acute pancreatitis

Question 1

where is the

pancreas located ?

Answer 1

in the epigastric region of the abdomen, as part of the retroperitoneal space

Question 2

what are the 4 parts of the pancreas ?

Answer 2

head, neck, body and tail

Question 3

characteristics of the : head

Answer 3

C shaped cavity (created by the duodenum)

has a small ulcinate process which hooks upwards behind the SMA and the SMV

Question 4

: neck

Answer 4

connects the head to the body

behind the neck is where the portal vein forms into the splenic and SMVs

Question 5

: body

Answer 5

runs upwards and to the left across the midline

Question 6

: tail

Answer 6

travels with the splenic vessels between the layers of splenorenal ligament, to reach the hilum of the spleen

Question 7

which part of the pancreas secretes pancreatic juice ?

Answer 7

exocrine - via the acinar and duct cells

Question 8

what part of the pancreas secretes glucagon and insulin ?

Answer 8

endocrine - via islets of langerhans

Question 9

what causes acute pancreatitis ?

Answer 9

inflammation - due to either hypersecretion or backflow (due to obstruction) of exocrine digestive enzymes > resulting in the auto-digestion of the pancreas

= GALLSTONES, DRUGS (steroids) and ALCOHOL are the main causes

Question 10

what are the two major categories of pancreatic damage ?

Answer 10

• interstitial oedematous pancreatitis

- necrotising pancreatitis

Question 11

which type of pancreatitis is irreversible ?

Answer 11

chronic

Question 12

IGETSMASHED

Answer 12

Idiopathic 
Gallstones
Ethanol
Trauma 
Steroids
Mumps/Malignancy 
Autoimmune disease
Scorpion sting 
Hypertriglyceridemia/hypercalcaemia 
ERCP 
Drugs - azathioprine, thiazides, paracetamol

Question 13

what are the risk factors for acute pancreatitis ?

Answer 13

male gender
old
obese
smoker

Question 14

symptoms & history

Answer 14

> epigastric pain - severe, sudden onset, and may radiate to the back
nausea / vomiting
decreased appetite
anorexia

• PMH of gallstones, biliary disease, previous pancreatitis
• past surgical history (ERCP)
• drug history (azathioprine)
• social history (alcohol and smoking)
• family history

Question 15

clinical findings

Answer 15

• epigastric tenderness
• abdominal distention
• reduced bowel sounds (ileus)
• systemic inflammatory response

these are late signs of severe intra-abdominal and retroperitoneal haemorrhage
-Cullen’s Sign (periumbilical bruising)
-Grey Turner’s (flank bruising)

Question 16

what criteria can be used for acute pancreatitis ?

Answer 16

Atlanta Criteria :

mild = most common, no organ dysfunction, resolves within the week
moderate = some evidence of organ failure which improves within 2 days 
severe = persistent organ dysfunction for more than 48hours with local or systemic complications

Question 17

what are the three main criteria to diagnose acute pancreatitis ?

Answer 17

• abdominal pain plus a suggestive history
• serum amylase/lipase 3x normal
• imagine findings of acute pancreatitis

(need 2/3 to confirm)

Question 18

investigations

Answer 18

> ECG - rule out MI

> urinalysis - routine for acute abdominal pain

>lab:
FBC - anaemia and raised WCC
CRP 
LFTs
Lipase - raised (normal is 15-60U/L)
Serum amylase - raised 
VBG 
ABG - essential for prognosis 
beta-hCG - rule out pregnancy 

> imaging:
CXR - will see free gas
Abdominal US
CTAP (abdomen and pelvis)

Question 19

what is the prognostic tool for severity of acute pancreatitis ?

Answer 19

glasgow-imrie score

-----------------------
PANCREAS 
P-PaO2 <7.9
Age >55
Neutrophils >15
Calcium <2.0
Renal function : urea >16mmol/L
Enzymes : LDH > 600
Albumin <32g/L
Sugar > 10mmol

Question 20

management (immediate)

Answer 20

>ABCDE 
>IV resuscitation and correction of electrolyte disturbances 
>analgesia 
>antiemetics 
>nothing to be taken orally 
>control of blood glucose

Question 21

management (nutrition)

Answer 21

NBM (nil by mouth) until pain improves

Question 22

management (specific)

Answer 22

for:

gallstone pancreatitis -
>ERCP to relieve obstruction, this can be done with or without a sphincterotomy (dilate the sphincter of Oddi)
>cholecystectomy - removal of the gall bladder

alcohol-induced pancreatitis -
>withdrawing from alcohol = benzodiazepines, thiamine, folate and vit B12 replacement

Question 23

complications

Answer 23

• chronic pancreatitis
• portal vein/splenic thrombosis
• pancreatic pseudocysts