Acute Pancreatitis Flashcards
Define acute pancreatitis. What are the types of severity?
A disorder of the exocrine pancreas, and is associated with acinar cell injury with local and systemic inflammatory responses.
What is the epidemiology of acute pancreatitis?
- Common
- Annual incidence 1/1000 in UK
- Peak age 60years
- Males
- Alcohol induced more common in white females
- Principal cause is gallstones
What are the risk factors for acute pancreatitis?
- Gallstones (biggest cause in UK)
- Ethanol (2nd)
What is the aetiology of acute pancreatitis?
Insult –> activation of pancreatic protoenzymes within duct/acini –> tissue damage and inflammation
What are the symptoms of acute pancreatitis?
- Abdominal pain/epigastric (relived by sitting forward, aggrevated by movement)
- Anorexia
- Nausea
- Vomiting
What are the 2 types of pancreatitis in terms of pathophysiology?
- Oedematous
- Haemorrhagic - can produce signs such as Cullen’s sign, Grey-Turner’s sign and Fox’s sign.
What are the signs of acute pancreatitis on examination?
- Epigastric tenderness
- Fever
- Shock, tachycardia, tachypnoea
- Reduced bowel sounds (due to ileus)
- If severe and haemorrhagic, Turner’s sign and Cullen’s sign
What investigations would you do for acute pancreatitis?
Bloods:
- Amylase/lipase high (usually x3 normal but does not correlate with severity, dip after first few days but remain elevated for 14 and 5 days respectively )
- FBC (high WCC)
- U&Es
- High glucose
- High CRP
- Reduced Ca
- LFTs (deranged in gallstone pancreatitis or alcohol)
- ABG (hypoxia or metabolic acidosis)
Imaging:
- USS - gallstones/ biliary dilatation
- Erect CXR - ?pleural effusion, exclude other causes
- AXR - exclude other acute abdomen
- CT scan - Balthazar score can be calculated from this to assess grade of pancreatitis and degree of necrosis
What 2 assessments of severity are used for acute pancreatitis?
- Modified Glasgow combined with CRP (>210mg/L)
- APACHE-II score
What is the medical management of acute pancreatitis?
Medical -
- Fluid and electrolyte resuscitation (Ringer’s lactate) - MAIN THERAPY - may reduce lactic acidosis
- Analgesia - IV opioids
- Nutritional support - NG tube if vomiting. Enteral feeding has lower complication and morbidity rates so offer to pts with moderate/severe acute pancreatitis
- Oxygen
- Anti-emetic - ondansetron
- Antibiotics should NOT be routinely given
Other:
- Ca and Mg replacement - calcium gluconate and magnesium sulfate
- Insulin
Other than medical management, how is acute pancreatitis treated?
- ERCP and sphincterotomy - within 72 hours for gallstone pancreatitis, cholangitis, jaundice, dilated CBD. Definitive management of gallstones on admission/within 2 weeks.
- Catheter drainage (percutaneous or endoscopic) - if fail to respond to antibiotics in infected pancreatic necrosis
- Nephrosectomy/debridement of all necrotic tissue - for patients who do not respond to drainage
What are the local, systemic and long term complications of acute pancreatitis?
- Local - necrosis, pseudocyst (>4 weeks), abscess, ascites (if high amylase content then can cause pleural effusion), pseudoaneurysm, venous thrombosis.
- Systemic - multi-organ dysfunction, sepsis, renal failure, ARDS, DIC, hypocalcaemia, diabetes
- Long term - chronic pancreatitis (w/ diabetes and malabsorption)
What is the prognosis for acute pancreatitis?
- 80% run mild disease course (with 5% mortality)
- 20% fulminating course with high mortality (infected pancreatic necrosis has 70% mortality)
What are the levels of severity of acute pancreatitis?
Severity // Organ failure // Local complications*
Mild: No // No
Moderate: No or transient (<48 hours) // Possible
Severe: Persistent (>48 hours) // Possible
*Local and systemic complications as seen on bloods and/or CT.
What are these signs in pancreatitis?