4.1. Pancreatic Disease - Acute Pancreatitis Flashcards
What is Acute Pancreatitis?
The inflammation of the Pancreas Gland initiated by Acute Injry
What are the main Aetiological Agents of Acute Pancreatitis?
- Alcohol Abuse (60-75% of cases)
- Gallstones (25-40% of cases)
- Idiopathic (Up to 10% of cases)
- Iatrogenic
- Miscellaneous Causes
What are some examples of Miscellaneous Causes?
- Drugs
- Viruses
- Cancer (Pancreatic Carcinoma)
- Metabolic Disturbances
- Autoimmune
What types of Drugs can cause Acute Pancreatitis?
- Steroids (e.g. Prednisolone)
- Steroid Sparing Agents (e.g. Azathioprine)
- Diuretics (e.g. Furosemide)
What Viruses can cause Acute Pancreatitis?
- Mumps
- Coxsackie B4
- HIV
- CMV
What type of Metabolic Disturbances can cause Acute Pancreatitis?
- Increased Calcium
2. Increased Triglycerides
What is the Autoimmune cause of Acute Pancreatitis?
IgG4
What is the pathology of Acute Pancreatitis?
- Due to the Aetiology, there is an acute rise in Pancreatic Intracellular Calcium
- The Calcium (is believed to) cause the Premature activation of Trypsogen to Trypsin
- The Activated Trypsin is then responsible for Cellular Necrosis (auto-digestion)
- The Cellular Necrosis leads to the Secondary Response of Acute Pancreatic Inflammation
How does the Pancreatic Intracellular Calcium become raised in Gallstone-related Acute Pancreatitis?
The stones occlude the Pancreatic Drainage, causing Pancreatic Ductal Hypertension. This can free Cytosolic Free Ionized Calcium
What will happen if Acute Pancreatitis is left untreated?
- Pro-Inflammatory Cytokines will be released, and a Reactive Oxygen Species formed
- Oedema and Fat Necroses which will lead to Haemorrhage
What is the Clinical Presentation of Acute Pancreatitis?
- Epigastric Pain
- Back Pain
- Nausea and Vomiting
- Acute Renal Failure
- Jaundice / Cholestatic Symptoms
- Absent Bowel Sounds
- Hyperglycaemia
How is the Epigastric Pain described?
Very Acute, Paralysing pain within the Abdomen
Why would Back Pain occur?
As the Pancreas is a Retroperitoneal Organ, there can be Retroperitoneal Involvement as an aspect of the Inflammation
Why does Nausea and Vomiting occur?
In relation to the Epigastric Pain
How would the potential Acute Renal Failure present?
With Oliguria (Abnormally small amounts of Urine)
Why might Jaundice / Cholestatic Symptoms occur?
Due to the blockage of the Common Bile Duct as well
Why are there Absent Bowel Sounds?
Due to a Paralytic Ileum - one of the effects of Acute Pancreatitis
Why might Hyperglycaemia occur?
Due to the Pancreas not being able to effectively control blood Glucose
How would an Acute Pancreatitis associated Haemorrhage present?
- Acute Pancreatitis Symptoms
- Tachycardia
- Hypotension
- Anaemia
- Ascitic Effusion
Why does Tachycardia and Hypotension appear in an Acute Pancreatitis associated Haemorrhage?
Due to the Hypovolaemic Shock
Why does Anaemia appear in an Acute Pancreatitis associated Haemorrhage?
Due to the loss of blood in circulation
Why does an Ascitic Effusion appear in an Acute Pancreatitis associated Haemorrhage?
Due to the potential leakage of Pancreatic Contents into the Peritoneum
What are some uncommon presentations of Acute Pancreatitis, along with the normal Symptoms?
- Pleural Effusion
2. Hypocalcaemia
What investigations are necessary in Acute Pancreatitis?
- Serum / Urinary Amylase
- Serum Lipase / Inflammatory Markers (CRP and ESR)
- Liver Function Test (and Biochemistry)
- Full Blood Count, with Calcium, U’s and E’s
- Chest X-Ray
- Contrast Enhanced CT / MRI / MRCP
- (Abdominal / Endoscopic) Ultrasound / ERCP
What will the results from the Serum Amylase show in a patient with Acute Pancreatitis?
