Acute and Chronic Pancreatitis (1*)

Question 1

Acute Pancreatitis:
What is it?

What are its causes?

How does it present?

What are its differentials?

Answer 1

➊ Rapid onset of inflammation and symptoms, with function returning to normal after an episode

➋ I GAT SMASHED:
• Idiopathic
• Gallstones
• Alcohol
• Trauma
• Steroids
• Mumps
• Autoimmune
• Scorpion venom
• Hyperlipidaemia
• ERCP
• Drugs (furosemide, thiazide diuretics, azathioprine)

➌ • Stabbing-like, epigastric pain which radiates to the back and is relieved by sitting forward or lying in foetal position
• Vomiting
• Hx of gallstones or recent alcohol binge
• O/E - Tachycardia, Dry mucous membranes, Grey-turners/Cullen’s sign (both signs of intra/retroperitoneal hemorrhage)

➍ • Perforated peptic ulcer
• AAA rupture
• Ruptured ectopic pregnancy
• MI in elderly/diabetics

Question 2

What are its early complications?

What are its late complications?

How is its severity measured?

Answer 2

➊ • ARDS - massive pancreatic inflammation leads to widespread extravasation of fluid into the 3rd space
• AKI and Shock - due to hypovolaemia
• DIC

➋ • Necrotising pancreatitis +/- Infection - indicates inadequate fluid resuscitation during initial management
• Pseudocyst - collections of pancreatic fluids after 4 wks
• Abscess
• Bleeding - elastase degrades major vessels (e.g. splenic artery)

➌ Glasgow Score - PANCREAS:
• PaO2 < 8 KPa
• Age > 55
• Neutrophilia - WCC > 15
• Calcium < 2
• Renal function - Urea > 16
• Enzymes - AST/ALT > 200 or LDH > 600
• Albumin < 32
• Sugar - Glucose > 10

Question 3

What are the investigations to do?

How is it managed?

Answer 3

➊ • FBC, U&E, LFT - Leukocytosis may indicate necrosis
• Amylase - x3↑ in acute pancreatitis
• Lipase - Raised - More sensitive and specific for pancreatitis but not as readily available
• USS, ERCP, CXR, CT - look for cause and complications
• ECG

➋ • Aggressive fluid resuscitation with crystalloids - Start with 1L bolus, followed by maintenance
• Anti-emetics
• Opioid analgesia
• IV Abx if necrotising pancreatitis

N.B. There will be bilateral pulmonary infiltrates on CXR if the pt develops ARDS

Question 4

Chronic Pancreatitis:
What is it?

What is its most common cause?
→ What are its other causes?

How does it present?

What are its complications?

What are the differentials?

Answer 4

➊ Chronic inflammation and fibrosis of both the exocrine and endocrine components of the pancreas

➋ Alcohol
→ Idiopathic, Genetics (e.g. CF), Obstruction (e.g. pancreatic ca.), and metabolic (e.g. raised triglyc.)

➌ • Epigastric pain, classically worse after eating fatty food and relieved by sitting forward
• Features of Pancreatic insufficiency
‣ Exocrine loss - Steatorrhoea and Malabsorption
‣ Endocrine loss - Diabetes

➍ • Obstruction
• Pseudocyst
• Abscess
• Pancreatic ca.

➎ • Peptic ulcer disease
• Pancreatic insufficiency syndromes e.g. CF, pancreatic resection

Question 5

How is it investigated?

How is it managed?

Answer 5

➊ • Abdomen CT/MRI - shows calcifications
• Faecal elastase - exocrine function
• Fasting glucose/OGTT - endocrine function
• Amylase

N.B. Amylase and lipase are not typically raised here, which differentiates it from acute pancreatitis

➋ • No alcohol!, and good diet
• Analgesia
• CREON (enzyme replacement) - for exocrine loss
• Insulin - for endocrine loss
• If no improvement, surgery may be done