Acute Pancreatitis Flashcards
Presenting symptoms of acute pancreatitis
- severe, constant, sudden onset upper or left upper abdominal pain, often radiates to the back
- improves leaning forwards
- Nausea, vomiting in 80%
- worsens with movement
- anorexia
- dyspnoea
- oliguria
- pleural effusion signs = dull percussion
- jaundice
- ARDS in critically ill
- ecchymotic bruising (cullen’s/grey turners sign)
Diagnosis of acute pancreatitis
- investigations
2 of:
- elevated serum lipase or amylase (>3 times upper limit):
- patients with diabetes have higher median lipase, accuracy decreases with time since symptom onset, lipase testing>amlylase (lipase remains elevated for longer)
- may be normal in alcohol related
- upper abdominal pain
- Imaging (not needed to confirm)
FBC:
- leukocytosis with left shift ( more immature neutrophils and macrophages)
- WBC >12 or <4*9/L
- haematocrit elevated >44% (hypovolaemia/dehydration)
- CRP >200 L = necrosis
-Urea >7.14 mmol/L /creatinine >2 mg/dL = dehydration/hypovalaemia
- ABG: PaO2 <60mmHg = organ failure
- LFTs: elevated ALT >3 x upper limit = predicts gallstones as cause
- Ca
- Triglycerides
- RUQ US for biliary aetiology, rule out cholelithiasis
CXR for causative factors- not diagnosis
-Chvostek’s sign - rare
- CECT- contrast-enhanced CT only when there is diagnostic doubt or failure to improve in 48-72hrs of treatment
- use MRCP is CECT contradicted
Risk stratification -using SIRS criteria 2 of: -HR>90 -RR >20 / PaCO2 <32 -temp >38, <36 -WBC >12, <4
Emerging tests:
- urinary trypsinogen-2 sensitive and specific as lipase/amylase for diagnosis
- IL-6, IL-8, IL-10 may predict development of severe AP
Causes of acute pancreatitis
I GET SMASHED
- idiopathic
- gallstones
- excessive alcohol/ethanol
- trauma
- steroids
- mumps/HIV/coxsackie (infection) & malignancy
- autoimmune
- scorpion venom
- hypercalcaemia/hyperPTH/ hyperlipidemia/ hypothermia
- ERCP and emboli
- Drugs (sodium valproate, thiazides, azathioprine etc)
- preganancy
- Pancreas divisum
- autoimmune sclerosing AP
Treatment of acute pancreatitis
- assess for haemodynamic status and look for fluid loss:
- crystalloid IV fluids- early! (Hartmann solution, Ringers lactate, PlasmaLyte)
- 5-10 mL/kg/hr
- catheter
-SIRS biggest risk to life in the first week - assess signs for organ dysfunction
- analgesia, nutritional support, oral feeding favoured (not pancreatic rest)
- nasogastric > parenteral nutrition
Gallstone pancreatitis - emergency ERCP in 24hrs, cholecystectomy
Alcohol related P - benzodiazepine for alcohol withdrawal
-replace thiamine B1, folic acid B9, B12
Step-up approach for infected pancreatic necrosis:
- catheter drainage
- necrosectomy
- support organ failure; drainage of pancreatic necrosis, antibiotics +- surgical necrosectomy
Antibiotics- carbapenem (imipenem,cilastatin) first line since good pancreatic penetration
-fluoroquinolone (ciprofloxacin), metronidazole
Definition of acute pancreatitis
-disorder of the exocrine pancreas, associated with acinar cell injury with local and systemic inflammatory responses
Risk factors for acute pancreatitis
- white women >60
- microlithiasis
- gallstones (backflow of activated enzymes into pancreas)
- alcohol
- hypertriglyceridaemia- (22-23 mmol/L)
- causative drugs: azathioprine, mercaptopurine, didanosine, thiazide diuretics, furosemide, sulfonamides, tetracyclines.
