Acute Pancreatitis

Question 1

A 45-year-old, diagnosed & managed for acute pancreatitis 2 weeks ago.
Now presents with vomiting, SOB & epigastric pain which is not improved
with PPIs. Examination revealed tachycardia & tachypnoea.

Q. Causes of Acute pancreatitis?

Answer 1

, The mnemonic “I GET SMASHED” is used to remember the causes of acute pancreatitis:

I: Idiopathic
G: Gallstones
E: Ethanol (alcohol)
T: Trauma
S: Steroids
M: Mumps (and other infections)
A: Autoimmune diseases
S: Scorpion sting
H: Hypercalcemia/Hyperlipidemia
E: ERCP (Endoscopic Retrograde Cholangiopancreatography)

Question 2

Q1. Which enzymes to be checked apart from Amylase & lipase? Are amylase & lipase valuable? Why?

Answer 2

LDH , Urinary amylase
less valuable
as they are increasing late not early, and may increase in chronic cases and other conditions

Question 3

Q2. What are Causes of post-cholecystectomy pancreatitis ?

Answer 3

Missed stone, infec. , stricture of CBD or injury

Question 4

Q3: Patient comes with jaundice and ascending cholangitis 6 months after surgery, reason?

Answer 4

Missed stone, stricture, malignancy, remenant of long cystic duct( incr. risk of infection)

Question 5

Q4. 5 weeks after the initial attack patient presented with epigastric fullness, vomiting and dyspcpsia, diagnosis?

Answer 5

Pancreatic pseudocyst

Question 6

Q5. Define pseudocyst and what are its contents?

Answer 6

Amylase risch fluid that surrounded by fibrous mesh which called psuedocapsule
content; fluid rich in amylase

Question 7

Q6.Difference between cancer & pseudocyst?

Answer 7

Pseudocyst; rich for amylase, No tumor markers, fluid is less viscus
Cancer; Fluid is more viscous and positive tumor markers and there is no pseudocyst

Question 8

Q7. In case of pancreatic Necrosis, what investigation of choice ?

Answer 8

CT angio for the abdomen and pelvis
Q8. What are the findings to look for in CT?
According to Belhazard classification; Edema, Necrosis, Abscess, Pseudocyst, collection.

Question 9

Q9. What are the biochemical findings ?

Answer 9

Increase in glucose and less albumen and Ca.
ABG – > Hypoxemia

Question 9

Q12: How could you classify obstructive jaundice according to cause?

Answer 9

Obstruction from inside lumen like Stone or parasite
Itralumenal; tumors of CBD
Outside; Cancer head of pancrease or LN enlargement

Question 10

Q11.Why is there hyperglycemia?

Answer 10

Due to autodigestion of beta cells leading to decrease insuline level and increase glucose in blood. Also Stress response in sepsis leading to release of chatecholamines and increasing glucose in blood.

Question 10

Q10. Why is the calcium level is low?

Answer 10

Early stages due to destruction of mesenteric fat and presence of free fatty acid that attached to Ca with chelation of calcium
Transient hypoTH and HypoMg
Late stage due to sepsis leading to increase catecholamines and shifting of Ca intracellular

Question 11

Q13. Whal could the cause for silent obstructive jaundice?

Answer 11

According to courvsier law it most commonly Ca head of Pancr.

Question 12

Q14. How would you manage a patient with acute pancreatitis? Does steroids have a role in acute pancreatitis?

Answer 12

CCRISP
Admission to HDU/ICU
Analgesia
Aggressive fluid rehydration
Supplemental oxygen
Invasive monitoring of vital signs, central venous pressure, urine output, blood gases
Frequent monitoring of haematological and biochemical parameters (including liver and renal function, clotting, serum calcium, blood glucose)
Nasogastric drainage (only initially)
Antibiotics if cholangitis suspected; prophylactic antibiotics can be considered
CT scan essential if organ failure, clinical deterioration or signs of sepsis develop
ERCP within 72 hours for severe gallstone pancreatitis or signs of cholangitis
Supportive therapy for organ failure if it develops (inotropes, ventilatory support, haemofiltration, etc.)
If nutritional support is required, consider enteral (nasogastric) feeding
Corticosteroids suppress the release of inflammatory cytokines in AP.
Corticosteroid therapy can benefit SAP (severe acute pancreatitis) patients by reducing the length of hospital stay, the need for surgical intervention and the mortality rate

Question 13

Q15.What scoring for pancreatitis do you know? Talk about each of them.

Answer 13

READ Glascow, Ranson’s, Belhazard’s

Question 14

Q16.What are the early and delayed complications of acute pancreatitis?

Answer 14

Early; MOF , Hyperglycemia, Hypovolumic shock, ARDS, AKI
Late; Abcess formation, Pseudocyst, Choronicity.

Question 15

Q17.How to treat splenic vein thrombosis in a patient with Haemorrhagic pseudocyst?

Answer 15

Coiling by interventional Radiology.

Question 16

Q18. Complications of coiling ?

Answer 16

Bleeding and Injury to surrounding tissue, infection

Question 17

Q. when to use Abx?

Answer 17

Infected pseudocyst, Sepsis and prophylaxis before major intervention ERCP

Question 17

Q. which Abx to use?

Answer 17

Quinolones

Question 18

Q. when to go for TPN?

Answer 18

If entral is not accessible/ Pt is in sever sepsis or sever pancreatitis/ Complicated by formation of high output fistula.

Question 19

Q. Which analgesia to give?

Answer 19

According to WHO ladder
If mild – > Paracetamol. (No NSAIDs – Incr. PU/Renal injury)
Sever – > PCA or Epidural ( Admit to ITU )