Acute pancreatitis

Question 1

What is acute pancreatitis?

Answer 1

Inflammation of the pancrease due to enzymes mediated auto-digestion
Repeated episodes can lead to chronic pancreatitis.

Question 2

What are the different outcomes of acute pancreatitis?

Answer 2

Majority are Mild presentations - 1% mortality rate
Severe presentations in 5-10% of cases with 30% mortality rate

Question 3

What are the common symptoms of acute pancreatitis?

Answer 3

Severe epigastric pain, radiating through to the back, increasing over hrs, illimitable
Associated vomiting - pylorospasm frequent and effortless
Abdominal tenderness
Systemically unwell ( hypotensive and tachycardia, +/- fever)
Dehydration
Hematemesis and malena if necoris of duodenum - poor prognostic sign

Question 4

What are the most common causes of acute pancreatitis in the UK NHS?

Answer 4

Ethanol - directly toxic to pancreatic cells, inflammation, more common in men and younger patients
Gallstones - obstruction Ampulla of Vater, reflux of bile and pancreatic enzymes into pancreatic duct causes inflammation

Question 5

What are the different potential causes of acute pancreatitis?

Answer 5

Idiopathic - up to 20%
Gallstones - 50%
Ethanol - 25%
Trauma -
Steroids -
Mumps -
Autoimmune - SLE
Scorpion venom -
Hyperlipidaemia/hypercalcemia/hypothermia
ERCP
Drugs - NSAIDs, diuretics, azathioprine

I GET SMASHED

Question 6

What is the pathophysiological process underpinning acute pancreatitis?

Answer 6

Trigger premature and exaggerated activation of digestive enzymes within the pancreas.
Resulting inflammatory response increases vascular permeability, causing third spacing and hypotension.
Enzymes released from pancreas into retroperitoneal space - autodigestion of fats by lipases ‘fat necrosis’ and blood vessels (can cause hemorrhage in the retroperitoneal space)
Increase free fatty acids, react with serum calcium to form chalky deposits in tissue and hypocalcemia.
Severe end-stage pancreatitis will eventually result in partial or complete necrosis of the pancrea.

Question 7

What are the different special signs in acute pancreatitis that should be tested for?

Answer 7

Prayer sign - pain partially relived on bending forward
Cullens sign - bluish discoloration around umbilicus
Grey turners sign - bluish discolouration in the flanks

Cullnes and Greys due to peripancreatic and retroperitoneal hemorrhage

Question 8

What are the different clinical signs in acute pancreaticis?

Answer 8

Vitals - tachypneic, tachycardic (due to pain), hypovolemic shock
Abdominla - tenderness and rebound tenderness, guarding and rigidity, abdominal distention
Resp - dullness, creps and rhonchi, due to inflammatory response

Question 9

What are the key differences between acute and chronic pancreatitis?

Answer 9

Limited damage to secretory function of the gland
No structural damage

Question 10

What investigations should be done in a patient with suspected acute pancreatitis?**

Answer 10

Bloods - amylase (3x norm range), lipase (more specific), CRP, wcc, Hb (low if hemorrhagic)
LFTs, ALT> 1500 suggestive of a gallstone etiology
Albumin low - due to high vascularity permeability and third space loss
U&Es rule out kidney failure in severe patients
Serum calcium - if hypo consider ECG
Blood gluoce may increase
Urine dipstick - glycosuria in nearly all patients.

Question 11

What clinical signs are shown in these images?
What conditions do they indicate?

Answer 11

A - cullens sign
B - grey Turners sign
Indicate acute appendicitis due to peripancreatic and retroperitoneal haemorrhage.

Question 12

What is important to consider about blood amylase and lipase interpretation in suspected acute pancreatitis?

Answer 12

Must be 3x upper limit of normal to indicate diagnosis
Amylase peaks at 24-48hrs then returns to normal within 3-4days
Amylase can also be raised in bowel perforation, ectopic pregnancy and diabetic ketoacidosis.
Lipase more accurate as remains elevated longer than amylase.

Question 13

What imaging should be ordered for an acute pancreatitis?

Answer 13

CXR - pleural effusion, ARDS, rule out perfoarion of a peptic ulcer
USG abdomen - for gallstones, duct dilation
CE CT abdomen - gold standard, performed 6-10 days after admission to avoid AKI.

Question 14

What is the purpose of the Glasgow score in acute pancreatitis?

Answer 14

Assess severity of acute pancreatitis
Performed at 48hrs
A score of more than 3 indicates severe pancreatitis - should receive a critical care review.

Question 15

How do you calculate the glasgow score for a patient with acute pancreatitis?

Answer 15

PANCREAS
P - PaO2 , 8KPa
Age - >55yrs
Neutrophils WCC>15x10^9/L
Calcium <2mmol/L
Renal - Urea >16mmol/L
Enzymes LDH >600IU/L or AST >200 IU/L
Albumin < 32 G/L
Sugar Glucose >10mmol/L

Score one for each of the met criteria

Question 16

What conservative management should be used for patients with acute pancreatitis?

Answer 16

NBM - avoid vomit/nausea
IV fluids - combat dehydration/third spacing to support cardio system
Analgesics and antiemetics
Monitor urine output with a catheter
Antibiotics only if concurrent biliary tree infections or infected necrosis

Question 17

What is the surgical management for patients with suspected acute pancreatitis?

Answer 17

ERCP within 72hrs in severe pancreatitis where gallstones are the cause
No role for surgery in the initial period of resus and stabilisation

Question 18

What are some complications of acute pancreatitis?

Answer 18

Local - pancreatic necorisis, pancreatic pseduocyst, pseudoanurysm, venous thrombosis

Systemic - shock, ARDS, renal failure

Question 19

What is the key epidemiology of acute pancreatitis?

Answer 19

More common in middle aged in elderly
Women - more likely to be a gallstone in cause
Men - more likely to be alcohol in cause
Is a common emergency admission, 56 cases per 100,000 per year.