Acute and Chronic Pancreatitis Flashcards
What is acute pancreatitis?
An inflammatory process with release of inflammatory cytokines (TNF alpha, IL-6) and pancreatic enzymes (trypsin, lipase).
What are the 3 different types of acute pancreatitis?
- 70% are oedematous; acute fluid collection.
- 25% are necrotising.
- 5% are haemorrhagic.
Give the 11 different causes of acute pancreatitis.
I GET SMASHED:
I - Idiopathic
G - Gallstones (majority - 60%)
E - Ethanol (i.e. alcohol - 30%)
T - Trauma
S - Steroids
M - Mumps
A - Autoimmune
S - Scorpion venom
H - Hyperlipidaemia
E - ERCP (endoscopic retrograde cholangiopancreatography)
D - Drugs e.g. azathioprine, furosemide (diuretics), corticosteroids,
NSAIDs, ACE inhibitors
What are the 3 main causes of acute pancreatitis?
- Gallstones
- Ethanol - alcohol
- Post-ERCP
Name 3 drugs or classes of drugs that can cause acute pancreatitis.
- NSAIDs
- Diuretics
- Steroids
- ACE inhibitors
Explain the pathophysiology of acute pancreatitis caused by gallstones.
Gallstone pancreatitis:
- Gallstones get trapped at the end of the biliary system (ampulla of Vater)
- Obstruct the pancreatic duct - blocking the flow of bile + pancreatic juice into the duodenum
- Enzyme-rich fluid accumulates WITHIN the pancreas
- Intracellular Ca2+ increases and causes the early activation of
trypsinogen. - Cleavage of trypsinogen to trypsin (by cathepsin B)
- Impaired + overwhelmed degradation of trypsin (by chymotrypsin C)
- Leading to a build up of trypsin
- Increased enzymatic digestion of the pancreas and inflammation, leading to extensive acinar damage
Explain the pathophysiology of acute pancreatitis caused by alcohol.
Alcohol-induced pancreatitis:
- Alcohol is shown to interfere with Ca2+ homeostasis in increased
stimulation of enzyme secretion and obstruction of the duct due to
contraction of the ampulla of Vater.
I.E. Directly toxic to pancreatic cells, leading to inflammation.
give 3 symptoms and signs of acute pancreatitis
pain, vomiting. tachycardia, fever, jaundice, shock, ileus, rigid abdomen ± local tenderness. Cullen’s and Grey Turner’s signs.
Give 4 symptoms of acute pancreatitis.
- Gradual or sudden severe epigastric or central abdominal pain that radiates to the back - sitting forward may relieve.
- Anorexia, nausea, vomiting.
- Signs of septic shock e.g. fever, dehydration, hypotension, tachycardia.
- Abdominal guarding and tenderness on examination.
- Periumbilical ecchymosis (skin discolouration due to blood under skin due to bruising) - Cullen’s sign.
- Left flank bruising (skin discolouration due to blood under skin due to bruising) - Grey Turner’s sign.
What can be observed in the clinical presentation as a result of retroperitoneal haemorrhage?
- Cullen’s sign
- Grey Turner’s sign
Describe the pain of acute pancreatitis.
Gradual or sudden severe epigastric/central abdominal pain.
Radiates to back.
May be relieved by sitting forward.
What are Cullen’s and Grey Turner’s signs?
What causes them?
Cullen’s = periumbilical ecchymosis - skin discolouration due to blood under skin due to bruising.
Grey Turner’s = left flank bruising - skin discolouration due to blood
under skin due to bruising.
Due to blood vessel autodigestion and retroperitoneal haemorrhage.
Name 3 investigations to do for acute pancreatitis.
- Bloods
- Erect CXR
- Imaging:
- Abdominal ultrasound
- Contrast enhanced CT
- MRI
What would you look for in the blood test for acute pancreatitis?
Blood tests:
- Raised serum amylase - 3-fold the upper limit of normal
- Note: may be normal even in severe pancreatitis as levels fall after
3-5 days of acute event & other things can cause raised amylase
e.g. upper GI perforation - Raised urinary amylase (urinalysis) - may DIAGNOSTIC as levels remain elevated
over long time period - Raised serum lipase - more sensitive and specific for pancreatitis than
amylase - Raised CRP level - monitoring severity and prognosis
What would be tested as part of initial investigations for acute pancreatitis?
- FBC (for white cell count)
- U&E (for urea)
- LFT (for transaminases and albumin)
- Calcium
- ABG (for PaO2 and blood glucose)
What 2 enzymes would you test for in acute pancreatitis?
What would the results be?
- Serum amylase - raised
- Serum lipase - raised (more sensitive/specific)
Why would an erect CXR be carried out for acute pancreatitis?
Erect CXR:
* Essential to exclude gastroduodenal perforation - which also raises serum amylase
* May show gallstones or pancreatic calcification
Describe the 3 different imaging methods carried out for acute pancreatitis.
- Abdominal ultrasound:
* Diagnoses gallstone pancreatitis - Contrast enhanced CT:
* To assess for complications of pancreatitis e.g. to identify extent of pancreatic necrosis, abscessed and fluid collections. - MRI:
* Identifies degree of pancreatic damage
* Useful in differentiating fluid and solid inflammatory masses
How can acute pancreatitis be diagnosed?
Pancreatitis is diagnosed on the basis of 2 out of 3 of the following:
- Characteristic severe epigastric pain radiating to the back.
- Raised serum amylase.
- Abdominal CT scan pathology.
Name a scoring system that can be used a prognostic tool in acute pancreatitis.
The abbreviated glasgow scoring system.
What 8 points make up the Glasgow scoring system?
What is the mnemonic for it?
PANCREAS:
- PaO2 < 8kPa.
- Age > 55 years.
