The clinical manifestations vary greatly and are more complex due to different pathological changes.
(A) symptoms
1, abdominal pain is the most dominant symptom (about 95% of patients), mostly sudden epigastric or left epigastric continuous severe pain or knife-like pain, epigastric lumbar girdle feeling, often occurs after a full meal or drinking, accompanied by paroxysmal intensification, can be enhanced by eating, can spread to the umbilicus or the whole abdomen. It often radiates to the left shoulder or both sides of the low back. The abdominal pain ranges mostly from chest 6 to waist 1, sometimes morphine alone is ineffective. If combined with bile duct stones or biliary ascaris, there is right upper abdominal pain and biliary colic.
2, nausea and vomiting 2/3 of patients have this symptom, frequent episodes, early reflexive, the content of food, bile. Late stage is caused by paralytic intestinal obstruction, the vomit is fecal-like. If vomiting roundworms, it is mostly pancreatitis complicated by biliary ascariasis.
3, abdominal distension in heavy cases due to the stimulation of intra-abdominal exudate and retroperitoneal hemorrhage, paralytic intestinal obstruction caused by pneumatization and fluid accumulation in the intestine caused by abdominal distension.
4, jaundice about 20% of patients in the disease 1-2 days after the appearance of varying degrees of jaundice. The cause may be the coexistence of bile duct stones, causing bile duct obstruction, or enlarged pancreatic head compression of the lower end of the common bile duct or impaired liver function jaundice, the heavier the jaundice, suggesting that the more serious the disease, giving bad.
5, fever is mostly moderate fever: between 38 ° ~ 39 ° C, generally 3 to 5 days after the gradual decline. However, in heavy cases, the fever may persist for many days, suggesting pancreatic infection or abscess formation and toxic symptoms, and in severe cases, the temperature may not rise. When combined with cholangitis, there can be chills and high fever.
6, hand and foot convulsions as a result of reduced blood calcium. It is the effect of lipase into the abdominal cavity, so that the large omentum, peritoneum on the fatty tissue is digested, decomposed into glycerol and fatty acids, the latter combined with calcium as insoluble fatty acid calcium, and therefore serum calcium decreased, such as serum calcium <1.98mmol/L (8mg%), it indicates a serious condition and poor prognosis.
7, shock is mostly seen in acute hemorrhagic necrotizing pancreatitis, due to large amounts of peritoneal and retroperitoneal bleeding, intestinal paralysis, fluid accumulation in the intestinal cavity, vomiting resulting in loss of body fluids causing hypovolemic shock. In addition, absorption of large amounts of proteolytic products, leading to the development of toxic shock. The main manifestations are irritability, cold sweat, thirst, cold extremities, thin pulse, shallow and rapid breathing, decreased blood pressure, and little urination. In severe cases, cyanosis, dyspnea, delirium, coma, rapid pulse, blood pressure cannot be measured, no urine, BUN>100mg%, renal failure, etc.
8. There may be manifestations of related complications (such as heart failure, lung failure, renal failure).
(II) Physical signs.
1, abdominal pressure pain and abdominal muscle tension its scope in the epigastrium or left upper abdomen, because the pancreas is located in the retroperitoneum, so generally light, light cases only pressure pain, not necessarily muscle tension, some cases have deep pressure pain at the left rib cage angle. When there is more intra-abdominal exudate in heavy cases, the pressure pain, rebound pain and muscle tension are obvious and more extensive, but not as “plate-like abdomen” as ulcer perforation.
2, abdominal distension heavy due to retroperitoneal hemorrhage stimulation of visceral nerves caused by paralytic intestinal obstruction, so that the abdominal distension is obvious, the disappearance of intestinal sounds, showing a “quiet abdomen”, when more exudate can have mobile turbid sounds, abdominal puncture can be extracted bloody fluid, its amylase content is very high, very meaningful for diagnosis.
3, abdominal masses in some heavy cases, due to inflammatory wrapping adhesions, exudate accumulation in the small omental sac, or abscess formation, or the occurrence of pseudopancreatic cysts, in the epigastrium can be found in the indistinct boundaries of the pressure painful masses.
