Acute Pancreatitis Flashcards
What is a typical presentation for Acute pancreatitis?
Sudden-onset mid-epigastric or left upper quadrant abdominal pain
Often radiates to the back
Nausea and vomiting is seen in 80% of patients
What confirms diagnosis of acute pancreatitis?
Elevated serum lipase or amylase (>3x upper normal limit)
What are the most common causes of Acute pancreatitis?
Gallstones
Excessive alcohol consumption
What does initial acute pancreatitis treatment focus on?
Resuscitation w/ IV fluids
Analgesia
Nutritional support
What treatment may be employed in extreme cases?
Support for organ failure
Drainage of pancreatic necrosis
Ab therapy +/- surgical necrosectomy for infected necrosis
What is necrosectomy?
Removal of necrosed pancreas
Define acute pancreatitis?
A disorder of the exocrine pancreas, and is associated with acinar cell injury with local and systemic inflammatory responses
What are the key diagnostic factors in AP?
Upper abdo pain
Nausea and Vomiting
Hypovolaemia
Signs of Pleural Effusion
What is the most common presenting symptoms in AP?
Mid-epigastric or left upper quadrant pain that radiates to the back
Usually sudden onset, increasing in severity before plateuing
Stabbing pain
Worsens with movement
What might an abdo exam reveal in AP?
Tender and distended abdomen
Voluntary guarding to palpation of the upper abdomen
Diminished bowel sounds (if an ileus has developed)
What is important to remember about pain in AP?
Intensity and location of the abdominal pain do not correlate with severity
Minority of patients present without any abdominal pain
What can vomiting lead to?
Dehydration
Electrolyte abnormalities
Hypokalaemic metabolic alkalosis
What are signs of hypovolaemia?
Hypotension Oliguria Dry mucous membranes Decreased skin turgor Sweating
Severe - tachycardic/tachypneic
What are signs of Pleural effusion?
Localised reduced air entry and dullness to percussion
What is anorexia secondary to in AP?
2ry to nausea, pain and general malaise
What are risk factors for AP?
Alcohol (esp. binge drinking)
Previous - gallstone disease, hypertriglyceridaemia, abdo trauma or invasive procedures
Azathioprine, mercaptopurine, didanosine
Recent infection e.g. EBV, mumps, mycoplasma
FH of pancreatitis
Middle aged women and young-middle men
What is important to remember re AP and alcohol?
Do not assume that a patient’s acute pancreatitis is alcohol-related just because they drink alcohol
Unlikely unless over 6 units daily
What are uncommon diagnostic factors in AP?
Signs of organ dysfunction Dyspnoea Jaunidce Signs of hypocalcaemia Bruising
What are the 1st investigations to order in AP?
Serum lipase or amylase FBS CRP Urea Cr Pulse Ox LFTs CXR Transabdominal US Serum calcium
Which is preferred amylase or lipase?
Serum lipase
Lipase remains elevated for longer
Up to 14 days after onset of symptoms vs. 5 days for amylase
What must you be careful about with lipase and amylase?
Sensitivity
1/4 have normal
Specificity
1/10 abnormal due to other condition
Pts with diabetes have higher median lipase levels
What are you looking for in FBC in AP?
WCC raised
Leukocytosis with left shift (more immature WC)
Elevated haematocrit is a predictor of poor prognosis
What does raised CRP indicate in AP?
CRP>200 units/L
indicated high risk of developing pancreatic necrosis
What do LFTs tell you in AP?
Elevated ALT levels strongly suggest gallstones as the cause
In the absence of choledocholithiasis, LFTs are usually normal
Why CXR in AP?
May identify possible causative factors and/or exclude other diagnoses
- Pleural effusion
- Basal atelectasis
- Elevated hemidiaphragm
Why serum calcium?
Hypercalcaemia, a rare cause of acute pancreatitis, may be identified.
What investigations should be considered in AP?
Serum trigylcerides - (elevated can be uncommon cause >11.3mmol/L)
Abdo CT - in diagnostic doubt and where pts fail to improve within 48-72 hours.
Late phase > 1 week can identify local complications
EUS (endoscopic ultrasound) indicated when cause is idiopathic to exclude other causes
MRCP if CT is contraindicated. But preferred in choledocholithiasis
ABG - can be hypoxemic and need O2
What are considered idiopathic causes of AP?
stones, biliary sludge, pancreatic divisum, and other abnormalities of the pancreatobiliary ducts
What are emerging tests for AP?
Urinary trypsinogen-2
Serum IL-6 and IL-8
What is treatment for gallstone pancreatitis with cholangitis?
Fluid resus
+analgesia (pain ladder)
consider sup. O2, antiemetic, IV Ab
+nutritional support
+severity assessment
consider Ca and Mg replacement
+ERCP
What must be done in the first 48 hours with AP?
Use SIRS criteria for severity assessment
What is treatment for gallstone pancreatitis without cholangitis or bile duct obstruction?
Fluid resus
+analgesia (pain ladder)
consider sup. O2, antiemetic, IV Abs
+nutrtional support
+severity assessment
consider Ca and Mg replacement
+cholecystectomy
What is treatment for gallstone pancreatitis with a bile duct obstruction?
Fluid resus
+analgesia (pain ladder)
consider sup. O2, antiemetic, IV Ab
+nutritional support
+severity assessment
consider Ca and Mg replacement
+ERCP
What is treatment for alcohol related pancreatitis?
Fluid resus
+analgesia (pain ladder)
consider sup. O2, antiemetic, IV Ab
+nutritional support
+severity assessment
consider Ca and Mg replacement
+vitamin replacement
+alcohol abstinence programme
What is done if a pt deteriorates or fails to improve in 5-7 days?
CECT - contrast enhanced computed tomography
Ongoing supportive treatment
Ongoing nutritional support
Consider fine needle aspiration and culture
What is the treatment for infected pancreatic necrosis?
CECT - contrast enhanced computed tomography
Ongoing supportive treatment
Ongoing nutritional support
Consider fine needle aspiration and culture
IV Abs
Consider catheter drainage
Consider necrosectomy/debridement
What is the treatment for sterile pancreatic necrosis?
CECT - contrast enhanced computed tomography
Ongoing supportive treatment
Ongoing nutritional support
Consider fine needle aspiration and culture
Catheter drainage or necrosectomy
