Acute Pancreatitis Flashcards by Georgia Leggett

What is acute pancreatitis?

Acute inflammatory condition of the pancreas

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Describe the classification of acute pancreatitis

Mild: minimal organ dysfunction + uneventful recovery
Severe: organ failure +/or local complications such as necrosis, abscesses + pseudocysts

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Describe the sequence of events in the pathophysiology of pancreatitis

Intrapancreatic activation of pancreatic pro-enzymes: secondary to pancreatic ductal outflow obstruction or direct injury to pancreatic acinar cells
Increased proteolytic + lipolytic enzyme activity → destruction of pancreatic parenchyma
Attraction of inflammatory cells (neutrophils, macrophages) → release of inflammatory cytokines → pancreatic inflammation (pancreatitis)

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List 3 potential sequelae of pancreatitis

Capillary leakage
Pancreatic necrosis
Hypocalcaemia

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Name 2 causes of direct injury to pancreatic acinar cells

Alcohol
Drugs

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Name 2 causes of pancreatic ductal outflow obstruction

Gallstones
Cystic fibrosis

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Describe what results from capillary leakage secondary to acute pancreatitis

Release of inflammatory cytokines + vascular injury by pancreatic enzymes
→ vasodilation + increased vascular permeability
→ shift of fluid from intravascular space into interstitial space (third-space fluid loss)
→ hypotension, tachycardia, warm + flushed skin
→ distributive shock

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Describe how pancreatic necrosis can arise secondary to acute pancreatitis

Uncorrected hypotension + third-spacing
→ decreased end-organ perfusion
→ multiorgan dysfunction (mainly renal) + pancreatic necrosis

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Describe how acute pancreatitis can lead to hypocalcaemia

Lipase breaks down peripancreatic + mesenteric fat
→ release of free fatty acids that bind calcium
→ hypocalcemia (fatty saponification)

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What are the 3 most common causes of acute pancreatitis?

Gallstones
Alcohol
Idiopathic

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What are the conventional causes of pancreatitis?

Idiopathic
Gallstones  
Ethanol 
Trauma 
Steroids 
Mumps/ HIV/ Coxsackie 
Autoimmune 
Scorpion Venom 
Hypercalcaemia/ hyperlipidaemia/ hypothermia 
ERCP 
Drugs (e.g. sodium valproate, thiazides + azathioprine)

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List 8 drugs that can cause acute pancreatitis

Azathioprine
Mesalazine
Didanosine
Bendroflumethiazide
Furosemide
Pentamidine
Steroids
Sodium valproate

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Summarise the epidemiology of pancreatitis

COMMON 
UK Annual Incidence: 10/10,000 
Peak age: 60 yrs  
Most common cause in: 
Young Males = alcohol  
Middle age Females = gallstones

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List 3 symptoms of acute pancreatitis

Constant severe epigastric pain
N+V
Fever

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Describe the pain in acute pancreatitis

Classically radiating towards the back
Worse after meals, when supine + on movement
Relieved by sitting forward

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List 5 general signs of pancreatitis on physical examination

Shock
Tachycardia
Hypotension
Oliguria/ Anuria
+/- Jaundice (in biliary pancreatitis)

List 4 signs found on abdominal examination in acute pancreatitis

Abdominal tenderness, distension + guarding
Ileus with reduced bowel sounds + tympani on percussion
Ascites
Skin changes (rare)

What causes ileus in acute pancreatitis?

Inflammation

What pulmonary S/S may be present in acute pancreatitis?

Chest pain + dyspnea
Signs of pleural effusion +/or ARDS

Name 3 signs of haemorrhagic pancreatitis

Cullen’s sign: periumbilical ecchymosis + discoloration
Grey Turner’s sign: flank ecchymosis + discoloration
Fox’s sign: ecchymosis over inguinal ligament

What is the diagnostic criteria for acute pancreatitis?

2 of:
Characteristic abdo pain
↑ Serum pancreatic enzymes: lipase or amylase ≥ 3× ULN
Characteristic findings on cross-sectional imaging (e.g. contrast enhanced CT)

What bloods are seen in acute pancreatitis?

WCC: High
U+Es: ?dehydration)
LFTs: deranged if gallstones or alcohol
CRP: High
LDH: High
Glucose: High
Lipase: High
Amylase: High
Calcium: Low

Describe the use of serum amylase in diagnosis of pancreatitis

Raised in 75%; typically >3x upper limit of normal
Levels do NOT correlate with disease severity
Specificity for pancreatitis is ~90%

List 5 causes of raised amylase other than acute pancreatitis

Pancreatic pseudocyst
Mesenteric infarct
Perforated viscus
Acute cholecystitis
DKA

Describe use of serum lipase in diagnosis of acute pancreatitis

More sensitive + specific than amylase Also has longer half-life than amylase + may be useful for late presentations > 24h

Other than bloods, what investigations may be performed for acute pancreatitis?

ABG: ?hypoxia or metabolic acidosis USS: ?gallstones/ biliary obstruction Erect CXR: ?pleural effusion/ bowel perforation CT: if dx uncertain or persisting organ failure

List 3 scoring systems is used in assessment of acute pancreatitis?

Glasgow-Irmie Score APACHE-II Score Ranson score

What parameters are used in the Modified Glasgow score?

PaO2 <8 kpa Age >55 Neutrophils, WCC >15 Calcium <2 Renal, urea >16 Enzymes, LDH >600 or AST >200 Albumin <32 Sugar, glucose >10

Describe the immediate management of Acute Pancreatitis

Fluid + electrolyte resus Analgesia +/- Antiemetics Early feeding (NG tube if vomiting) ?HDU + ITU care

When should antibiotics be used in acute pancreatitis?

ONLY if evidence of infected necrosis.

Describe definitive management of biliary pancreatitis

Gallstone pancreatitis + cholangitis: ERCP Gallstone pancreatitis without cholangitis/ bile duct obstruction: Cholecystectomy Gallstone pancreatitis with bile duct obstruction: ERCP + sphincterectomy

Describe management of alcohol related acute pancreatitis

Vitamin supplementation: Thiamine, Folic acid, Cyanocobalamin Brief alcohol counselling during admission

When and what surgical methods are used in acute pancreatitis?

Necrotising pancreatitis | Necresectomy (drainage + debridement of necrotic tissue)

What 4 local complications may arise from acute pancreatitis?

Pancreatic necrosis Abscess (infected necrosis of pancreas) Pseudocyst (typically several weeks later) Chronic pancreatitis (fibrotic scarring; typically from alcoholic pancreatitis)

What 5 systemic complications may arise from acute pancreatitis?

ARDS DIC Electrolyte derangement (typically Hypocalcaemic) Glucose homeostasis derangement (H or L) Hypovolaemic shock

What should you check about the patient's PMH?

Hx of high alcohol intake Hx of gallstones

Describe management of pancreatic necrosis

Sterile necrosis: conservatively (at least initially) Early necrosectomy is a/w a high mortality rate (+ should be avoided unless compelling indications for surgery exist)