Acute Pancreatitis Flashcards
Acute pancreatitis pathophysiology
Pancreatic enzymes released and activated
• Oedema + fluid shift + vomiting → hypovolaemic
shock while enzymes cause autodigestion and fat
necrosis
- Vessel autodigestion causes retroperitoneal haemorrhage
- Inflammation → pancreatic necrosis
- Super-added infection: 50% of pts. with necrosis
Acute pancreatitis aetiology (I GET SMASHED)
• Idiopathic
- Gallstones
- Ethanol
- Trauma
- Steroids
- Mumps + other infections: Coxsackie B
- Autoimmune: e.g. PAN
- Scorpion bite
- Hyperlipidaemia (I and V), ↑Ca, Hypothermia
- ERCP: 5% risk
- Drugs: e.g. thiazides, azathioprine
Presentation of acute pancreatitis
Symptoms
• Severe epigastric pain radiating to back
- May be relieved by sitting forward
• Vomiting
Signs • ↑HR, ↑RR • Fever • Hypovolaemia shock • Epigastric tenderness • Jaundice • Ileus → absent bowel sounds
§ Grey Turners: flanks
§ Cullens: periumbilical (tracks up Falciform)
Modified Glasgow Criteria
PANCREAS
• Valid for EtOH and gallstones
• Assess severity and predict mortality
• Ranson’s criteria are only applicable to EtOH and can
only be fully applied after 48hrs
1- mild
2 - moderate
3 - severe
Investigations for acute pancreatitis
- Bloods
- ABG: ↓O2 suggests ARDS
- Urine: glucose, conjugated bilirubin, ↓urobilinogen
- Imaging
- CXR: ARDS, exclude perforated DU
- AXR: sentinel loop, pancreatic calcification
- USS: Gallstones and dilated ducts, inflammation
- Contrast CT: Balthazar Severity Score
Bloods for acute pancreatitis
- FBC: ↑WCC
- ↑amylase and ↑lipase x 3 higher
- Ca2+: ↓
- Glucose: ↑
- CRP
- U+E: dehydration and renal failure
- LFTs: ↑AST, ↑LDH
Initial management of acute pancreatitis
Conservative Mx: • ITU if severe • Constant reassessment: - Hrly - Temp, pulse, RR, urine output - Daily FBC, U+E, Ca2+, glucose, amylase ABG
• Fluid Resuscitation
- Catheter ± CVP
• Pancreatic Rest
- NBM
- NGT if vomiting
• TPN may be required if severe
- Analgesia - morphine
- Antibiotics
- Used if suspicion of infection or before ERCP
- meropenem
Managing complications of acute pancreatitis
- ARDS- O2 therapy or ventilation
- ↑ glucose- insulin sliding scale
- Correct calcium
- EtOH withdrawal: chlordiazepoxide
Interventional Mx: ERCP
• If pancreatitis with dilated ducts secondary to gallstones
• ERCP + sphincterotomy reduces complications
Acute pancreatitis surgical Mx indications
- Infected pancreatic necrosis
- Pseudocyst or abscess
- Diagnosis unsure
Surgical Mx of acute pancreatitis
- Laparotomy + necrosectomy (pancreatic debridement)
- Laparotomy + peritoneal lavage
- Laparostomy: abdomen left open with sterile packs in ITU
Early systemic complications of acute pancreatitis
Early systemic: • Respiratory: ARDS, pleural effusion • Shock: hypovolaemic or septic • Renal failure • DIC
Metabolic:
- ↓ Ca2+
- ↑ glucose
- Metabolic acidosis
Late (>1wk) complications of acute pancreatitis
• Pancreatic necrosis • Pancreatic infection • Pancreatic abscess - pseudocyst or in pancreas • Bleeding e.g. from splenic artery • Thrombosis - Splenic artery - Gastric duodenal artery - Colic branches of SMA - May cause bowel necrosis - Portal vein causing portal HTN • Fistula formation - Pancreato-cutaneous → skin breakdown
Pancreatic Pseudocyst
Collection of pancreatic fluid in the lesser sac
surrounded by granulation tissue
Presentation:
- 4-6wks after acute attack
- Persisting abdominal pain
- Epigastric mass → early satiety
- mildly elevated amylase
Complications of pancreatic pseudocyst
- Infection → abscess
- Obstruction of duodenum or CBD
Investigation and Mx of pancreatic psuedocyst
- Persistently ↑ amylase ± LFTs
- US / CT
Tx
- <6cm: spontaneous resolution
- > 6cm: Endoscopic cyst-gastrostomy or percutaneous drainage under US/CT