4, skin petechiae some patients appear around the umbilicus skin Lan-purple petechiae (Cullen sign) or brownish-yellow petechiae on both sides of the waist (Grey Turner sign), such petechiae can be seen under the sun, so it is easy to be ignored. It is a late manifestation due to fat necrosis caused by pancreatic enzymes crossing the peritoneum and muscle layer into the subcutis. The hemorrhage reaches the subcutaneous fat through the retroperitoneal space, causing petechiae and discoloration on one or both sides of the abdomen (Grey Turner sign). Iron salt deposition may cause permanent discoloration.
(C) Laboratory tests
1. The white blood cell count is usually between 10 and 20×109 /L. If the infection is severe, the count is high and there is a significant left shift of the nucleus. Some patients have increased urine sugar, and in severe cases, there are protein, red blood cells and tubular type in the urine.
2. Blood and urine amylase measurement has important diagnostic significance.
Normal values: serum: 8 to 64 Winslow (Winslow) units, or 40 to 180 Somogyi units; urine: 4 to 32 Winslow units.
Acute pancreatitis patients pancreatic amylase overflow outside the pancreas, rapidly absorbed into the blood and excreted by the urine, so the blood and urine amylase greatly increased, is an important laboratory test to diagnose the disease. Serum amylase begins to increase 1 to 2 hours after the onset of the disease, 8 to 12 hours specimen is the most valuable, to 24 hours to reach a peak of 500 to 3000 Somogyi’s units, and last 24 to 72 hours, 2 to 5 days gradually drop to normal, while urinary amylase begins to increase 12 to 24 hours after the onset of the disease, 48 hours to reach a peak, maintain 5 to 7 days, decline slowly.
In the case of severe necrosis, the amylase value is not increased because of the severe destruction of glandular vesicles and little amylase production. If the amylase value goes down and then goes up again, it indicates that there is a recurrence of the disease, and if it continues to increase, there may be complications. In some cases of peritonitis, biliary tract disease, ulcer perforation, strangulated intestinal obstruction, post-gastrectomy input collaterals obstruction, etc., amylase values can be increased to varying degrees, but are generally less than 500 SU units. Therefore, the diagnosis of acute pancreatitis is only meaningful when the measured value is >256 Winn units or >500 So units.
3.Serum lipase measurement
Normal value of 0.2 to 1.5 mg%, its value increases for the same reason as 2, the onset of 24 hours after the onset of the rise can last for 5 to 10 days more than 1Cherry-Crandall units or Comfort method 1.5 units have diagnostic value. Because of its late decline, the measurement of its value can be helpful for the diagnosis of those who visit the clinic late.
4.Serum calcium measurement
The normal value is not less than 2.12 mmol/L (8.5 mg/d1). The blood calcium starts to drop two days after the onset of the disease, and it is significant after the 4th to 5th day, and it can drop to below 1.75mmol/L (7mg/d1) in heavy cases, which indicates serious illness and poor prognosis. Medical all online www.med126.com
5, serum orthoferrin (Methemalbumin, MHA) measurement
MHA comes from the hemoglobin released from the destruction of red blood cells in the bloody pancreatic fluid, which is converted into methemoglobin under the action of lipase and elastase, and is absorbed into the blood and combined with albumin to form methemoglobin. MHA is often seen 12 hours after the onset of severe disease and is positive in patients with severe acute pancreatitis and negative in the edematous type.
(iv) X-ray examination
Restricted or extensive intestinal paralysis (dilated and inflated small intestine without tension, enlarged pneumatization of the left transverse colon) is seen in the abdomen. Fluid and gas accumulation in the small omental sac. There is a calcified shadow around the pancreas. Diaphragmatic elevation, pleural effusion, occasional disciform atelectasis, and a “hairy glass” lung field in the presence of ARDS are also seen.
(E) Ultrasound and CT
Both can show the outline of pancreatic enlargement, the amount and distribution of exudate, and can also show pseudo-pancreatic cysts and abscesses.