Acute Pancreatitis Flashcards
what is acute pancreatitis
inflammation of the pancreas
how can acute and chronic pancreatitis be distinguished
in acute pancreatitis, there is limited damage to the secretory function of the gland
- but repeat episodes of acute panc –> chronic
what are the 2 main causes of acute pancreatitis
- gallstone disease
2 . excessive alcohol consumption
what are other causes of acute pancreatitis
Gallstone
Ethanol
Trauma
Steroids
Mumps
Autoimmune e.g. SLE or Sjogren’s
Scorpion venom
Hypercalcaemia
ERCP
Drugs e.g, azathioprine, NSAIDs, diuretics
explain the pathophysiology of acute pancreatitis
- premature/exaggerated activation of the digestive enzymes within the pancreas
- pancreatic inflamm response can cause an increase in vascular perm and fluid shifts (third spacing)
- enzymes are released into the s.circulation = autodigestion of fats (resulting in fat necrosis) and blood vessels
- fat necrosis = release of free FA which can react with serum Ca to form chalky deposits in fatty tissue = hypocalcaemia
what can severe end-stage pancreatitis eventually lead to
partial or complete necrosis of the pancreas
what is the presentation of a pt w acute pancreatitis
clinical feautures, examination
- severe epigastric pain radiating to the back +/- N&V
- O/E: epigastric tenderness +/- guarding
- less common but Cullen‘s sign (bruising around umbilicus) & Grey Turner’s (bruising in flanks) = retroperitoneal haemorrhage
- ? tetany from hypocalcaemia/ gallstone = obstructive jaundice
give some ddx for acute pancreatitis
- AAA
- renal calculi
- chronic pancreatitis
- aortic dissection
- peptic ulcer disease
what lab tests should be considered in acute pancreatitis
serum amylase/lipase: diagnostic if it is x3 upper limit of normal
- amylase can also be raised in other pathologies e.g. bowel perf, ectopic pregnancy, DKA so raised serum lipase is more accurate as it remains elevated for longer
LFTs: assess for cholestatic disease
- ALT > 150U/L has a PPV of 85% for gallstones as the underlying cause
what scoring system is used to assess the severity of acute pancreatitis
modified Glasgow criteria - within 48hrs of admission
- pt scoring >3 = severe pancreatitis and a high-dependency care referral is needed
PO2 <8Kpa
Age >55
Nuetrophils
Calcium < 2mmol/ L
Renal function (urea)
Enzymes lDH/AST
Albumin <32g/L
Sugar >10mmol/L
what imaging might be indicated in acute pancreatitis and what are the findings of each
- abdo USS: identify gallstones and evidence of duct dilatation
- AXR: ‘sentinal loop sign’ which is dilated proximal bowel loop adjacent to pancreas secondary to localised inflammation - then CXR to look for pleural effusion or ARDs
- contrast enhanced CT: 48hrs later shows pancreatic odema/swelling or necrosis
CT scan only 6-10 days after admission
what is the management plan for acute pancreatitis
treat underlying cause & supportive treatment:
- ERCP for gallstones
- IV fluids resuscitation + O2 (balanced crystalloid)
- NGT if vomiting
- catheter to monitor urine output and start fluid balance (0.5ml/kg/hr)
- opioids only after assessing risk
how is severe acute pancreatitis managed
high dependency unit or ITU
- broad spectrum abx e.g. imipenem for prophylaxis only against infection caused by pancreatic necrosis
- lap chole for gallstone related disease
what are some systemic complications of acute pancreatitis (4)
- DIC
- ARDS
- hypocalcaemia
- hyperglycaemia: secondary to destruction of islets of Langerhans and disturbances to insulin metabolism
what are local complications of acute pancreatitis
- pancreatic necrosis
- pancreatic pseudocyst
why does pancreatic necrosis arise and how is it treated
ongoing inflamm –> ischaemic infarction of pancreatic tissue
- confirm by CT
- pancreatic necrosectomy
- prone to infection so this should be suspected if cinical deterioration in pt + ↑ raised infection markers
- fine needle aspiration = definitive!
what is a pancreatic pseudocyst and where are they most commonly found
collection of fluid containing pancreatic enzymes, blood, and necrotic tissue
- usually seen in the lesser sac obstructing the gastro-epiploic foramen by inflammatory adhesion
how are pancreatic pseudocysts formed
week after intial acute pancreatitis epsiode
- lack epithelial lining and instead have a vascular and fibrotic wall surrounding collection
how are pancreatic pseudocysts treated
50% resolve spontaneously
- if >6 weeks then unlikely to resolve so consider surgical debridement or endoscopic drainage
what helps chronic pancreatitis patients digest food
replacement of pancreatic enzymes e.g. Creon
what are other causes of chronic pancreatitis other than alcohol
- CF, HH
- tumours, stones
what are features of chronic pancreatitis
- pain is typically worse 15 to 30 minutes following a meal
- steatorrhoea: symptoms of pancreatic insufficiency usually develop between 5 and 25 years after the onset of pain
- diabetes mellitus develops in the majority of patients - typically occurs more than 20 years after symptom begin
what are the investigations for chronic pancreatitis
- AXR shows pancreatic calcification in 30% cases but CT more sensitive
- faecal elastase to assess exocrine function if imaging inconclusive
