their normal level (amylase - up to several thousand units of Wohlgemuth). Increased amylase in blood and urine is marked at 75-95% of patients with acute pancreatitis. The increase in the maintenance of enzymes in the blood and urine develops during the first hours of the disease and usually lasts a few days. However, hyperfermentemia and hyperfermentemia can be and in a short time, therefore the study of enzymes should be performed in series in the early stages of the disease. Negative results of research in the later stages of the disease do not exclude the diagnosis of acute pancreatitis. Increased amylase activity less than 4-6 times compared to normal is not a reliable sign of acute pancreatitis, though not eliminate the disease. However, full compliance between the degree amylasemia and severity of the disease does not exist. If amylase blood remains high after 3-5 days from the onset of the disease, it usually indicates a severe illness. Re-development of hyperamylasemia indicates the new exacerbation of the disease. Sometimes this is the second increase of amylase activity of the blood may be associated with possible resorption of enzymes from the abdominal cavity. Under normal renal function changes amylase level in the blood and urine are almost simultaneously, and these studies are essentially equivalent. However, in violation of the kidney (which in severe acute pancreatitis often), despite the high hyperamylasemia, amylase content in the urine may be normal or low. Usually amylase blood reaches its maximum before the urine amylase, and faster than normal.
There is an opinion that the increasing of lipase blood in acute pancreatitis occurs more often (up to 99%)than increased amylasemia, and lasts longer. Special value was given to amoxil.medicine the lipase Comfort (1940), Lopusniak, Bockus (1950).

It is necessary to consider that at the massive destructive process in the pancreas, attracting a nearly complete destruction of tissue, the maintenance of enzymes in the blood and urine not be increased or may be even lower. Certain diagnostic value in such cases is detected, the reduction of calcium in the blood and increased content glutamicoxaloacetic transaminases. The content of calcium in the blood is reduced in approximately 1/3 of patients with severe acute pancreatitis, he goes to the formation of soap in the foci of necrosis. Calcium levels can be reduced to 7 mg% or below, while there may be signs tetanii. Maximum reduction of calcium in the blood is usually by the end of the first week of the disease. Sharp extended drop of blood calcium usually indicates a poor prognosis. Along with the fall of the level of calcium in patients with severe acute pancreatitis are imbalances and other electrolytes, in particular potassium, sodium and magnesium that you should consider when saline infusion.
Hypokalemia occurs in half of patients with severe pancreatitis during the first and second week of illness. Reduction of potassium in the blood is accompanied by increased its allocation of urine.
Giperkaliemia at the beginning of the disease may be due to the massive tissue disintegration and along with the increase of residual nitrogen may indicate the development of severe renal failure requiring urgent actions, up to the use of artificial kidney. All this indicates greater practical importance of the research electrolyte balance not only for diagnostics, but also for the correct treatment.
X-ray examination in the initial period of the disease is possible only without the use of contrast agents. You can find atony intestines and stomach, flatulence small intestine, limited mobility left dome of the diaphragm, the presence of exudate in the left pleural cavity, etc. However, these signs are not pathognomonic for acute pancreatitis.
The use of tests to determine the extent of the violations of the digestive function of the pancreas is possible in the later period of the disease, as well as the study of infringements of secretory process in the study of duodenal content using the probe. These tests help in making a retrospective diagnosis of acute pancreatitis and allow more detail to characterize the dynamics of the recovery period. In acute pancreatitis frequently observed abnormalities in carbohydrate metabolism, manifested hyperglycemia and glycosuria.
In case of receipt of acute pancreatitis peritoneal fluid or fluid from the left pleural cavity great diagnostic value is detected in them pancreatic enzymes.
The diagnosis of acute pancreatitis, of course, should be put not only on the basis of functional tests, reflecting the activities of the pancreas, but in light of all of the clinical picture disease, other data of laboratory and instrumental studies, allowing to exclude diseases with similar period of acute pancreatitis or combined with it. It should be borne in mind that the revaluation of the diagnostic values of individual functional tests, in particular giperfermentemii and carbohydrate metabolism, may lead to the erroneous diagnosis of acute pancreatitis.
The diagnosis of acute pancreatitis should be differentiated from a number of diseases that have similar clinical manifestations, and first of all with acute cholecystitis, the attack of biliary colic, perforated gastric ulcer, acute intestinal obstruction, acute peritonitis, food diseases, myocardial infarction; rarely there is a need to differentiate acute pancreatitis with thrombosis of vessels of the abdominal cavity, dissecting aortic aneurysm, infringement of diaphragmatic hernia, gangrenous appendicitis, lead colic, acute porphyria, tablecheck stroke, heart attack, spleen and other diseases.
From the attack of biliary colic acute pancreatitis can be distinguished by the presence of sudden prolonged pain in epigastralna area in the middle and to the left from the middle line, radiating to the left to the waist, is not relieved after vomiting and not yielding to the influence of drugs, in the absence of jaundice. In case of biliary colic pain paroxysmal, to the right of the center line, iradionet in the region of the right shoulder and collarbone, yield to the influence of drugs; often accompanied by jaundice, and palpation has a local pain at gelceutical point.
Fast-paced collapse and signs of partial intestinal obstruction show more about acute pancreatitis.
From perforation of the stomach acute pancreatitis is different rapidly developing collapse, lack of muscles of the anterior abdominal wall, the localization of pain to the left and above the navel, the preservation of hepatic stupidity, improving diastase and lipase in the blood and in the urine diastase, hyperglycemia. For perforation of the stomach ulcers characterized by the presence of doskoobraznye anterior abdominal wall, pain in the right iliac region in the initial period (in connection with the leaking of gastric contents) and diffuse pain in the later period, decrease or disappearance of hepatic stupidity.
Unlike acute intestinal obstruction, acute pancreatitis no gain peristalsis, local flatulence (symptom Valya), fecal vomiting, excessive indican with urine, accumulation of fluid in the abdominal cavity.
With spilled peritonitis acute pancreatitis can be differentiated due to the absence of fever, spilled pain on palpation of the abdomen, positive symptom Shchetkina - Blomberg, muscles of the anterior abdominal wall; furthermore, peritonitis no peristaltic noise of the intestine, increased content of indican in the urine, drugs and cropped pain.
In acute pancreatitis, unlike myocardial infarction, ECG remains normal, and in cases of severe hypocalcemia, there has only a prolongation of the QT interval and the flattening of the teeth So
Existing aphorism that the first step to put the correct diagnosis, is to think about it especially appropriate in respect of acute pancreatitis.
On the basis of clinical cannot accurately judge the nature of morphological changes in the pancreas in acute pancreatitis.
About swollen-interstitial acute pancreatitis or a light necrosis is possible to think in that case, if the clinical manifestations of the disease are expressed moderately, and laboratory parameters do not give sharp deviations from the norm. In favor of a deathly-hemorrhagic form evidenced by the rapid onset date with the development of a shock, and a sharp increase in the maintenance of enzymes in the blood and urine (oliguria, the potential increase in nitrogen), significant changes in carbohydrate metabolism, reducing the level of calcium in the blood (less than 8.5 mg%). However, taking into account these data the possible diagnostic error, as it is not always there is a direct relationship between the severity of the disease and the severity of the symptoms. Less obvious are the symptoms of acute pancreatitis in the elderly and persons depleted other and previous diseases.