Acute Pancreatitis

Question 1

What is the Glasgow Pancreatic Severity Score? When should a patient be transfered to ITU?

Answer 1

Scoring system using 8 factors to assess the risk of patient developing severe pancreatitis i.e. PANCREAS
PaO2 
Age
Neutrophilia 
Calcium
Renal function 
Enzymes 
Albumin 
Sugar 

When 3(+) factors detected within 48hrs

Question 2

What occurs in pancreatitis?
What are the different causes of acute pancreatitis?
What are the 3 most common?

Answer 2

Inflammation of the pancreas leading to release of exocrine enzymes causing autodigestion 
I GET SMASHED
Iatrogenic 
Gallstones 
Ethanol 
Trauma 
Steroids 
Mumps 
Autoimmune 
Scorpion venom 
Hyperlipidaemia/hypothermia/hypercalcaemia 
ERCP/emboli

Gallstones 
Alcohol 
Hyperlipidaemia 
Post-ERCP
Drugs

Question 3

How might someone with pancreatitis present?

Answer 3

Symptoms:

• gradual or sudden epigastric pain which can radiate to back
• vomiting
• severe and relentless pain
• relief sitting forwards

Signs:

• tachycardia or increased HR
• Fever
• jaundice (if obstructive)
• shock (increase RR and HR/HypoTN/decreased urine output/cyanosed)
• signs of alcoholic liver disease
• Absent bowel sound-> indicates general peritoneal inflammation
• rigid abdomen or generalised tenderness
• Periumbilical bruising (i.e. Cullen’s sign )
• Flank brusing (Grey-turners sign)

Question 4

Why does periumbilical and flank bruising occur in acute pancreatitis?

Answer 4

BV auto digestion

Retroperitoneal haemorrhage

Question 5

Which enzymes can be measure in serum to assess whether patient has acute pancreatitis? What results would you expect to see?

Answer 5

Amylase= raised i.e. >1000u/mL or 3x upper limit of normal

Lipase= raised
More sensitive and specific test than amylase due to levels rising earlier and falling later

Question 6

What is the management for acute pancreatitis?

Answer 6

• Nil by mouth and consider NJ feeding to decrease pancreatic stimulation or NG tube if vomiting
• catheter
• crystalloid solution
• analgesia
• hourly OBS and daily bloods
• ITU with worsening symptoms
• gallstone removal if cause

NOTE: important to push fluids to try and prevent renal failure

Question 7

What are the early complications of acute pancreatitis?

Answer 7

Shock
Acute respiratory distress syndrome
Renal failure
Disseminated intravascular coagulation= overreactive clotting proteins
Sepsis
Decreased calcium= due to increased lipase release causes increased fat levels which acts to sequester serum calcium
Increased glucose= inflammation can lead to damage to cells producing insulin which then disrupts blood-glucose regulation

Question 8

Why does ARD occur as a complication of acute pancreatitis?

Answer 8

Pancreatitis leads to high levels of inflammatory chemicals being released which causes systemic inflammation and therefore effect the lungs

ARDs= due to fluid accumulation in alveoli

Question 9

What is the pathophysiology of gallstones pancreatitis?

Answer 9

Gallstones trapped in ampulla of Vater preventing flow of bile and pancreatic juice leading REFLUX of bile into pancreatic duct and BUILD UP of pancreatic enzymes in pancreas

Question 10

Why can alcohol causes pancreatitis?

Answer 10

Alcohol is directly toxic to pancreatic cells

Question 11

What investigations are down in person showing signs of pancreatitis and why?

Answer 11

Urine dipstick= infection or haematuria
FBC= WCC to indicate infection
U+E= rise in urea asks as marker for intravascular depletion= mediator of inflammatory response
LFT
Amylase= will be raised 3x upper limit of normal
ECG= MI
Erect CXR/AXR= signs of bowel perforation or bowel obstruction
ABG= if patient unwell + evidence of acidosis

Question 12

What investigations should be done after a diagnosis of pancreatitis?
What imaging can be done to investigate pancreatitis?

Answer 12

LDH= done to see if patient has developed pancreatic necrosis
Blood sugar= assess if endocrine function of pancreas has been affected
Calcium= calcium levels can rise
USS= looking for gallstones which might be causing the pancreatitis

MRCP/ERCP/CT if stones thought to be the cause

Question 13

What scoring system is used to assess the severity of pancreatitis?

Answer 13

Glasgow score 
P PaO2 
A age?>55 
N neutrophils >15 
C calcium <2
R uRea 
E Enzymes (LDH>600 or AST/ALT>200)
A albumin <32
S Sugar >10

Question 14

How is acute pancreatitis managed?

Answer 14

IV fluids 
NBM
Analgesia 
ERCP/Cholestectomy if gallstones the cause
Abx if evidence of infection/abscess
Drainage of large collections

Question 15

Why might amylase not be raised in patient with symptoms of pancreatitis?

Answer 15

The pancreatitis might be chronic

Chronic pancreatitis doesn’t effect amylase levels due to the pancreas having reduce function generally

Question 16

Why can calcium fall in acute pancreatitis?

Answer 16

Damaged pancreas leads to release of pancreatic lipase which generates free fatty acids
Free fatty acids chelate insoluble calcium salts in pancreas which leads to calcium deposition in the retroperitoneum
THEREFORE calcium levels falls

Question 17

What is the difference between mild and severe acute pancreatitis?

Answer 17

Mild:

• resolves w/o serious complication
• admit and treat with analgesia/IV fluids/NG tube if vomiting
• treat underlying cause

Severe:

• Complicated by more than one organ or system failure
• SIRS
• admit to HDU/ITU
• early ERCP for gall stones or cholangitis
• enteral nutrition

Question 18

What are possible complications of acute pancreatitis?

Answer 18

Multi organ failure (in case of severe)

Pancreatic necrosis (reason why LDH tested for)

Pancreatic abscess

Pancreatic pseudo cyst

Chronic pancreatitis

Diabetes

Question 19

Why does pain radiate to the back in pancreatitis?

Answer 19

Due to part of the pancreas being retroperitoneal