Acute pancreatitis

Question 1

Causes: GET SMASHED

Answer 1

Gallstones (most common worldwide)
Ethanol (most common cause in Europe)
Trauma
Steroids
Mumps
Autoimmune disease (Polyarteritis Nodosa/SLE)
Scorpion bite
Hypercalcaemia, hypertriglycerideaemia, hypothermia
ERCP
Drugs (as below)

Question 2

Iatrogenic (drug) causes of pancreatitis FATSHEEP

Answer 2

Furosemide
Azathioprine/Asparaginase
Thiazides/Tetracycline
Statins/Sulfonamides/Sodium Valproate
Hydrochlorothiazide
Estrogens
Ethanol
Protease inhibitors and NRTIs

Question 3

Features

Answer 3

1. stabbing-like, epigastric pain which radiates to the back that is relieved by sitting forward or lying in the fetal position
2. Vomiting
3. A recent alcoholic binge or a history of gallstones are highly suggestive

Question 4

Signs

Answer 4

1. hypovolaemia 2ndary to 3rd-spacing of fluids (tachycardia, dry mucous membranes)
2. guarding in the epigastric region, however, these are relatively non-specific signs.
3. Cullen’s sign is highly associated with pancreatitis.
4. (rare) Haemorrhagic pancreatitis, –>Grey-Turner’s sign (bruising along the flanks) and indicates retroperitoneal bleeding which is highly associated with acute pancreatitis.

+/- Fever is only present if pancreatitis has been complicated with infection

Question 5

Third space fluid sequestration in pancreatitis

Answer 5

inflammatory mediators, vasoactive mediators and tissues which lead to vascular injury, vasoconstriction and increased capillary permeability

– ARDS (Acute Respiratory Distress Syndrome), pleural effusions and hypovolaemia leading to AKI (Acute Kidney Injury).

Question 6

Bloods for pancreatitis

Answer 6

1. FBC and U&Es
   - Leucocytosis - necrotising pancreatitis.
2. LFT’s - gallstone disease.

An amylase 3x the upper limit of normal is extremely suggestive of acute pancreatitis.

!degree of elevation of amylase is not related to the severity of the disease!

However, other causes such as perforated duodenal ulcer, cholecystitis and mesenteric infarction may also elevate amylase although to a lesser extent.

Question 7

Amylase or lipase for pancreatitis

Answer 7

Lipase is a more sensitive and specific marker than amylase and should be used if available.

it also has a longer half-life than amylase and may be useful for late presentations > 24 hours

However, it should be noted that it is often not readily available in UK hospitals

Question 8

Diagnosis

Answer 8

if characteristic pain + amylase/lipase > 3 times normal level –> NO IMAGING

USS - gallstones.
MRCP - obstructive pancreatitis.
(ERCP is often preferred in these cases compared to MRCP and can be therapeutic)
A CT scan can be performed to at a later stage if complications of pancreatitis are suspected such as pseudocysts or necrotizing pancreatitis.

Question 9

Severity of pancreatitis - modified Glasgow criteria (PANCREAS)

Answer 9

at admission and after 48 hours of admission

3 or more positive factors indicates transfer to ITU/HDU for intensive monitoring and aggressive fluid resuscitation

PaO2 < 8kPa (60mmHg)
Age > 55 years
Neutrophils - WBC >15 x109/l
Calcium < 2mmol/l
Renal function - Urea > 16mmol/l
Enzymes - AST/ALT > 200 iu/L or LDH > 600 iu/L
Albumin < 32g/l
Sugar - Glucose >10mmol/L

Question 10

Complications of pancreatitis

Answer 10

Necrotizing pancreatitis –> saponification, reduced hormone output (insulin) and ARDS.
Pseudocysts