A 40 year old female presented with complains of abdominal pain, nausea and vomiting since 2-3 days. The pain was severe and radiating to back. Ultrasound abdomen showed bulky pancreas. Serum amylase levels were normal. What is the most likely diagnosis?
(Ref.: Sabiston 18th / chapter no 54 and 55)
Swollen/ Edematous pancreas is one of the earliest USG sign of acute pancreatitis, aparrt from others being peripancreatic fuzzy fat planes, intrapancreatic nerosis/pseudocysts and peripancreatic fliud.
a. Gallstones and inflammation of the gallbladder are the most frequent causes of abdominal pain from biliary tract disease.
b. The pain is described as a bandlike tightness of the upper abdomen that may be associated with nausea and vomiting.
c. This is due to a normal gallbladder contracting against a luminal obstruction, such as a gallstone impacted in the neck of the gallbladder, the cystic duct, or the common bile duct. The pain is most commonly triggered by fatty foods, but it can also be initiated by other types of food or even occur spontaneously.
d. The pain of biliary colic is distinct from that associated with acute cholecystitis.
e. Although biliary colic can also be localized to the right upper quadrant, the pain of acute cholecystitis is exacerbated by touch, is somatic in nature, and is often associated with fever and leukocytosis.
f. Irritation of the visceral and parietal peritoneum due to transmural inflammation from cholecystitis results in a positive Murphy's sign.
g. Abdominal pain, nausea, and vomiting are the dominant symptoms of pancreatitis.
h. Typically, the pain is located in the epigastrium, but it may also involve both upper quadrants, the lower abdomen, or the lower chest.
i. It may have a pleuritic component and be felt in one or both shoulders.
j. The pain is usually constant, although it may be somewhat relieved by leaning forward or lying on the side with the knees drawn upward. Patients with chronic pancreatitis frequently describe similar prior attacks that are often noted to occur within 12 to 24 hours of ethanol consumption.
k. The nausea and vomiting of pancreatitis usually persists even after the stomach has been emptied. The vomiting may lead to gastroesophageal tears (i.e., Mallory-Weiss syndrome) and upper gastrointestinal bleeding.
l. Although vomiting and retching may be relieved by passage of a nasogastric tube, the pain usually persists even after gastric decompression.
m. Serum amylase activity is usually, but not always, elevated during pancreatitis, but the magnitude of that elevation does not parallel the severity of the attack.
n. Typically, amylase levels rise 2 to 12 hours after the onset of symptoms and then decline, so that 3 to 6 days after the onset of an attack, the serum amylase levels are usually normal.
o. Elevations that persist beyond a week suggest either ongoing inflammation or the development of a complication such as pseudocyst, abscess, or pancreatic ascites.
p. Urinary amylase levels remain elevated longer than serum amylase levels; thus, measurement of urinary amylase levels may be of diagnostic help in patients who present long after the onset of symptoms.
q. Although amylase can enter the circulation from nonpancreatic sites, including the salivary glands, lung, prostate, and ovary, it is pancreatic amylase that accounts for the rise in circulating amylase activity during pancreatitis.