- ERCP- use of contrast linked to inflammation (2-3%)
- trauma
- SLE
- Sjogren’s syndrome
-males - alcohol
-females - gallstones
Weakr RFs:
-hypercalcaemia
-mumps
-coxsackievirus
-mycoplasma pneumoniae
-pancreas divisum
-pancreatic cancer
-sphincter of Oddi dysfunction
-Fx
Pathophysiology of acute pancreatitis
- unknown exactly
- intracellular Ca accumulation- premature enzymatic activation
- ethanol is directly toxic to acinar cells- inflammation and membrane destruction, increased ductal pressures
Classification of acute pancreatitis
Atlanta Classification:
-mild
-moderately sever- transient organ failure resolves, local complications
-severe- persistent organ failure, necrosis
=ICU if fit Atlanta Criteria for organ failure
Balthazar Classification -based on extent of inflammation and fluid/gas suggesting necrosis on CT with contrast A-normal B-focal C,D,E
General classification:
Oedematous pancreatitis- engorged with interstitial fluid
Haemorrhagic pancreatitis - bleeding
APACHE-II score
Differentials other than acute pancreatitis
- peptic ulcer disease- does not radiate to back
- Perforated viscus- tender in all quadrants, less amylase elevation
- Oesophageal spasm- dysphagia, odynophagia
- Intestinal obstruction- distension, normal lipase/amylase
- AAA
- Cholangitis - charcot’s triad
- Choledocholithiasis- acholia, choluria
- Cholecystitis - pain after fatty meal
- Viral gastroenteritis
- Hepatitis
- Mesenteric ischaemia- older, atrial fibrillation
- MI- retrosternal pain radiation to jaw, neck, SOB, cardiac enzymes (creatine kinase/phosphokinase, troponins)
Treatment algorithm for acute pancreatitis
Acute:
- fluid resus
- analgesia- ibuprofen, codeine phosphate, morphine phosphate
- oxygen
- antiemetic- ondansetron
- IV antibiotics -imipenem/cilastatin, metronidazole, ciprofloxacin
- nutritional support
- severity assessment - SIRS
- Ca, Mg replacement
Gallstone pancreatitis:
- with cholangitis- ERCP
- without cholangitis or bile duct obstruction - cholecystectomy
- with bile duct obstruction - ERCP with sphincterotomy
Alcohol
- vitamin replacement
- alcohol abstinence programme
Ongoing:
- deteriorating or failing to improve after 5-7 days:
- CECT
- ongoing supportive treatment- ICU if Atlanta Criteria for organ failure
FNA - fine needle aspiration and culture
Infected pancreatic necrosis:
- CECT
- support
- FNA and culture
- IV antibiotics
- catheter drainage
- necrosectomy/debridement
Sterile pancreatic necrosis:
- CECT
- support
- FNA and culture
- catheter drainage or necrosectomy
Emerging treatments for acute pancreatitis
Gastric antisecretory agents
-H2 antagonists and PPI may decrease pancreatic stimulation
CM4620
-novel Ca release-activated Ca channel inhibitor reduced cell damage/death
Prevention of acute pancreatitis
Secondary
- balanced, low-fat diet, low alcohol, cigarette smoking
- statins for hypertriglyceridaemia
- genetic testing
Complications of acute pancreatitis
High
-Acute renal failure -toxins, hypovolaemia, inflammation
Medium
-Sepsis
-acute lung injury/ARDS
(due to inflammatory mediators)
Low
- Pancreatic abscess
- Abdominal compartment syndrome (over aggressive fluid resus)
- Chronic pancreatitis- recurrent attacks = chronic scarring
- Enteric fistulas
- Pseudocyst
- Pancreatic ascites/pleural effusion - high amylase in ascitic fluid
Prognosis of acute pancreatitis
80% have mild disease, improve in 3-7 days
5% mortality ut 30% in severe AP
(SIRS?-biphasic death pattern, early mortality (<2 weeks) related to systemic inflammatory response syndrome SIRS and later (>2weeks) due to local complications including infected necrosis)
