Acute Pancreatitis

1. Definition:

Acute pancreatitis (AP) is a sudden inflammation of the pancreas. It occurs when digestive enzymes within the pancreas become prematurely activated within the pancreas itself, rather than in the small intestine, leading to pancreatic tissue damage.

2. Diagnostic Criteria:

According to the Atlanta Criteria, AP is definitively diagnosed when two out of three criteria are met:

• 1. Abdominal Pain Consistent with AP:

• Pain in the upper abdomen, radiating to the back.

• Constant, sudden, gnawing pain.

• Pain reduced when leaning forward, increased with movement.

• Accompanied by nausea, vomiting, with no pain relief after vomiting.

• 2. Serum Amylase or Lipase Levels Elevated ≥ 2-3 Times the Upper Limit of Normal.

• Normal serum amylase value: 90 UI/l.

• Normal serum lipase value: 250 UI/l.

• 3. Characteristic Imaging Findings on CT Scan:

• Diffuse or focal pancreatic enlargement.

• Uneven enhancement.

• Blurring of the fat layer surrounding the pancreas.

• Retroperitoneal fluid collection.

3. Causes of AP:

• 1. Gallstones: The most common cause, accounting for approximately 40-50% of cases.

• 2. Alcohol Abuse: Alcohol increases pancreatic secretions, leading to obstruction of the pancreatic duct and premature activation of digestive enzymes.

• 3. Hypertriglyceridemia: High levels of triglycerides in the blood can obstruct the pancreatic duct.

• 4. Trauma: Endoscopic retrograde cholangiopancreatography (ERCP), pancreatic stone extraction through endoscopy, abdominal trauma.

• 5. Medications: Some medications can cause AP, such as antibiotics, anti-inflammatory drugs, and chemotherapy agents.

• 6. Sphincter of Oddi Dysfunction: Obstructs the flow of pancreatic juice, leading to increased pressure and pancreatitis.

• 7. Other Causes: Pancreatic tumors, infections, autoimmune diseases, genetics, allergies.

Note:

• Acute pancreatitis can progress rapidly and severely, requiring prompt treatment.

• Early diagnosis and effective treatment help reduce complications and mortality.

4. Recommended Workup for AP:

• 1. Blood Tests:

• CBC, CRP: Evaluate inflammation and severity of the disease.

• Blood glucose: Check blood sugar levels, rule out diabetes mellitus.

• Serum lipase, serum amylase, urinary amylase: Determine the level of increased digestive enzymes.

• Liver function tests (LFTs): AST, ALT, total bilirubin, TP: Evaluate liver function.

• Kidney function tests (KFTs): Urea, creatinine: Evaluate kidney function.

• Electrolytes, ionized calcium: Check for dehydration and electrolyte imbalances.

• Lipid profile: Determine the level of hypertriglyceridemia.

• 2. Imaging Studies:

• Contrast-enhanced abdominal CT scan: Evaluate pancreatic damage, severity of inflammation, and complications.

5. Indications for Contrast-enhanced Abdominal CT Scan in AP:

• 1. Severe AP: Evaluate pancreatic damage and complications.

• 2. Suspected AP due to Pancreatic Cancer: Differentiate AP from pancreatic cancer.

• 3. Abdominal Pain with Other Differential Diagnoses: Bowel obstruction, mesenteric ischemia, etc.

6. Contraindications to Contrast Media:

• 1. History of Allergy to Contrast Media: Risk of severe allergic reaction.

• 2. Renal Impairment, Creatinine > 2mg/dl: Contrast media can further damage the kidneys.

7. Treatment of AP:

• 1. Medical Management:

• Complete fasting: Until pain subsides and other symptoms improve.

• Fluid resuscitation: Replenish fluids and electrolytes intravenously.

• Pain management: Use opioid analgesics.

• Antibiotics: Use in case of infection.

• 2. Surgical Management:

• Cholecystectomy: If gallstones are the cause.

• Pancreatic duct drainage: If there is obstruction of the pancreatic duct.

Note:

• Treatment of AP should be performed by a gastroenterologist.

• Depending on the severity of the disease, treatment approaches may vary.

## Heart Failure

1. Definition:

Heart failure is a condition in which the heart is unable to pump enough blood to meet the body’s needs.

2. Framingham Criteria:

• Major Criteria:

• Paroxysmal nocturnal dyspnea or orthopnea.

• Jugular venous distention.

• Systemic venous pressure > 16cmH20.

• Hepatojugular reflux.

• Rales.

• Acute pulmonary edema.

• Cardiomegaly.

• T3 (this criterion was later removed).

• Minor Criteria:

• Ankle edema.

• Nocturnal cough.

• Dyspnea on exertion.

• Pleural effusion.

• Vital capacity reduced by 1/3 of maximum.

• Heart rate > 120 beats/minute.

• Hepatomegaly.

• Major or minor criterion: Weight loss of 4.5 kg/5 days of heart failure treatment.

3. Diagnosis of Heart Failure According to Framingham:

Heart failure is diagnosed when 2 major criteria or 1 major criterion plus 2 minor criteria are present.

4. NYHA Classification of Heart Failure:

• Class 1: No limitation. Ordinary physical activity does not cause undue fatigue, dyspnea, or palpitation.

• Class 2: Slight limitation. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain.

