Acue pancreatitis

Question 1

What is the pathogenesis?

Answer 1

Pancreatitis enzymes (esp. trypsin) are activated in the pancreas leading to auto-digestion

Question 2

What are the causes?

Answer 2

I GET SMASHED

• Idiopathic
• Gallstones
• Ethanol
• Trauma
• Steroids
• Mumps
• Autoimmune
• Scorpian venom
• Hyperlipidaemia/ hypothermia/ hypercalcaemia
• ERCP (endoscopic retrograde cholangiopancreatography)
• Drugs
• Also pregnancy and neoplasia

Question 3

What are the symptoms & signs?

Answer 3

• Sudden sever epigastric/ central abdo pain
• Pain radiates to back (sitting forward relieves)
• Vomitting
• Haemodynamic instability/ hypovolaemic shock with low BP +/- tachycardia
• Fever
• Jaundice
• Ilius
• Rigid abdomen + tenderness
• Cullen’s sign - periumbilical bruising
• Lumbar region discoloration
• Grey Turner’s sign - flank bruising (due to blood vessel autodigestion & retroperitoneal haemorrhage)

Question 4

What is Cullen’s sign?

Answer 4

Periumbilical bruising

Question 5

What is Grey Turner’s sign?

Answer 5

Flank bruising (due to blood vessel autodigestion & retroperitoneal haemorrhage)

Question 6

What investigations are relevent?

Answer 6

• ↑Amylase (>1000u/ml or x3 normal)
  
  • Not proportional to severity, lesser rises common in other diseases
• ↑Lipase (more sensitive)
• Hypercalcaemia
• ABG: Monitor oxygenation & acid-base status
• AXR
  
  • No psoas shadow (↑retroperitoneal fluid)
  • Sentinel Loop (due to local ilius)
• Erect CXR
  
  • Exclude pneumoperitoneum, pleural effusions
• CT/ MRI & CRP: Assess severity

Question 7

What are some important differential diagnoses?

Answer 7

• Peptic ulcer
• Biliary colic or acute cholecystitis
• MI
• Intestinal ischaemia
• Ruptured AAA
• Perforated viscus (organ)

Question 8

How could you predict the severity of pancreatitis?

Answer 8

1. Modified Glasgow criteria for predicting severity of pancreatitis

• Pa02 <8kPa
• Age >55
• Neutrophilia WBC >15x109/L
• Calcium <2mmol/L
• Renal function Urea >16mmol/L
• Enzymes LDH >600iu/L; AST >200iu/L
• Albumin <32g/L (serum)
• Sugar Blood glucose >10mmol/L

3+ score suggests severe pancreatitis

1. CT/ MRI assessment
2. CRP marker

& apache’s score

Question 9

Outline the management

Answer 9

• Analgesia
  
  • Pethidine or morphine (may cause Oddie constriction)
• NBM (NG Tube) – Bowel rest
• IVI – 0.9% saline to counter 3rd space sequestration (until stats & urine output normal) [U catheter] - Nutrition
• Hourly pulse, BP, urine output
• Daily FBC, U&E, CA2+, glucose, amylase, ABG
• ERCP + gallstone removal if needed
• Repeat imaging (usually CT)

Question 10

What are the early complications?

Answer 10

• Shock
• Acute respiratory distress syndrome
• Sepsis
• Systemic inflammatory response syndrome
• Low blood calcium
• High blood glucose
• Dehydration

Question 11

What are the late complications?

Answer 11

• Pancreatic necrosis & pseudocyst
  
  • Fluid in lesser sac containing panc. enzymes, blood and necrotic tissue
  • Mass +/- persistent ↑amylase
  • May resolve or need drainage
• Abscesses need draining
• Bleeding (elastase eroding major vessel)
• Thrombosis
• Fistulae