Acute pancreatitis

Question 1

What is the diagnostic criteria for acute pancreatitis

Answer 1

– Classical pain
* Severe, Persistant, Epigastric, radiating to back

– Serum Lipase/Amylase >3x normal

– Radiological features on CT/MRI/US

Question 2

What are the causes of acute pancreatitis

Answer 2

• Gallstones: microlithiasis (40%)
• Alcohol: (35%)
• Anatomic obstruction: panc division, choledochocele
• Drugs: Stavudine NB, sulphonamides, flagyl, tetracyclines, lasix, statins, epilim etc
• Metabolic: Ca++> converts trypsin, Triglyceridaemia
• Viral: HIV, Mumps, coksackie, hepB, CMV, VZV, HSV
• Other: trauma, hypotension/surgery, scorpion, organophosphate poisoning, ERCP, renal transplant, alpga-1-antitrypsin def, CFTR

Question 3

Explain the pathophysiology of acute pancreatitis

Answer 3

• Exact mechanism unknown
• Theories are based on PD obstruction, trypsinogen activation within PD
• bile or enterokinase reflux into PD and acinar- sensitization
• Ca++
• accumulation of spontaneously activated trypsin due to failure of first line defense mechanisms
• PSTI/SPINK1/mesotrypsin and enzyme Y

Question 4

Explain interstitial Oedematous Pancreatitis

Answer 4

• Majority of cases
• Diffuse inflammatory oedema of pancreas
• On CT: Pancreatic parenchyma homogenous
  enhancement with haziness of fat or mild fat stranding
• Symptoms usually resolve in 1/52

Question 5

Explain Necrotizing Pancreatitis

Answer 5

• 5-10% of cases
• Necrosis of both pancreatic parenchyma and peri- pancreatic tissue/fat
• On CT: Initial scan may underestimate extent. Non- enhancing areas at 1/52 post onset should be seen as pancreatic parenchymal necrosis
• The natural Hx is variable:
  » Sterile/Infected (30%)
  » Resolution/Persist
• Worse prognosis

Question 6

Explain the phases of acute pancreatitis

Answer 6

Early Phase
* SIRS (systemic inflammatory response system) response due to host response to pancreatic injury
* Lasts +/- 1/52

Late Phase (driven by infection)
– Characterized by persistence
* Systemic, local or organ failure

– Only in Moderately-severe or severe type
– Radiologic features of local complications have evolved
– SIRS may be followed by CARS (compensatory inflammatory response system

Question 7

What are the complications of acute pancreatitis

Answer 7

(Enzymes go up, pain and symptoms persists, SIRS, Organ dysfunction)

Organ failure
* Respiratory conditions (PF<300)
* Cardiovascular conditions (SBP<90,non-responsive to fluid)
* Renal conditions (Cr>170mmol/L)

Systemic conditions
* Haematological
* CNS
* Metabolic

Question 8

Explain the different classifications of acute pancreatitis

Answer 8

Mild Acute Pancreatitis
* No organ failure
* No systemic or local complications
* Mortality is rare and early discharge is allowed

Moderate severe Acute Pancreatitis
* Transient organ failure <48hrs
* Local or Systemic complications without persistent organ failure

Severe Acute Pancreatitis
* Persistent organ failure >48hrs
* Persistent SIRS >48hrs treat as SAP

Question 9

Explain the management of acute pancreatitis

Answer 9

• Level of care
  – Classify – if moderate – severe manage in ICU/HC
• Adequate Fluid resuscitation
• Adequate nutrition
• Analgesia
• (ERCP) - not routinely part of management

Question 10

Which pharmacological agents are used in acute pancreatitis

Answer 10

Analgesics
Antibiotics for prophylactic use
- carbapenems
- quinolones (not used)

Question 11

When to image in acute pancreatitis

Answer 11

Acute Phase:
* Diagnostic uncertainty
* Persistent organ dysfunction resistant to optimal management or worsening on Rx

Late phase:
* Late complications i.e. heamorrhage/sepsis/mass