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Gastroenterology > Acute and chronic pancreatitis > Flashcards

Acute and chronic pancreatitis Flashcards

1
Q

What is the pathogenesis of gallstone pancreatitis?

A

Obstruction of pancreatic duct by gall stones and biliary sludge => backup of pancreatic enzymes => autodigestion of pancreas.

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2
Q

What is Inglefinger’s sign?

A

Pain worse when supine, relieved when sitting forwards

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3
Q

What are the clinical features of pancreatitis?

A
  • Pain (epigastric radiating to back; non-colicky);
  • N/V
  • Abdo distension due to paralytic ileus
  • peritoneal signs
  • jaundice: compression or obstruction of bile duct
  • fever (chemical; not due to infection)
  • tetany: transient hypocalcemia
  • ARDS
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4
Q

Investigation results in gallstone pancreatitis?

A
  • High amylase (greater than EtOH pancreatitis)
  • Lipase
  • Leukocytosis
  • Elevated AST/ALT indicates gallstone aetiology of pancreatitis
  • U/S => multiple stones, oedematous pancreas
  • CXR/AXR/CT (for complications)
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5
Q

Treatment of gallstone pancreatitis?

A
  • NBM
  • Hydration
  • Analgesia
  • ABx (for severe cases necrotising pancreatitis, signs of sepsis)
  • Stone generally passes. Cholecystectomy recommended.
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6
Q

Complications of gallstone pancreatitis?

A
  • Pseudocyst
  • Abscess/infection, necrosis
  • Diabetes
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7
Q

What are the indications for surgical management of chronic pancreatitis?

A
  • Failure of medical treatment
  • Debilitating abdominal pain
  • Pseudocyst complications: persistence, haemorrhage, infection, rupture
  • CBD obstruction, duodenal obstruction
  • Splenic vein obstruction with variceal haemorrhage
  • Rule out pancreatic Ca
  • anatomical abnormality precipitating recurrence
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8
Q

Minimally invasive options for management of chronic pancreatitis?

A
  • Endoscopic duct decompression
  • Extracorporeal shockwave lithotripsy (if duct stones)
  • Celiac plexus block
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9
Q

Surgical options for Mx chronic pancreatitis?

A
  • Drainage procedures e.g. Puestow (longitudinal pancreatojejunostomy)
  • Pancreatectomy
  • Denervation of celiac ganglion and splanchnic nerves
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10
Q

When are drainage procedures the most effective surgical management of chronic pancreatitis?

A

Only effective if ductal system is dilated

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11
Q

What are the types of pancreatectomy?

A
  • Proximal disease = Whipple (pancreatoduodenectomy)

- Distal disease = pancreatectomy +/- Roux-en-Y pancreatojejunostomy

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12
Q

What is the aetiology of acute pancreatitis?

A 
I GET SMASHED
Idiopathic
Gallstones (45%)
Ethanol (35%)
Tumours
Scorpion stings
Microbiological
Autoimmune
Surgery/Trauma
Hyperlipidemia/hypercalcemia/hypothermia
Emobli/ischaemia
Drugs/toxins
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13
Q

Which tumours can precipitate acute pancreatitis?

A

Pancreas, ampulla, choledochocele

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14
Q

Microbiological causes of pancreatitis?

A

Bacterial: mycoplasma, campylobacter, TB
Viral: mumps, rubella, varicella, viral hepatitis

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15
Q

AI causes of acute pancreatitis?

A

SLE, polyarteritis nodosa, Crohn’s

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16
Q

Surgical/traumatic causes of acute pancreatitis?

A
  • Manipulation of sphincter of Oddi (e.g. ERCP)
  • Post-cardiac surgery
  • Blunt trauma to abdomen
  • Penetrating peptic ulcer
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17
Q

Drugs precipitating acute pancreatitis?

A

Azathioprine, mercaptopurine, frusemide, oestrogens, methyldopa, H2-blockers, valproic acid, ABx, paracetamol, salicylates, methanol, organophosphates, steroids.

18
Q

Pathogenesis of acute pancreatitis?

A

Activation of proteolytic enzymes within pancreatic cells, starting with trypsin, leading to local and systemic inflammatory response

19
Q

Pathology of mild interstitial pancreatitis?

A

Peri-pancreatic fat necrosis and interstitial oedema.