If this is 3 x the upper limit of normal, it suggests Acute Pancreatitis
What will the results from the Urinary Amylase show in a patient with Acute Pancreatitis?
If this is elevated, this suggests that the Acute Pancreatitis has been happening for a while
What will the results from the Serum Lipase show in a patient with Acute Pancreatitis?
This will be raised
What will the results from the Serum Inflammatory Markers (CRP and ESR)show in a patient with Acute Pancreatitis?
These are useful for staging the disease severity and prognosis
Whatis the purpose of a Liver Function Test (and Biochemistry) in a patient with Acute Pancreatitis?
This will show any other causes for the Symptoms - it is used to eliminate other causes
What is the purpose of a Chest-X-Ray in a patient with Acute Pancreatitis?
It is used to exclude any Gastroduodenal Perforation
What is the purpose of a Contrast Enhanced CT / MRI / MRCP in a patient with Acute Pancreatitis?
This is done to assess the extent of pancreatic necrosis (damage), and to identify a Gallstone (if that is the cause)
What is the purpose of a (Abdominal / Endoscopic) Ultrasound / ERCP in a patient with Acute Pancreatitis?
This is used to view the inside of the pancreas and find a potential blockage
What course do the Majority of cases follow?
A short-run, self-limiting course
What is the name of the Scoring System, used to differentiate the Severity of Acute Pancreatitis?
The Glasgow Criteria
What does the Glasgow Criteria include?
Each item will score 1 point
- White Cell Count (>15x10^9/L)
- Blood Glucose (>10mmol/L)
- Blood Urea (>16mmol/L)
- Aspartate Aminottransferase (>0.2mmol/L)
- Lactate Dehydrogenase (>0.6mmol/L)
- Serum Albumin (<32g/L)
- Serum Calcium (<2.0mmol/L)
- Partial Pressure of Oxygen (<55mmHg in arteries)
How many points, from the Glasgow Critera, are required within 48 hours to suggest Severe Acute Pancreatitis?
3
What are the General Measures for treating Acute Pancreatitis?
- Nasogastric Suction
- Baseline Arterial Blood Gase
- Prophylactic Antibiotics
- Analgesia
- Nasogastric Tube
- Anticoagulation Therapy
- Blood Transfusion
- Insulin / Calcium Supplement
- Catheterisation
What is the purpose of Nasogastric Suction?
This prevents abdominal distension and reduces the risk of Aspiration Pneumonia from Vomiting
What is the purpose of a Baseline Arterial Blood Gas?
As this is a key factor in the severity of the condition, it is needed to be closely monitored
What is the purpose of Prophylactic Antibiotics?
Beta-Lactams are used to reduce the risk of further pancreatic necrosis by infection
What is the purpose of Analgesia?
To relieve the Symptom of Pain
Due to the severity of the pain, what type of Analgesics are used?
High Dose Opioids
What is the purpose of a Nasogastric Tube?
To allow for feedign (nutrition)
What is the Nasogastric Tube done in combination with?
I.V. fluids - for stabilization
What is the purpose of Anticoagulation Therapy?
Deep Vein Thrombosis Prophylaxis - used LMWH
What is the purpose of a Blood Transfusion?
To counteract the effects of Anaemia if a haemorrhage has occurred
What is the purpose of Insulin / Calcium Supplements?
As these are often low if the Endocrine function of the Pancreas is effected
What is the purpose of Catheterisation?
To monitor urine output
What specific treatment may be required?
- ERCP / Cholecystectomy if Gallstones are the cause
- Percutaneous Drain + Antibiotics if a Pancreatic Abscess is the cause
- Endoscopic Drain if a Pancreatic Pseudocyst is the cause
Are there any benefits from Antiproteases, Antibiotics, Inhibitors of Pancreatic Secretion, or Peritoneal Lavage on the outcome of the Disease?
No
