19. Pancreatitis

Question 1

Severe Acute pancreatitis - Management

Resus

Answer 1

1. Early & aggressive fluid resus
   - reg clin exam & test
   - FBC + U&E + LFT + Clotting / Amylase / lipase / abg
2. Reg assessment for deterioration
   - consider scoring systems to stratify
   - Ranson / Imrie / APACHEII
3. Awareness increase risk develop MODS
   local complications

age >70
BMI >30
Evidence effusions
Necrosis
high Ranson

Rad Scan
US Abdo
CT Abdo - gold standard - assess local complications

Analgesia
Thoracic epidural / PVB
awareness coagulopathy

Question 2

Mx -

ABX

Answer 2

Prophylactic abx not routinely prescribed

Infection abscess
FNA
Abx - per local guide

Question 3

Nutrition

Answer 3

Early enteral feed - NJ
Encourage good intake

No advantage to TPN
failure of NJ after 1/52

Maintain strict glycaemic control

Question 4

Surgery

Answer 4

CT guide FNA gold standard for detecting infected necrotic pancreas

Evidence of RP gas on CT
BSA & Surgical drainage and debridement

Delated surgery a/w increase survival
allow demarc necrotic pancreas
optimal tissue preservation

Question 5

Gallstone pancreatitis

Answer 5

Obstructive jaundice
ERCP - remove CBD stones

Coagulation corrected prior to procedure

Question 6

Critical care bundles

Answer 6

Known bundles
Glycaemic control
VTE prop
Gut protection
Lung Protective vent (LPV) - prevent ac lung injury

Septic

Question 7

Complications

Answer 7

Clinical factors 
pain persistent pyrexia 
N+V
Palp mass
inflamm markers

= presence abscess

Abscess
delayed presentation
3-4 post onset
risk min early scanning
CT/US

Rx Perc drain / surgery

Question 8

Complication cont

Answer 8

Pseudocyst
intervention if significant symptoms
Rx
endoscopic drain / perc aspiration / catheter drain

Infected necrosis - urgent surgery
sterile - supportive Rx

IAH - Serial pressure determine need decomp

Haemorrhage
rupture pseudoaneurysm splenic artery