Acute pancreatitis Flashcards
What is pancreatitis?
inflammation of pancreas (digested by its own enzymes)
caused by excess alcohol -> protein plug at sphincter of oddi
gallstones -> blocks pancreatic duct
How does AP usually present?
- mid-epigastric or left upper quadrant pain
- severe, constant upper abdominal pain, usually sudden in onset and often radiating to the back - with associated nausea/vomiting in 80% of patients
- stabbing pain
- signs of hypovolaemia - hypotension, oliguria, dry mucous membranes, decreased skin turgor and sweating.
- severe - tachycardic and/or tachypneic.
- signs of pleural effusion on left (dull precussion)
- anorexia
What are some risk factors of acute pancreatitis?
- Alcohol use - after 5 years binge drinking
- Known gallstone disease or past biliary-colic type pain.
- Previous episodes of acute pancreatitis.
- Hypertriglyceridaemia (an uncommon cause).
- Recent abdominal trauma or invasive procedures, particularly endoscopic retrograde cholangiopancreatography (ERCP) - a rare cause.
- Medication (e.g., azathioprine, mercaptopurine, didanosine).
- Recent symptoms of infection (e.g., mumps, mycoplasma, Epstein-Barr virus [a rare cause]).
- A detailed family history to rule out collagen vascular diseases, cancer, or hereditary pancreatitis.
- Hereditary pancreatitis is very rare and patients usually present in early childhood.
- Time since symptoms started:
- Most people present within 12 to 24 hours of symptom onset at the latest.
- Patients occasionally present after several days of symptoms, in which case their serum lipase/amylase levels may have returned to normal.
What are some rare presentations of AP?
- jaundice
- hypocalcaemia (trosseau’s/chvosteks sign)
- bruising - cullens (belly button ring), grey turners (flanks), Fox’s sign (inguinal)
- organ dysfunction eg SIRS
- dyspnoea (ARDS)
What 1st line Ix should you order for AP (in order)?
- serum amylase/lipase. Lipase is better. both may be delayed. Might be elevated for other reasons
- FBC - leukocytosis & elevated haematocrit
- CRP - >200 necrosis
- elevated urea/creatinine
- pulse oximetry - hypoxaemia
- LFTs - ↑ALT x3 = gallstones
- CXR - atelectasis + pleural effusion
- transabdominal US - gallstones, may show inflamm. usually not needed, diagnosis made based on symptoms & serum enzymes
- serum Ca ↑
What 2nd line Ix can we order for AP?
- serum triglycerides >11.3
- CT (not usually needed) - shows pancreatic enlargement w/ less fat, necrosis, pseudocysts.
- CT used when: atypical presentation. normal serum lipase/amylase. to rule out bowel ishcaemia/perforations
- EUS (endoscopic US) - screen for choledocholithiasis if it is highly suspected in the absence of cholangitis and/or jaundice.
- To exclude strictures, occult biliary microlithiasis, neoplasms, and chronic pancreatitis
- MRCP
- ABG
What Tx for sterile pancreatic necrosis?
Same Tx as AP complications + FNA/culture + catheter drainage/necrosectomy
What Tx for infected pancreatic necrosis?
Same as Tx for complications + IV ABx (carbapenem)
Catheter drainage if no improvement w/ ABx - after necrotic collection fully walled off
necrosectomy if catheter drainage unsuccessful, after walled off (less bleeding)
What to do if patient deteriorating after 5-7 days?
- CECT - check for complications
- ongoing support & nutritional Tx
- fine needle aspiration & culture ONLY to confirm/exclude necrosis
What Tx is given for alcohol related pancreatitis?
Same Tx as normal + Vit replacement: thiamine, folic acid, B12
abstain from alcohol/counselling
What Tx is given to pancreatitis with BD obstruction?
EUS - endoscopic US (detects if common bile duct stones)
MRCP ^^
EUS > MRCP for small stones
if stones → ERCP
What Tx given to gallstone pancreatitis w/o cholangitis/bile duct obstruction
Same Tx as normal + cholecystectomy (even if mild pancreatitis)
if disease more severe, delay cholecystectomy until inflamm resolved
In patients who are unfit for surgery, consider endoscopic biliary
What Tx given to gallstone pancreatitis w/ cholangitis?
Same Tx given to everyone + ERCP
What treatment should we give to all patients w/ AP?
- fluid resuscitaction + analgesia → check HR, MAP, urine output, HCT
- (if SIRS/organ failure by Atlanta criteria → ICU)
- 02
- antiemetic for nausea
- IV Abx if infection ONLY (fever, leukocytosis)
- oral nutrition once pain/nausea subsides
- Ca therapy
- Mg therapy
What Tx given to gallstone pancreatitis w/o cholangitis/bile duct obstruction
Same Tx as normal + cholecystectomy (even if mild pancreatitis)
if disease more severe, delay cholecystectomy until inflamm resolved
In patients who are unfit for surgery, consider endoscopic biliary
