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Surgery > Acute Pancreatitis > Flashcards

Acute Pancreatitis Flashcards

1
Q

define acute pancreatitis

A

acute inflammation of the pancreas

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2
Q

main features of the pancreas

A

exocrine and endocrine gland
sits in retro peritoneum behind the stomach
has a close relationship with major vascular and biliary structures

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3
Q

mortality of acute pancreatitis

A

majority are self limiting
mortality is 20-30% of those who develop infected necrosis of pancreas

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4
Q

auto digestion of the pancreas

A

usually related to activation of trypsinogen
fusion of zymogens with lysosomes activates enzymes (colocalisation)
fusion is mediated by calcium influx

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5
Q

signals that may cause calcium influx

A

ductal hypertension
NF-kB
ethanol metabolites
low pH

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6
Q

local response of auto digestion

A
  • inflammation and pain
  • oedema and fluid leak
  • tissue damage and necrosis
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7
Q

systemic response of auto digestion

A

systemic inflammatory response syndrome (SIRS)
near by organs can be obstructed or paralysed

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8
Q

inflammatory cascade

A

local vasodilation and increase in permeability
oedema
vascular injury and hypo perfusion
ischaemia and tissue necrosis

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9
Q

SIRS

A

systemic inflammatory response syndrome
systemic release of IL1 and TNFa

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10
Q

essential pathophysiology of acute pancreatitis

A
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11
Q

trypsin activates

A

lipase
phospholipase A
elastase
chymotrypsin
kvllikrein-kinin lipase

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12
Q

lipase causes

A

fat necrosis

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13
Q

phospholipase A causes

A

coagulation, destroys cell membranes

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14
Q

elastase causes

A

vascular damage and haemorrhage

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15
Q

chymotrypsin causes

A

oedema and vascular damage

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16
Q

kallikrein-kinin lipase causes

A

oedema and inflammation

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17
Q

leading causes of acute pancreatitis

A

alcohol and gallstones

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18
Q

other causes of acute pancreatitis

A

idiopathic
autoimmune
metabolic (hypertriglyceridaemia and hypercalcaemia)
malignancy
ERCP
drug induced
traumatic
viral
bacterial and parasites

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19
Q

virusess that might cause pancreatitis

A

mumps, coxsackie B, rarely HIV, Hep

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20
Q

for diagnosis of acute pancreatitis

A

you need presence of 2 of:
- pain typical of pancreatitis
- serum lipase 3x normal value
- imaging confirming inflammation of the pancreas (can be enough on its own)

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21
Q

why is amylase not sensitive

A

has shorter half life

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22
Q

2 types of acute pancreatitis

A
  • interstitial oedematous pancreatitis
  • necrotising pancreatitis
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23
Q

interstitial oedematous pancreatitis

A

diffuse gland enlargement
fluid collections can happen
uniform enhancement of the gland

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24
Q

necrotising pancreatitis

A

usually involves necrosis of both gland and peripancreatic tissue
rarely pancreas only
needs days to evolve and confirm
associated with higher mortality

25
Q

at what point should imaging be conducted

A

should not be conducted early
eg. necrotising pancreatitis needs days to evolve and confirm so early CT is unreliable
best beyond the 5th day
perfusion is impaired in early phases

26
Q

early phase of acute pancreatitis

A

1 week
usually relates to SIRS and acute inflammatory process
can have systemic effects and organ failure

27
Q

late phase of acute pancreatitis

A

persistence of systemic complication and organ failure
evolution of local complications and progression

28
Q

mild acute pancreatitis

A

interstitial oedema and rapid recovery
no necrosis, complications or organ failure

29
Q

moderate acute pancreatitis

A

local complications (necrosis, feud collection, pseudocysts) OR
systemic complications (temporary organ failure eg. kidney) improving within 48 hours

30
Q

severe pancreatitis

A

persistant single or multi organ failure >48 hours

31
Q

complications in pancreatic region

A

fluid collections around pancreas
necrosis of tissue
infection of fluid or necrosis

32
Q

pancreatic pseudocyst is

A

fibrous capsule containing sterile lipase rich fluid collection

33
Q

what is chronic pancreatitis

A

long term outcome of scarring and obstruction of parenchyma or ducts

34
Q

luminal complications

A

gastric outlet obstruction
colonic stricture
colonic performaation
biliary obstruction

35
Q

vascular complications

A

venous thrombosis
arterial pseudo-aneurysm
heamorrhage (direct or DIC)

36
Q

compartment complications

A

intre-abdominal hypertension and ACS
pseudo obstruction
ileus

37
Q

death typically occurs due to

A

death is rare
usually occur in the first week as a result of SIRS and multi organ failure

38
Q

if death occurs after the first week

A

rare
usually due to infective complications

39
Q

pain profile of acute pancreatitis

A

central epigastric pain
sudden onset
severe, sharp
radiates through to back
vomiting, anorexia
constant from onset
worse with movement
mild to severe

40
Q

signs and risk factors for pancreatitis

A

gall stones; recent cholecystectomy or Hx of biliary colic
alcohol
drugs
systemic signs of hypercalcaemia or malignancy
family Hx
recent procedures

41
Q

what are systemic signs of hypercalcaemia

A

constipation, kidney stones

42
Q

mild pancreatitis on examination

A

mild tachycardia
acute abdo pain
minimal abdo distention
central upper abdo/epigastric tenderness

43
Q

severe pancreatitis on examination

A

tachycardia, fever, hypotension
severe acute abdominal pain
peritonism

44
Q

Cullen’s sign

A

periumbilical eccymosis and discolouration (bluish-red)

45
Q

grey turner’s sign

A

flank ecchymosis with discolouration

46
Q

fox’s sign

A

ecchymosis over the inguinal ligament

47
Q

glasgow prognostic criteria of acute pancreatitis

A

assessed in the first 48 hours

48
Q

APACHE II severity predictor

A

commonly used in ICU
score >8 is clinically severe
immediate but many people with severe disease score low

49
Q

CRP severity predictor

A

15omg/L is usual cut off for severity
usually peaks at 48 hours

50
Q

PCT severity predictor

A

procalcitonin
good marker for infection

51
Q

CT scan scoring as a severity predictor

A

confirms local complications and severity

52
Q

fluid resuscitation

A

must be balanced
- enough to maintain organ perfusion
- avoid over load and resultant organ dysfunction and increase risk of intra abdominal hypertension
- CSL is preferred crystalloid

53
Q

nutrition

A

NBM/sips only
- resting the gland might help disease progression
- limited to 24-48 hours
enteral nutrition is best
- normal route
- beyond the duodenum with nasojejunal tube in severe case
- keeps the gut occupied to prevent bacterial translocation
TPN when gut not working

54
Q

ERCP is indicated in

A

gallstone pancreatitis with cholangitis
best in the first 72 hours as proven reduction in mortality
has no role in other conditions and may increase complications

55
Q

cholecystectomy is indicated in

A

gall stone pancreatitis

56
Q

when to perform cholecystectomy

A

immediately in mild pancreatitis
in moderate or severe, should wait for recovery

57
Q

only intervene in pseudocysts if

A

three S’s
- Symptomatic
- greater than Six cm
- longer than Six weeks

58
Q

when to intervene in management of local complications

A

proven infection that won’t respond to antibiotics
failure of recovery
symptomatic collections (large and painful or gastric outlet obstruction)

Surgery (18 decks)

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