- Neutrophils > 15x10^9.
- Calcium < 2mmol/L.
- Raised urea > 15mmol/L.
- Elevated enzymes.
- Albumin < 32g/L.
- Sugar - serum glucose > 15mmol/L.
How is the Glasgow scoring system used for acute pancreatitis?
Used as a predictor of severity and prognostic tool.
It gives a numerical score based on how many of the key criteria are present:
0 or 1 – mild pancreatitis
2 – moderate pancreatitis
3 or more – severe pancreatitis
What is APACHE-II?
APACHE II (Acute Physiology And Chronic Health Evaluation) score:
- Used to assess severity
- Based on common physiological and laboratory values, age and presence/absence of chronic conditions e.g. obesity
- Has a high sensitivity and can be applied as early as 24 hours after
symptom onset
Describe the treatment for acute pancreatitis.
- Severity assessment - initial resuscitation - ABCDE approach
- Nil by mouth - nasogastric tube for DIETARY SUPPLEMENTS
- To decrease pancreatic stimulation - Urinary catheter
- Analgesics
- Drainage of oedematous fluid collections.
- Prophylactic antibiotics
- Like beta-lactams e.g. CEFUROXIME or another type e.g. METRONIDAZOLE to reduce risk of infected pancreatic necrosis - Careful monitoring and Treat complications
- ERCP / cholecystectomy for gallstones
- Endoscopic or percutaneous drainage of large collections
Why is morphine contraindicated in acute pancreatitis?
Morphine increases sphincter of Oddi pressure and so aggravates pancreatitis.
Give 2 potential complications of acute pancreatitis.
- Systemic inflammatory response syndrome.
- Multiple organ dysfunction.
Give 2 early and 2 late possible complications of acute pancreatitis.
Early:
1. Shock
2. ARDS
3. Renal failure
4. DIC
5. Sepsis
6. Hypocalcaemia.
Late:
1. Pancreatic necrosis
2. Abscesses
3. Bleeding
4. Thrombosis
5. Fistulae
Define chronic pancreatitis.
Debilitating continuing inflammatory process of the pancreas, resulting in
progressive loss of exocrine pancreatic tissue, which is replaced with by fibrosis.
Simpler terms:
Chronic inflammation of the pancreas leads to irreversible damage.
Explain the pathphysiology of chronic pancreatitis.
- Obstruction or reduction in bicarbonate secretion in the pancreatic lumen
- Produces an alkaline pH
- Initiates autodigestion
- Inappropriate activation of enzymes within the pancreas
- Stabilises trypsinogen, leads to the activation of trypsinogen as pH rises, making it more unstable and causing its activation into trypsin - Leads to precipitation of protein plugs within duct lumen
- Forms a point for calcification
- Duct blockage
- Ductal hypertension + pancreatic damage
- Pancreatic inflammation + impaired function
Give 3 causes of chronic pancreatitis.
- Chronic alcohol abuse - most common cause!
- Hereditary
- Autoimmune
- Cystic fibrosis
- CKD
- Idiopathic
Describe how alcohol can cause chronic pancreatitis.
Alcohol -> proteins precipitate in the ductal structure of the pancreas (obstruction) -> pancreatic fibrosis.
Give 5 symptoms of chronic pancreatitis.
- Severe abdominal pain.
- Epigastric pain radiating to the back.
- Nausea, vomiting.
- Decreased appetite.
- Exocrine/endocrine dysfunction.
A sign of chronic pancreatitis is exocrine dysfunction. What can be a consequence of this?
- Malabsorption - presenting feature in absence of pain.
- Weight loss.
- Diarrhoea.
- Steatorrhoea (presence of excess fat in faeces).
- Protein deficiency.
A sign of chronic pancreatitis is endocrine dysfunction. What can be a consequence of this?
Diabetes mellitus
- Due to damaged beta cells.
Differential diagnosis of chronic pancreatitis?
Pancreatic malignancy
- Lots of common symptoms should be thought of especially when there is a short history and pancreatic mass
what would you expect serum pancreatic enzymes levels to be in chronic pancreatitis?
amylase and lipase are normal
What investigations would you run in chronic pancreatitis?
- Serum amylase and lipase:
* May be elevated, but in advanced disease, there may not be sufficient
residual acinar cells to produce elevation - Faecal elastase will be abnormal in majority patients with moderate-severe disease
- Abdominal ultrasound and contrast-enhance CT:
* Detects pancreatic calcification and a dilated pancreatic duct to CONFIRM DIAGNOSIS - MRI with MRCP
- To identify more subtle abnormalities
How would you treat a patient with chronic pancreatitis?
- Alcohol cessation
- Abdominal pain:
2. NSAIDs
3. Opiate e.g. ORAL TRAMADOL
4. Tricyclic antidepressants e.g. AMITRYPTYLINE - for more chronic episodes
- Duct drainage
- Shock wave lithotripsy to fragment gallstones in the head of pancreas
- Steatorrhea:
7. Pancreatic enzyme supplements
8. PPI e.g. LANSOPRAZOLE to help supplement pass stomach - Diabetes:
9. INSULIN
Give 3 possible complications of pancreatitis.
- Pseudocyst
- Diabetes
- Biliary obstruction
- Local arterial aneurysm
- Splenic vein thrombosis
- Gastric varices
- Pancreatic carcinoma
Define autoimmune chronic pancreatitis.
Chronic pancreatic inflammation which results from an autoimmune process
What immunoglobulin might be elevated in someone with autoimmune chronic pancreatitis?
IgG4.
How is autoimmune chronic pancreatitis treated?
This condition is steroid responsive with glucocorticoid therapy
e.g. ORAL PREDNISOLONE for 4-6 weeks
What might pain radiating to the back be a sign of?
Pancreatitis or AAA.
