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[41] Acute Pancreatitis Flashcards

1
Q

What is acute pancreatitis characterised by?

A

Self-perpetuating pancreatic enzyme-mediated autodigestion

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2
Q

What can cause hypovolaemia in acute pancreatitis?

A

Oedema and fluid shifts

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3
Q

What fluid shifts cause hypovolaemia in acute pancreatitis?

A

Extracellular fluid gets trapped in the gut, peritoneum, and retroperitoneal space

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4
Q

What % of acute pancreatitis cases are mild?

A

80%

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5
Q

What will 20% of acute pancreatitis cases develop to?

A

Serious and life threatening disease

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6
Q

How fast does the progression of acute pancreatitis occur?

A

May be rapid

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7
Q

What can severe cases of acute pancreatitis develop into?

A

Necrotising pancreatitis

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8
Q

What may cases of necrotising pancreatitis be further complicated by?

A

Infection

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9
Q

What % of cases of necrotising pancreatitis are further complicated by infection?

A

50%

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10
Q

When does acute pancreatitis occur?

A

When there is abnormal activation of digestive enzymes within the pancreas

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11
Q

What causes the abnormal activation of digestive enzymes in acute pancreatitis?

A

Inappropriate activation of inactive enzyme precursors called zymogens inside the pancreas, most notably trypsinogen

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12
Q

What normally happens to trypsinogen?

A

It is converted to it’s active form (trypsin) in the duodenum

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13
Q

What is the physiological role of trypsin?

A

To aid in the digestion of proteins

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14
Q

What happens to trypsinogen during an episode of acute pancreatitis?

A

Trypsinogen comes into contact with cathpepsin, which is a lysosomal enzyme, which activates it

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15
Q

What does the inappropriate activation of trypsinogen to trypsin in acute pancreatitis cause?

A
  • Inflammation
  • Oedema
  • Vascular injury
  • Cell death via necrosis or apoptosis
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16
Q

What can pancreatitis be classified into?

A

Mild and severe

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17
Q

What is the classification of pancreatitis based on?

A

Wether the predominant response to cell injury is inflammation (mild) or necrosis (severe)

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18
Q

What happens in mild pancreatitis?

A

There is inflammation and oedema of the pancreas

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19
Q

What happens in severe pancreatitis?

A

There is necrosis of the pancreas, and nearby organs may become injured

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20
Q

What are the causes of acute pancreatitis?

A
  • Gallstones
  • Ethanol
  • Trauma
  • Steroids
  • Mumps
  • Autoimmune
  • Scorpion venom
  • Hyperlipidaemia
  • Hypothermia
  • Hypercalcaemia
  • ERCP
  • Emboli
  • Drugs
  • Pregnancy
  • Neoplasia
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21
Q

What are the symptoms of acute pancreatitis?

A
  • Pain
  • Nausea and vomiting
  • Diarrhoea
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22
Q

Describe the pain in acute pancreatitis?

A

It is gradual or sudden onset severe epigastric or central abdominal pain, which radiates o the back

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23
Q

What might relieve the pain in pancreatitis?

A

Sitting forwards

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24
Q

What are the signs of acute pancreatitis?

