Acute Pancreatitis Flashcards
define acute pancreatitis
acute inflammation of the pancreas
main features of the pancreas
exocrine and endocrine gland
sits in retro peritoneum behind the stomach
has a close relationship with major vascular and biliary structures
mortality of acute pancreatitis
majority are self limiting
mortality is 20-30% of those who develop infected necrosis of pancreas
auto digestion of the pancreas
usually related to activation of trypsinogen
fusion of zymogens with lysosomes activates enzymes (colocalisation)
fusion is mediated by calcium influx
signals that may cause calcium influx
ductal hypertension
NF-kB
ethanol metabolites
low pH
local response of auto digestion
- inflammation and pain
- oedema and fluid leak
- tissue damage and necrosis
systemic response of auto digestion
systemic inflammatory response syndrome (SIRS)
near by organs can be obstructed or paralysed
inflammatory cascade
local vasodilation and increase in permeability
oedema
vascular injury and hypo perfusion
ischaemia and tissue necrosis
SIRS
systemic inflammatory response syndrome
systemic release of IL1 and TNFa
essential pathophysiology of acute pancreatitis
trypsin activates
lipase
phospholipase A
elastase
chymotrypsin
kvllikrein-kinin lipase
lipase causes
fat necrosis
phospholipase A causes
coagulation, destroys cell membranes
elastase causes
vascular damage and haemorrhage
chymotrypsin causes
oedema and vascular damage
kallikrein-kinin lipase causes
oedema and inflammation
leading causes of acute pancreatitis
alcohol and gallstones
other causes of acute pancreatitis
idiopathic
autoimmune
metabolic (hypertriglyceridaemia and hypercalcaemia)
malignancy
ERCP
drug induced
traumatic
viral
bacterial and parasites
virusess that might cause pancreatitis
mumps, coxsackie B, rarely HIV, Hep
for diagnosis of acute pancreatitis
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)
why is amylase not sensitive
has shorter half life
2 types of acute pancreatitis
- interstitial oedematous pancreatitis
- necrotising pancreatitis
interstitial oedematous pancreatitis
diffuse gland enlargement
fluid collections can happen
uniform enhancement of the gland
necrotising pancreatitis
usually involves necrosis of both gland and peripancreatic tissue
rarely pancreas only
needs days to evolve and confirm
associated with higher mortality
at what point should imaging be conducted
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
early phase of acute pancreatitis
1 week
usually relates to SIRS and acute inflammatory process
can have systemic effects and organ failure
late phase of acute pancreatitis
persistence of systemic complication and organ failure
evolution of local complications and progression
mild acute pancreatitis
interstitial oedema and rapid recovery
no necrosis, complications or organ failure
moderate acute pancreatitis
local complications (necrosis, feud collection, pseudocysts) OR
systemic complications (temporary organ failure eg. kidney) improving within 48 hours
severe pancreatitis
persistant single or multi organ failure >48 hours
complications in pancreatic region
fluid collections around pancreas
necrosis of tissue
infection of fluid or necrosis
pancreatic pseudocyst is
fibrous capsule containing sterile lipase rich fluid collection
what is chronic pancreatitis
long term outcome of scarring and obstruction of parenchyma or ducts
luminal complications
gastric outlet obstruction
colonic stricture
colonic performaation
biliary obstruction
vascular complications
venous thrombosis
arterial pseudo-aneurysm
heamorrhage (direct or DIC)
compartment complications
intre-abdominal hypertension and ACS
pseudo obstruction
ileus
death typically occurs due to
death is rare
usually occur in the first week as a result of SIRS and multi organ failure
if death occurs after the first week
rare
usually due to infective complications
pain profile of acute pancreatitis
central epigastric pain
sudden onset
severe, sharp
radiates through to back
vomiting, anorexia
constant from onset
worse with movement
mild to severe
signs and risk factors for pancreatitis
gall stones; recent cholecystectomy or Hx of biliary colic
alcohol
drugs
systemic signs of hypercalcaemia or malignancy
family Hx
recent procedures
what are systemic signs of hypercalcaemia
constipation, kidney stones
mild pancreatitis on examination
mild tachycardia
acute abdo pain
minimal abdo distention
central upper abdo/epigastric tenderness
severe pancreatitis on examination
tachycardia, fever, hypotension
severe acute abdominal pain
peritonism
Cullen’s sign
periumbilical eccymosis and discolouration (bluish-red)
grey turner’s sign
flank ecchymosis with discolouration
fox’s sign
ecchymosis over the inguinal ligament
glasgow prognostic criteria of acute pancreatitis
assessed in the first 48 hours
APACHE II severity predictor
commonly used in ICU
score >8 is clinically severe
immediate but many people with severe disease score low
CRP severity predictor
15omg/L is usual cut off for severity
usually peaks at 48 hours
PCT severity predictor
procalcitonin
good marker for infection
CT scan scoring as a severity predictor
confirms local complications and severity
fluid resuscitation
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
nutrition
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
ERCP is indicated in
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
cholecystectomy is indicated in
gall stone pancreatitis
when to perform cholecystectomy
immediately in mild pancreatitis
in moderate or severe, should wait for recovery
only intervene in pseudocysts if
three S’s
- Symptomatic
- greater than Six cm
- longer than Six weeks
when to intervene in management of local complications
proven infection that won’t respond to antibiotics
failure of recovery
symptomatic collections (large and painful or gastric outlet obstruction)
