Acute Pancreatitis Flashcards
What is acute pancreatitis?
Acute inflammatory condition of the pancreas
Describe the classification of acute pancreatitis
Mild: minimal organ dysfunction + uneventful recovery
Severe: organ failure +/or local complications such as necrosis, abscesses + pseudocysts
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)
List 3 potential sequelae of pancreatitis
Capillary leakage
Pancreatic necrosis
Hypocalcaemia
Name 2 causes of direct injury to pancreatic acinar cells
Alcohol
Drugs
Name 2 causes of pancreatic ductal outflow obstruction
Gallstones
Cystic fibrosis
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
Describe how pancreatic necrosis can arise secondary to acute pancreatitis
Uncorrected hypotension + third-spacing
→ decreased end-organ perfusion
→ multiorgan dysfunction (mainly renal) + pancreatic necrosis
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)
What are the 3 most common causes of acute pancreatitis?
Gallstones
Alcohol
Idiopathic
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)
List 8 drugs that can cause acute pancreatitis
Azathioprine
Mesalazine
Didanosine
Bendroflumethiazide
Furosemide
Pentamidine
Steroids
Sodium valproate
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
List 3 symptoms of acute pancreatitis
Constant severe epigastric pain
N+V
Fever
Describe the pain in acute pancreatitis
Classically radiating towards the back
Worse after meals, when supine + on movement
Relieved by sitting forward
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)