20
Q

Pathology of severe (necrotic) pancreatitis?

A
  • Extensive peri-pancreatic and intra-pancreatic fat necrosis.
  • Parenchymal necrosis and haemorrhage (infection in 60%)
21
Q

Describe pancreatic enzymes in terms of sensitivity and specificity.

A

Increased Amylase: sensitive, not specific.

Increased Lipase: higher sensitivity and specificity, elevated for longer.

22
Q

Ix in acute pancreatitis?

A
  • Increased serum pancreatic enzymes (amylase, lipase)
  • ALT >100 suggests biliary pancreatitis
  • Increased WBC, glucose, low calcium
  • Imaging: CT most useful
23
Q

Imaging in acute pancreatitis?

A
  • Xray: sentinel loop (dilated proximal jejunum), calcification, colon cut off sign (colonic spasm)
  • U/S: best for biliary tree
  • CT Contrast: contrast only seen in viable pancreatic tissue
  • ERCP: if cause uncertain. Assess for duct stone, pancreatic/ampullary tumour.
24
Q

Complications of severe pancreatitis?

A
  • Shock
  • Pulmonary oedema
  • Multi organ dysfunction syndrome
  • GI ulceration due to stress
  • Death
25
Q

What are Ranson’s criteria used for?

A

Prognostic indication of mortality in pancreatitis not due to gallstones.
Difficult course if 2 criteria
High mortality if 3+ criteria

26
Q

What are Ranson’s criteria?

A 
GALAW CHOBBS
At admission:
-Glucose >11mmol/L
-Age >55
-LDH >350 IU/L
-AST >250 IU/L
-WBC >16x10^9
First 48h:
-Calcium 10%
-haematocrit
-Arterial O2 4mmol/L
-BUN rise >1.8mmol/L
-base deficit
-Fluid Sequestration >6L
27
Q

Goals of pancreatitis treatment?

A
  • Haemodynamic stability
  • Analgesia
  • Oxygen
  • Stop progression of local damage
  • Treat local and systemic complications
28
Q

What is chronic pancreatitis?

A

Irreversible damage to pancreas characterised by:

1) pancreatic cell loss (from necrosis)
2) Inflammation
3) Fibrosis

29
Q

Aetiology of chronic pancreatitis?

A

Almost always alcohol! (90%).

Unusual causes: CF, severe protein calorie malnutrition, hereditary.

30
Q

Do gallstones cause chronic pancreatitis?

A

NO. Only acute pancreatitis.

31
Q

Signs of late stage chronic pancreatitis?

A
  • Malabsorption sydrome (>90% loss); steatorrhoea

- Diabetes, calcification, jaundice, weight loss, pseudocyst, ascites, GI bleed

32
Q

Treatment of chronic pancreatitis?

A
  • Alcohol abstinence
  • Pancreatic enzyme replacement
  • Analgesics
  • Pancreatic resection if ductular blockage
33
Q

Ix in chronic pancreatitis?

A

-Increased BSL, increase ALP
-Amylase and lipase usually normal.
Imaging (AXR/US/CT) looking for calcification, duct dilation, pseudocyst etc.

34
Q

What is Cullen’s sign?

A

Periumbilical ecchymosis

35
Q

What is Grey Turner’s sign?

A

Flank ecchymosis

36
Q

What are the pancreatic enzymes?

A

TALC

  • Trypsin
  • Amylase
  • Lipase
  • Chymotrypsin
37
Q

Management pancreatic necrosis?

A

Step up approach in mx pancreatic necrosis:

  1. IV ABx
  2. Percutaneous drainage of peripancreatic space / collections
  3. Up size the drain
  4. Consider percutaneous necrosectomy (retro/intra)
  5. If all fail: necrosectomy
38
Q

What must be excluded as a complication of gallstone pancreatitis?

A

Cholangitis if there is any suspicion of infection/complication (i.e. fever). Looking for Charcot’s etc.

39
Q

Management mild pancreatitis?

A
  • NBM
  • Analgesia
  • If gallstones: lap chole + IOC once pancreatitis resolved
40
Q

Management of severe pancreatitis?

A
  • Supportive: ICU, fluid resus, O2, inotropes, haemofiltration, analgesia
  • Specific: ERCP, ABx utrition
  • Treat complications

Gastroenterology (54 decks)

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