A
  • Increased HR
  • Fever
  • Jaundice
  • Shock
  • Ileus
  • Rigid abdomen, with local or general tenderness
  • Periumbilical bruising, or bruising in flanks
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25
What investigations can be done into acute pancreatitis?
* Serum amylase and lipase * ABG * AXR * Other imaging * CRP
26
What is considered to be raised serum amylase?
\>1000u/mL
27
Is the degree of elevation of serum amylase related to the severity of the disease in acute pancreatitis?
No
28
Why may serum amylase be misleading in acute pancreatitis?
It can be normal, even in severe pancreatitis
29
How is amylase secreted?
Renally
30
What is the result of amylase being excreted renally?
Renal failure will increase levels
31
Is serum amylase a specific test for acute pancreatitis?
No
32
What other conditions can cause raised serum amylase?
* Cholecystitis * Mesenteric infarction * GI perforation
33
How does serum amylase rises in cholecystitis, mesenteric infarction, and GI perforation compare to in acute pancreatitis?
These conditions cause the levels to rise less than in acute pancreatitis
34
How does testing serum lipase compare to serum amylase in acute pancreatitis?
It is more sensitive and specific for pancreatitis, especially when related to alcohol, rises earlier, and falls later
35
What may be shown on an AXR in acute pancreatitis?
* No psoas shadow * ‘Sentinel loop’ of proximal jejunum from ileus
36
Why is there no psoas shadow on AXR in acute pancreatitis?
Due to increased retroperitoneal fluid
37
Other than AXR, what imaging modalities can be used in suspected acute pancreatitis?
* CT * Erect CXR * Ultrasound
38
How is CT used in acute pancreatitis?
It is the standard choice of imaging to assess severity and for complications
39
What are erect CXR used for in acute pancreatitis?
Rule out other causes, e.g. bowel perforation
40
What are ultrasounds used for in acute pancreatitis?
May be used if there is suspected gallstones or increased AST
41
What can CRP be used for in acute pancreatitis?
As an indicator of severity
42
What CRP is an indicator of severe pancreatitis?
\>150mg/L at 36 hours after admission
43
How is the Modified Glasgow Criteria used in acute pancreatitis?
It is used to predict the severity of acute pancreatitis
44
What suggests severe pancreatitis in the Modified Glasgow criteria?
Three or more positive factors detected within 48 hours of onset
45
What are the factors in the Modified Glasgow Criteria for acute pancreatitis?
* PaO2 \<8kPa * Age \>55years * WBC \>15x109/L * Calcium \<2mmol/L * Urea \>16mmol/L * Albumin \<32g/L * Blood glucose \>10mmol/L
46
Where are mild cases of acute pancreatitis managed?
General ward
47
What is involved in the management of mild acute pancreatitis?
* Pain relief * IV fluids with NBM * Antibiotics for specific infections * NG tubes
48
What pain relief should be given in acute pancreatitis?
Buprenorphine, with or without IV benzodiazepines
49
Is morphine used in the management of acute pancreatitis?
No, it is relatively contraindicated
50
Why is morphine relatively contraindicated in acute pancreatitis?
Due to possible spastic effect on the sphincter of Oddi
51
When might NSAIDs be effective in acute pancreatitis?
In the recovery phase
52
When should a NG tube be used in acute pancreatitis?
Only for severe vomiting
53
Is a CT scan necessary in mild acute pancreatitis?
No
54
When can oral fluids be resumed in acute pancreatitis?
When pain and other symptoms have resolved and blood tests are normal
55
Should oral fluids and solids be resumed at the same time following acute pancreatitis?
No, solids should be resumed a bit after
56
What can be considered in the management of mild acute pancreatitis when gallstones are the cause?
Common bile duct clearance and cholecystectomy after recovery
57
Where should severe cases of acute pancreatitis be treated?
ITU, or in high dependency unit
58
What treatment should be given in severe acute pancreatitis?
* Antibiotics * Enternal nutrition via NG tube * Fluid replacement and pain relief * Early ERCP if co-existing cholangitis or biliary obstruction
59
When should IV antibiotics be given in severe acute pancreatitis?
When there is evidence of significant pancreatic necrosis
60
Why should patients with severe acute pancreatitis be fed with enternal nutrition via a NG tube?
It has been shown to significantly reduce mortality, multiple organ failure, systemic infections, and the need for operative interventions
61
When is surgery required in severe acute pancreatitis?
Only when there is infection and necrosis
62
What was the original surgical treatment for severe acute pancreatitis?
Open surgical debridement
63
What is open surgical debridement be largely replaced by in severe acute pancreatitis?
Newer, minimally invasive techniques such as transgastric endoscopy
64
What procedure can sometimes avoid surgery in acute severe pancreatitis?
Percutaneous catheter drainage wtih saline irrigation
65
What are the early complications of acute pancreatitis?
* Shock * ARDS * Renal failure * DIC * Sepsis * Hypocalcaemia * Hyperglycaemia
66
What are the late complications of acute pancreatitis?
* Pancreatic necrosis and pseudocyst * Abscess * Bleeding * Thrombosis * Fistulae
67
What causes pancreatic necrosis as a complication of acute pancreatitis?
Ongoing inflammation eventually leads to ischeamic infarction of the pancreatic tissue
68
When should pancreatic necrosis be considered in an acute pancreatitis patient?
When patients have evidence of persistent systemic inflammation for more than 7-10 days after the onset of pancreatitis
69
How should any suspected pancreatic necrosis be confirmed?
By CT scan
70
What will treatment of pancreatic necrosis often warrant?
Pancreatic necrosectomy (open or endoscopic)
71
What is pancreatic necrosis prone to?
Infection
72
When should pancreatic necrosis be suspected, related to it being prone to infection?
If there is a clinical deterioration in the patient associated with raised infection markers
73
How can definitive diagnosis of pancreatic necrosis be made?
By fine needle aspiration of the necrosis
74
What is the problem with fine needle aspiration of pancreatic necrosis?
It can be associated with a risk of seeding infection, therefore must be performed with care
75
What is the general consensus for intervention in cases of confirmed pancreatitis?
That it should be delayed until walled-off necrosis has been developed, typically 3-5 weeks after the onset of symptoms
76
What is a pancreatic pseudocyst?
A collection of fluid within the pancreatic tissue
77
When is a pancreatic pseudocyst typically formed?
Weeks after the initial acute pancreatitis episode
78
How does a pancreatic pseudocyst form?
The inflammation reaction produces a necrotic space in the pancreas that fills with pancreatic fluid, surrounding by fibrous tissue
79
Why is a pancreatic pseudocyst so named, rather than a pancreatic cyst?
Because it lacks epithelial or endothelial cells surrounding the collection
80
How do pseudocysts present?
They may present incidentally on imaging, or can prsent with symptoms of mass effects
81
What symptoms of mass effects might pancreatic pseudocysts present with?
* Biliary obstruction * Gastric outlet obstruction
82
What can complicate pancreatic pseudocysts?
* Haemorhage * Rupture * Infected
83
When are cysts unlikely to resolve spontaneously?
When they have been present for longer than 6 weeks
84
What are the treatment options for pancreatic pseudocysts?
* Surgical debridement * Endoscopic drainage (often into the stomach)
85
What causes bleeding in acute pancreatitis?
Elastases eroding into a major vessel, e.g. the splenic artery
86
How is bleeding in acute pancreatitis managed?
Embolisation - may be life-saving
87
Where can thrombosis occur in acute pancreatitis?
* Splenic or gastroduodenal arteries * Colic branches of the SMA
88
What can thrombosis in acute pancreatitis cause?
Bowel necrosis

ANKI GI (43 decks)

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