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
key points to note
Symptoms can show 48 Hours after admitted
dont use ERCP unless have to
What is the prognosis like for AP?
80% mild disease → resolves in 3-7 days conservative management
mortality 5%
raises to 30% in severe acute pancreatitis
