Acute pancreatitis

Question 1

A 38 year old woman presents with severe epigastric pain and tenderness. Her serum lipase is markedly elevated. How would you assess and manage her?

Answer 1

Impression
Given clinical signs and elevated lipase, this meets clinical criteria for provisional diagnosis of acute pancreatitis. This is a medical emergency and requires prompt treatment. Consider the aetiology of the pancreatitis (I GET SMASHED);
- alcohol
- gallstones
- trauma
- mumps
- hypertriglyceridaemia
- drugs

DDx:

• cardiac: ACS
• resp: PE, pneumothorax

Goals

• Conduct thorough H/E/I
• arrange appropriate emergent treatment, prevent complications (SIRS, necrotising pancreatitis, organ failure)
• institute appropriate long-term management for prevention of complications and future presentations

Question 2

Acute pancreatitis - Assessment

Answer 2

Assessment

• Constitutes a medical emergency
• Call for senior help, ICU referral if patient severely unwell (
• read patient notes to determine if any other underlying comorbidities
• assess for signs of shock, haemodynamic instability
• initiate appropriate treatment for reversible causes (ERCP

A - patent, maintaining
B - RR, sats. Respiratory support as req
C - BP, HR, ECG. 2xIVC, 
- fluid balance assessment (examination)
- fluid resus as necessary
- assess for signs of organ failure/SIRS/necrotising pancreatitis (Cullens/Grey-turners)
D - GCS
- abdominal ultrasound
E - Secondary survey
F - electrolytes, fluid resus

Question 3

Acute pancreatitis - History

Answer 3

History

• sx: acute abdominal pain (epigastric), SOCRATES, bowel changes (steatorrhoea), urinary changes, nausea/vomiting
• HPC: Jaundice, alcohol intake
• PMHx: previous gallstones disease
• medications: chemotherapies, immunotherapies
• SNAP

Question 4

Acute pancreatitis - Examination

Answer 4

Examination

• General obs + vitals - haemodynamic stability
• Gastro exam: epigastric pain, cullens/grey-turners, bowel sounds
• Cardiorespiratory: pleural effusion
• Systemic review: fluid balance (HR, BP, UO, intake, mucous membranes, skin turgor), hyperpyrexia (SIRS)

Question 5

Acute pancreatitis - Investigations

Answer 5

Investigations
- Key/diagnostic: clinical, lipase >2x upper limit normal, US/CT abdo findings consistent

• Bedside: ECG, VBG, vitals
• Bloods: FBC, UEC, CMP (hypocalcaemia), LFT, Lipase, group + hold
• Imaging: Abdo ultrasound, then CT abdomen

Question 6

Acute pancreatitis - Management

Answer 6

Management

• initial assessment and management as per A to E approach
• ICU involvement depending on severity, patient may require intubation and BP support

Supportive

• analgesia
• supplemental 02 > escalate as required
• fluids
• NG tube
• urinary catheter

Definitive

• gallstones - may go for therapeutic ERCP - involve gen surg
• alcohol: AWS protocol (benzo’s, IV thiamine 300mg TDS)
• other according to specific aetiology

Question 7

Acute pancreatitis - complications

Answer 7

Complications
Acute
- SIRS (ARDS, AKI, DIC)
- Ileus
- Necrotising pancreatits
- hypovolaemia and hypotension - organ failure
- pleural effusion

Long-term

• pancreatic pseudocyst
• type 2 diabetes mellitus
• chronic pancreatitis

Question 8

Acute pancreatitis - Severity scores

Answer 8

Severity scores
- APACHE
- Glasgow prognostic indicator
P - Pa02 < 60mmHg
A - age >55
N - neutrophils >16
C - Calcium <2
R - renal - urea >16
E - LDH >600
A - Albumin <32
S - BSL >10mmol
- Balthazar criteria: For grading CT image severity of pancreatitis
- Ranson criteria - for alcohol-induced pancreatitis