Acute Pancreatitis

Question 1

what is acute pancreatitis

Answer 1

inflammation of the pancreas

Question 2

how can acute and chronic pancreatitis be distinguished

Answer 2

in acute pancreatitis, there is limited damage to the secretory function of the gland
- but repeat episodes of acute panc –> chronic

Question 3

what are the 2 main causes of acute pancreatitis

Answer 3

1. gallstone disease
   2 . excessive alcohol consumption

Question 4

what are other causes of acute pancreatitis

Answer 4

Gallstone
Ethanol
Trauma

Steroids
Mumps
Autoimmune e.g. SLE or Sjogren’s
Scorpion venom
Hypercalcaemia
ERCP
Drugs e.g, azathioprine, NSAIDs, diuretics

Question 5

explain the pathophysiology of acute pancreatitis

Answer 5

• 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

Question 6

what can severe end-stage pancreatitis eventually lead to

Answer 6

partial or complete necrosis of the pancreas

Question 7

what is the presentation of a pt w acute pancreatitis

clinical feautures, examination

Answer 7

• 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

Question 8

give some ddx for acute pancreatitis

Answer 8

• AAA
• renal calculi
• chronic pancreatitis
• aortic dissection
• peptic ulcer disease

Question 9

what lab tests should be considered in acute pancreatitis

Answer 9

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

Question 10

what scoring system is used to assess the severity of acute pancreatitis

Answer 10

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

Question 11

what imaging might be indicated in acute pancreatitis and what are the findings of each

Answer 11

• 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

Question 12

what is the management plan for acute pancreatitis

Answer 12

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

Question 13

how is severe acute pancreatitis managed

Answer 13

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

Question 14

what are some systemic complications of acute pancreatitis (4)

Answer 14

• DIC
• ARDS
• hypocalcaemia
• hyperglycaemia: secondary to destruction of islets of Langerhans and disturbances to insulin metabolism

Question 15

what are local complications of acute pancreatitis

Answer 15

• pancreatic necrosis
• pancreatic pseudocyst

Question 16

why does pancreatic necrosis arise and how is it treated

Answer 16

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!

Question 17

what is a pancreatic pseudocyst and where are they most commonly found

Answer 17

collection of fluid containing pancreatic enzymes, blood, and necrotic tissue
- usually seen in the lesser sac obstructing the gastro-epiploic foramen by inflammatory adhesion

Question 18

how are pancreatic pseudocysts formed

Answer 18

week after intial acute pancreatitis epsiode
- lack epithelial lining and instead have a vascular and fibrotic wall surrounding collection

Question 19

how are pancreatic pseudocysts treated

Answer 19

50% resolve spontaneously
- if >6 weeks then unlikely to resolve so consider surgical debridement or endoscopic drainage

Question 20

what helps chronic pancreatitis patients digest food

Answer 20

replacement of pancreatic enzymes e.g. Creon

Question 21

what are other causes of chronic pancreatitis other than alcohol

Answer 21

• CF, HH
• tumours, stones

Question 22

what are features of chronic pancreatitis

Answer 22

• 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

Question 23

what are the investigations for chronic pancreatitis

Answer 23

• AXR shows pancreatic calcification in 30% cases but CT more sensitive
• faecal elastase to assess exocrine function if imaging inconclusive