Acute Pancreatitis

Question 1

Definition

Answer 1

Occurs due to inflammation of the pancreas and has a variety of different causes

Question 2

Epidemiology

Answer 2

Advanced age
Afro-Caribbean ethnicity
Sex:
- Alcohol related = MALES
- Gall stones related = FEMALES

Question 3

Risk factors

Answer 3

Diet: high glycaemic foods is associated with non-gallstone related pancreatitis
T2DM
Family history

Question 4

Aetiology (I GET SMASHED)

Answer 4

Iatrogenic
Gallstones (MC)
Ethanol abuse (Alcohol)
Trauma (usually blunt abdominal trauma)
Scorpion and spider bites
Mumps virus (+ measles, coxsackie B4, mycoplasma)
Autoimmune (SLE, Sjogren’s)
Steroids
Hypercalcaemia, Hyperlipidaemia
ERCP (also other procedures e.g gastric surgery)
Drugs (valproate, azathioprine, thiazide diuretics, tetracyclines, mesalazine, oestrogen, sitagliptin, vildagliptin)

Question 5

Pathophysiology

Answer 5

Rapid onset of inflammation and symptoms = reversible
- Obstruction of the pancreatic secretory transport (end of biliary system = Ampulla of Vater) blocking flow of bile and pancreatic juices into the duodenum
- Premature activation of pancreatic pro-enzymes (zymogens), such as trypsinogen to trypsin
- Self perpetuating inflammation of the pancreas causing leakage of enzymes and autodigestion of:
= blood vessels: retroperitoneal haemorrhage -> grey turners sign
= autodigestion of fats: fat necrosis
- Deranged pancreatic function cause hyperglycaemia from reduction of insulin production.

Question 6

Signs

Answer 6

Abdominal tenderness and guarding
Abdominal distension: common mainly due to leakage of fluid into retroperitoneum
Tachycardic +/or hypotensive
Jaundice
Pyrexic
Cullen’s sign: periumbilical bleeding secondary to intraperitoneal haemorrhage
Grey Turners sign: flank bleeding secondary to retroperitoneal haemorrhage = bruising in flank regions

Question 7

Symptoms

Answer 7

SUDDEN SEVERE EPIGASTRIC PAIN RADIATING TO BACK: RUQ, or LUQ
Nausea, vomiting and anorexia (COMMON)
Steatorrhea
Poor urinary output: due to insensible fluid loss, third-spacing and vomiting

Question 8

Diagnosis

Answer 8

GOLD STANDARD:
- Serum amylase (higher for longer, less specific, more routine)
- Serum lipase (more specific, less routine)
= 3 times the upper limit of normal, lipase is more specific esp in alcohol induced

Question 9

Acute pancreatitis can be diagnosed when 2 out of the following 3 criteria are met:

Answer 9

Clinical features: consistent with pancreatitis
Elevation of serum amylase or serum lipase (3x)
Radiological features: inflammation on CT

Question 10

Scoring system

Answer 10

MODIFIED GLASGOW SCORE: 3 points or more within the first 48 hours should be considered for referral to high-dependency care
P - pO2 <8kPa
A - Age > 55 years
N - Neutrophils - WCC > 15x109/L
C - Calcium <2mmol/L
R - Renal function = urea >16mmol/L
E - enzymes = AST >200U/L or LDH>600U/L
A - Albumin <32g/L
S - Sugar (Blood sugar >10mmol/L
Ranson’s criteria for pancreatitis mortality from initial and 48 hour lab values
APACHE II = assess severity within 24 hours = non specific for acute pancreatitis

Question 11

Treatment

Answer 11

ANTIBIOTICS NOT ROUTINELY RECOMMENDED
Acute emergency
FIRST LINE = IV FLUIDS
- Nil by mouth (NG feeding tube)
- Analgesia e.g. IV morphine
- Catheterise = monitor urine output
- O2 <94% supplementary oxygen required
Specific management:
- ERCP: gall stones, and cholangitis
- Cholecystectomy
- Alcohol cessation and withdrawal management
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Question 12

Complication

Answer 12

SIRS (systemically inflammatory response syndrome) = 2 + of
Tachycardia (90+ bpm)
Tachypnoea (20+ RR)
Pyrexia (38+)
WCC increased
Chronic pancreatitis
Pancreatic pseudocysts