51. Acute pancreatitis

Question 1

Acute pancreatitis definition

Answer 1

Inflammation of the pancreas caused by the release of activated pancreatic enzymes - acute, chronic or relapsing.

Question 2

Acute pancreatitis types

Answer 2

Mild: characterised by intestinal edema +
minimal organ dysfunction

• Severe: characterised by pancreatic necrosis +
  multi-organ function

Question 3

Acute pancreatitis Etiology - basic

Answer 3

Biliary calculi (more common in women)

Alcohol abuse (more common in men)

Question 4

Acute pancreatitis Etiology - other - mneumonic

Answer 4

I GET SMASHED

Question 5

Acute pancreatitis Etiology - other -

Answer 5

Idiopathic

Gallstones
Ethanol
Trauma

Steroids
Mumps
Autoimmune
Scorpion venom
Hyperlipidemia
ERCP + emboli
Drugs

Question 6

Acute pancreatitis : Pathogenesis:

Answer 6

• Gallstones:
  o Gallstone lodged in distal ampulla of
  vater, causing bile reflux into
  pancreatic duct

o Gallstones obstructs pancreatic duct =
ductal hypertention = pancreatitis

• Alcohol: excessive compulsion. Ethanol is a
  metabolic toxin to pancreatic acinar cells
  which leads to a period of secretory increase
  thus when combined with ethanol it causes
  for spasm of sphincter of oddi.

o Ethanol also induces ductal
permeability thus premature
activation of enzymes that causes
damage to parenchyma

Question 7

Pathophysiology:

Answer 7

• Pancreatitis is triggered by obstruction of pancreatic duct + injury begins within the acinar cells
• The intra-acinar cells injury is due to activation of zymogens (digestive enzymes)
• Normally pancreatic enzymes secreted as inactive form + activated into trypsinogen by enterokinase
• Blocked pancreatic duct = activation inside pancreas by lyposomes

Question 8

Clinical Presenation

Answer 8

Sudden severe epigastric pain that radiates to back

• Pain relieved by sitting down

N/V

increased HR

fever

jaundice

rigid abdomen,

Question 9

Clinical Presenation - signs

Answer 9

Cullens sign (peri-umbilical bruising),

Grey turners sign (bruising along flanks)

Question 10

Diagnostic Investigations

Answer 10

Increased serum amylase, lipase, CRP

ABGs,
X-ray, 
CT,
US, 
ERCP, 
hypocalemia

Question 11

Treatment - criteria

Answer 11

Assess severity using “Modified Glasgow criteria”

Question 12

“Modified Glasgow criteria”

Answer 12

o PaO2   <8Kpa
o Age   >55
o Neutrophilic   >15x109/L
o Ca2+    <2 mmol/L
o Renal function Urea   > 16 mmol/L
o Enzymes     LDH + ALT
o Albumin       <32g / L
o Sugar         >10 mmol/L

Question 13

Treatment - criteria : mneumonic

Answer 13

P A N C R E A S

Question 14

Treatment

Answer 14

NBM with NG tube = decreased pancreatic stimulation

• I.V. fluids
• Analgesia = NSAIDs or Pethidine

o NOT MORPHINE – causes contraction of smooth muscles in sphincter of oddi

• ERCP or gallstone removal if jaundice worsens
• Abx in case of complications

Question 15

Complications:

Answer 15

• Early = shock, renal failure, sepsis

- Late = pancreatic necrosis,
pseudocysts, 
abscess,
bleeding (from elastase eroding artery wall)
fistulas

Question 16

RANSON CRITERIA

Answer 16

RANSON CRITERIA

predicts severity of acute pancreatitis

At admission – “GALAN”Gluc – 10mmol/L
Age - >55
LDH - >350
AST - >250
WBC - >16000 cells/mm3

@48hrs – “CHOBBS”
Ca2+ - <8mg/dL

Ht drop >10%

PaO2 - <60mmHg

Base def >4mg/dL

Bun increased >5mg/dL

Sequestration of fluid >6L

Question 17

Criteria 2

Answer 17

RANSON CRITERIA

Question 18

Bicard deficit

Answer 18

Bicard deficit estimated by: 0.5 x bodyweight (24HCO3)

Question 19

Somatostin

Answer 19

Somatostin – inhibit insulin + glucagon

Question 20

Indications for Surgical Intervention

Answer 20

(10% cases) require surgical intervention

1. If condition of patient deteriorates in spite of good conservative treatment.
2. If there is pancreatic infected necrosis.
3. In severe necrotising pancreatitis as a trial to save the life of the patient which has got
   very high mortality.