Upper GIT 3 Investigation Plain Xray abdomen in

Upper GIT 3

Investigation ● Plain X-ray abdomen in errect posture A/P view reveal – a) crescentic(free) gas shadow under the domes of diaphgram ( commonly rt ) – pneumoperitoneum. ( 70% cases ) b) ground glass opacity – feature of generalised peritonitis c) multiple gas fluid levels – F / parelytic ileus. X –ray features in acute pancreatitis ØSentinel loop (dilated proximal small bowel – localized ileus ) ØColon cut off sign > ØRenal halo sign – ring of light around kidney. ØObliteration of psoas shadow ØAir fluid level in duodenum ØLocalized ground glass appearance. For perforated DU – no more image investigation.

● CXR in errect posture – better visualization of domes. pleural effusion, F / ARDS ( diffuse alveolar interstitial shadow) in acute pancreatitis. ● USG of whole abdomen – gall / pancreatic sones, dilated ducts, swollen pancreas. ● S Amylase, S. Lipase ● CT scan( contrast enhanced ) of abdomen indication > v Diagnostic uncertainity v. Severe attack of acute pancreatitis v. Complicated ( abscess, pseudocyst ) v. Progressive clinical deterioration with sepsis, organ failure. ● S. electrolytes – for general assessment. q ERCP – severe acute gall stone pancreatitis.

Treatment Resuscitation of patient Ø Nothing per oral Ø Intravenous fluids Ø Nasogastric suction Ø Inj. Analgesic – Ø Inj. Anti stress ulcer Rx Ø Inj. Antibiotic Ø Urinary catheterization – Ø Monitoring ( vital signs, degree of dehydration, urine output /hr) in acute pancreatitis – more intense / invasive monitor pt may need admission in ICU / HDU for supportive therapy for organ failure. q ERCP – within 72 hrs of onset of symptoms of acute pancreatitis with jaundice, cholangitis, dilated CBD. ► sphincterotomy, removal of stone ± stenting.

Surgical treatment : for perforation of ch, DU laparotomy under G/A by upper midline incision ► repair of perforaion usually in ant. Wall of 1 st part of duodenum(reinforced by omental patch) with thorough peritoneal toileting (to remove all of the fluid & food debris). v ulcer in post wall of 1 st part of duodenum – tend to bleed by eroding the gastroduodenal artery ►Laparoscopic method – thorough peritoneal toileting + intracorporeal suturing. ►if untreated – shock (hypovolaemic, septic), intraperitoneal abscess. Stages of perforated peritonitis 1. Stage of peritonism – irritation of peritoneum by gastric juice. 2. Stage of reaction 3. Stage of diffuse peritonitis.

Indication of surgical Rx in Acute pancreatitis Ø Diagnostic uncertainity – suspicious of perforation Ø Failed conservative Rx Ø Gall stone pancreatitis – impacted stone cannot be removed endoscopically Ø When complicated – panreatic abscess, infective pancreatic necrosis q Role of ERCP in acute pancreatitis – Complications acute pancreatitis I) Local – usually after 1 st wk § Acute fluid collection § Pancreatic necrosis → abscess § Pancreatic ascites § Pseudocyst ( after 4 wks ) § Pleural effusion § Portal / splenic vein thrombosis § Pseudoaneurysm. • colonic stricture.

II) Systemic > common in 1 st wk § CVS – shock, arrythmia § Pulmonary – ARDS § Renal failure § Haematological – DIC § Metabolic – hypocalcaemia, hyper glycaemia, hyperlipidaemia § GIT – ileus § Neurological – confusion, visual disturbance, encephalopathy § Miscellaneous – subacute fat necrosis, arthralgia. Assessment of severity - scoring system v Ranson score – severe if 3 or more factors present v Glasgow scale v APACHE – II (ICU ). Etiology of acute pancreatitis.