• Class 3: Marked limitation. Comfortable at rest, but less than ordinary physical activity causes fatigue, palpitation, dyspnea, or anginal pain.

• Class 4: Unable to carry on any physical activity without discomfort. Symptoms of heart failure are present even at rest.

5. Medications that Improve Survival in Chronic Heart Failure:

• 1. Aldosterone Antagonists: Spironolactone, Eplerenone.

• 2. Digitalis/Cardiac Glycosides: Digoxin, ACEI, ARB.

• 3. Beta Blockers: Carvedilol, Metoprolol, Bisoprolol, Nebivolol.

• 4. Sodium Channel Blockers: Ivabradine.

• 5. Valsartan + Sacubitril: (Entresto).

6. 4 Beta Blockers in Chronic Heart Failure Treatment:

• 1. Carvedilol: 3.125 mg x 2 times/day.

• 2. Metoprolol: 12.5 – 25 mg x 2 times/day.

• 3. Bisoprolol: 1.25 mg x 1 time/day.

• 4. Nebivolol: 1.25 mg x 1 time/day.

Note:

• Medication dosage should be adjusted by a physician according to the patient’s condition.

• Do not self-medicate without a doctor’s prescription.

7. Left Heart Failure Syndrome:

• Decreased Cardiac Output Syndrome: Dizziness, fatigue, cold extremities, oliguria, dyspnea on exertion.

• Pulmonary Hypertension Syndrome: Cough, dyspnea when lying down, relief when sitting up, nocturnal dyspnea, waking up at night to breathe.

• Cardiomegaly: Enlarged heart shadow, apex beat displaced downwards and outwards.

8. Right Heart Failure Syndrome:

• Jugular venous distention/Hepatojugular reflux (+): Signs of venous congestion.

• Hepatomegaly, Splenomegaly: Due to increased portal venous pressure.

• Ankle edema: Due to reduced venous return.

• Harzer (+): Sign of water accumulation in the liver.

9. Factors that Trigger Acute Heart Failure:

• CHAMP:

• MI – PCI: Myocardial infarction – percutaneous coronary intervention.

• HTN – Hypotension: Hypertension – sudden hypotension.

• Arrhythmias – Electric Shock: Rapid, slow, or irregular heartbeats.

• Cardiac tamponade – Pericardiocentesis: Increased pressure within the pericardium.

• Pulmonary embolism – Thrombolysis: Obstruction of pulmonary blood vessels.

10. Examination of Patients with Heart Failure Symptoms of Congestion and Reduced Organ Perfusion:

• 1. Congestion:

• Intravascular: Hepatomegaly, jugular venous distention, rales in the lungs.

• Extravascular: Pleural effusion (PE), ascites (AC), ankle edema.

• 2. Reduced Organ Perfusion:

• Brain: Altered mental status.

• Liver: Liver failure.

• Kidneys: Reduced urine output, elevated urea.

• Limbs: Cold extremities, low blood pressure, elevated blood lactate.

11. Types of Acute Heart Failure:

• Congestion (+): Wet.

• Congestion (-): Dry.

• Reduced Perfusion (+): Cold.

• Reduced Perfusion (-): Warm.

Note:

• Types of acute heart failure can transition between each other.

• Close monitoring of the patient’s condition is needed for timely treatment.

12. Blood Pressure Targets in Chronic Heart Failure (CHF) Patients:

• Proteinuria <= 1g/24h: <= 130/80mmHg.

• Proteinuria > 1g/24h or DM: <= 125/75 mmHg.

• Patients on Regular Dialysis: 135/85 mmHg.

13. Classification of CHF According to Nguyễn Văn Xang:

• I: 60-41 ml/ph/1.73m2.

• II: 40-21 ml/ph/1.73m2.

• IIIa: 20-11 ml/ph/1.73m2.

• IIIb: 10-5 ml/ph/1.73m2.

• IV: < 5 ml/ph/1.73m2.

14. Classification of CHF According to KDIGO:

• Stage 1: > 90ml/ph/1.73m2.

• Stage 2: 60-89 ml/ph/1.73m2.

• Stage 3: 30-59 ml/ph/1.73m2.

• Stage 4: 15-29 ml/ph/1.73m2.

• Stage 5: < 15ml/ph/1.73m2.

Note:

• CHF classification based on renal function helps assess the degree of kidney damage and risk of mortality.

15. HAS-BLED Score for Assessing Risk of Bleeding:

• H: Hypertension.

• A: Abnormal liver or renal function.

• S: Stroke.

• B: Bleeding history.

• L: Labile INR.

• E: Elderly.

• D: Drugs or alcohol use.

16. CHA2D2-VASc Score:

• Prior stroke, TIA, or systemic embolism: 2 points.

• Age >= 75: 2 points.

• Congestive heart failure: 1 point.

• Hypertension: 1 point.

• Diabetes mellitus: 1 point.

• Age 65-74: 1 point.

• Female gender: 1 point.

• Vascular disease: 1 point.

Note:

• HAS-BLED and CHA2D2-VASc scores help assess the risk of bleeding and stroke in patients with atrial fibrillation.

## Conclusion:

Acute pancreatitis and heart failure are serious medical conditions that require timely diagnosis and treatment. Understanding the symptoms, causes, diagnosis, and treatment of these conditions is essential to enhance treatment effectiveness and reduce complications.