Acute and chronic pancreatitis Flashcards
Define acute pancreatitis
An acute inflammatory process of the pancreas with variable involvement of other regional tissues or remote organ systems.
What happens when activation of trypsinogen to trypsin occurs in the pancreatic cells
Stimulates the production of inflammatory cytokines which in turn triggers an inflammatory cascade causing a systemic inflammatory response syndrome (SIRS). SIRS
may develop into an acute respiratory stress syndrome (ARDS), multi-organ dysfunction syndrome (MODS) or organ failure.
What are the two distinct pathological entities in acute pancreatitis
- Acute interstitial oedematous pancreatitis (IOP) where there is diffuse or localised enlargement of the pancreas due to interstitial oedema together with peripancreatic inflammation and fluid. This type usually presents
with a mild attack. - Acute necrotising pancreatitis (NP) where there is necrosis of the parenchyma, peripancreatic tissue or both. This type represents the more severe form of the disease. The natural history of the necrotic tissue is variable, as it may remain solid or liquefy, remain sterile or become infected and persist or disappear over time.
Local complications of acute pancreatitis
Collections -
1. An acute peripancreatic fluid collection (associated with
IOP)
2. A pancreatic pseudocyst (IOP)
3. An acute necrotic collection (associated with NP)
4. Walled off necrosis (NP)
Other organ complications -
- Gastric outlet dysfunction
- Splenic / portal veinthrombosis
- Intestinal necrosis
The diagnosis of pancreatitis requires 2 of the following:
- Abdominal pain consistent with acute pancreatitis (acute onset, epigastric, severe, often radiating to the back).
- Serum lipase or amylase ≥3x normal
- Characteristic findings on CT or MRI scan
What is Grey Turner’s sign
Ecchymosis in the flanks
What is Cullen’s sign
Ecchymosis in the periumbilical region
In which groups is the onset of pancreatitis insidious,
presenting with cardio-respiratory failure and non-specific abdominal signs such as unexplained ileus.
After major surgery (eg, cardiac)
Immune compromised patients
Define SIRS
Severe inflammatory response syndrome 2 or more of the following criteria: · Heart rate > 90 beats per minute · Core temperature 38°C · White blood cell count 12000/mm³ · Respirations >20/min or PCO2
Two phases of pancreatitis
The early phase lasts 1-2 weeks and is characterised by the host’s response to pancreatic injury -> SIRS
The late phase of pancreatitis is characterised by the persistence of systemic signs of inflammation or the presence of local complications which evolve during the late phase. Persistent organ failure is the result of the necrotising process and secondary infections. The morphological characteristics of local complications are assessed by radiological imaging, typically CT scan.
What system is used to define organ failure
The modified Marshall scoring system
Why does organ failure occur in pancreatitis
The organ failure is secondary to the host’s systemic inflammatory response.
Hypovolaemic shock due to third space fluid sequestration (not bleeding), and ARDS are most commonly seen early on followed by renal failure and DIC.
Renal failure is caused by a combination of factors
which include shock and the development of an abdominal compartmental syndrome.
Three degrees of severity in pancreatitis are defined as:
- Mild acute pancreatitis - MAP (80% of patients)
a. No organ failure
b. No local or systemic complications - Moderately severe acute pancreatitis - MSAP
a. Transient organ failure that resolves within 48 hours
b. Local / systemic complications without persistent organ failure - Severe acute pancreatitis - SAP
a. Persistent single / multiple organ failure lasting >48 hours
Investigations in pancreatitis
Serum lipase and amylase (non-specific)
Bloods (for cause and severity)
CXR/AXR (exclude other conditions - pleural effusion, caclium deposits)
U/S (for gall stones) and CT (complications)
[ERCP is contraindicated in acute - only use for gall stones]
In what conditions are amylase and lipase raised
Pancreatitis (only one that regularly gets above 3xnormal)
PUD
Bowel obstruction
General treatment of mild pancreatitis
Supportive measures such as bed rest, nil per mouth, intravenous fluids and analgesics usually suffice.
General treatment of gallstone pancreatitis
Conservative initially
Elective cholecystectomy 1-4 weeks after the acute attack is strongly recommended to pre-empt a possible second attack
If progressive jaundice -> ERCP/pappilotomy
Early indicators for severe pancreatitis
- Haemodynamic instability.
- Hypoxic confusion.
- Pleural effusion and pulmonary infiltrates on chest X rays.
- SIRS response (2 or more criteria).
Management of SAP
Hypovolaemic shock must be treated vigorously with volume replacement.
Inotrope support is often required.
The early recognition and appropriate management of respiratory failure and many patients will require ventilation.
Other metabolic parameters; hyperglycaemia, hypocalcaemia and renal failure
Nutritional support
There is no place for surgery during the early phases of severe pancreatitis, unless there is ischaemic large bowel necrosis which occurs rarely during this phase.
What features are associated with a poor prognosis in pancreatitis
Obesity (BMI>30), age over 60 years and multiple organ failure
Management flow of local complications in pancreatitis
Percutaneous drainage
Endoscopic
Open surgery
Angiographic embolisation for bleeding
Causes of pancreatitis
Alcohol
Gall stones
Idiopathic
Others…READ
Define chronic pancreatitis
A continuing inflammatory disease of the pancreas characterized by irreversible morphologic changes,
often associated with pain and with the loss of exocrine and/or endocrine function which may be clinically
relevant. The disease involves both the parenchyma and the ductal system of the pancreas.
Aetiology of chronic pancreatitis
Alcohol Nutritional (tropical Africa & Asia) Cystic fibrosis Hereditary Idiopathic (10-30%) Autoimmune Obstructive · Pancreas Divisum · Duct Obstruction (eg. Carcinaoma)
Hypothesis for alcohol induced chronic pancreatitis
necrosis-inflammation-fibrosis sequence, mediated by the formation of fatty acid ethanol esters (FAEEs)
Complications of chronic pancreatitis
Endo and exocrine failure - diabetes, fat malabsorption
Collections - psuedocysts, pancreatic ascites
False aneurysm
Splenic vein thrombosis
Why chronic pancreatitis more sensitive to insulin
No glucagon production
Tests in chronic pancreatitis
Bloods (amylase/lipase, HBA1c, low albumin, LFTs)
Feacal acid steatocrit and elastase
Options to treat pain in chronic pancreatitis
Low fat diet
Medication (step wise)
Percutaneous coeliac plexus block
Surgery (drainage [Frey} or resection)
