Acute Pancreatitis

Question 1

What is the acronym for remembering the causes of acute pancreatitis?

Answer 1

I GET SMASHED

Question 2

What does I GET SMASHED stand for?

Answer 2

Idiopathic, gallstones, ethanol, trauma, steroids, mumps, autoimmune, scorpion venom, hyperlipidaemia/hypercalcaemia/hypothermia, ERCP, drugs (diuretics/immunosuppressants)

Question 3

What percentage of cases are caused by gallstones and alcohol?

Answer 3

80%

Question 4

What occurs in acute pancreatitis?

Answer 4

Insult to the pancreas causes pancreatic enzymes to leak and autodigest the pancreas parenchyma causing damage and self perpetuating inflammation

Question 5

What response may be activated by acute pancreatitis?

Answer 5

The SIRS

Question 6

What are the two most severe complications of acute pancreatitis?

Answer 6

Haemorrhagic pancreatic necrosis

Infected pancreatic necrosis

Question 7

What percentage of cases are mild?

Answer 7

80%

Question 8

What are the symptoms of acute pancreatitis?

Answer 8

Generalised or sudden severe epigastric pain/central abdominal pain, pain radiates to the back, pain relieved by sitting forward, nausea and vomiting

Question 9

What are the signs of acute pancreatitis?

Answer 9

Tachycardia, shock, fever, ileus, guarding, left flank tenderness, Cullens sign, grey-turners sign

Question 10

What is Cullens sign?

Answer 10

Peri-umbilical discolouration

Question 11

What is grey-turners sign and what causes it?

Answer 11

Bruising on the left flank due to blood vessel autodigestion and haemorrhage

Question 12

What investigations would you do?

Answer 12

Amylase levels, serum lipase, LFTs, USS, AXR, CXR, CT, CRP

Question 13

At what level is amylase diagnostic?

Answer 13

When it is above 3 times the normal limit

Question 14

Why might amylase be normal?

Answer 14

As amylase levels fall within 24-48hrs

Question 15

What co-morbidity may increase the amylase levels?

Answer 15

Renal failure as this causes means less amylase is excreted

Question 16

What other conditions may raise amylase?

Answer 16

Cholecystitis, peptic ulcer, pregnancy, mesenteric infarction, rhabdomyolysis

Question 17

Why is serum lipase a better test?

Answer 17

It is both more sensitive and more specific

Question 18

What might an AXR show?

Answer 18

Loop of proximal jejunum on causes by local ileus known as a sentinel loop

Question 19

What might the CT show?

Answer 19

The extent of necrosis of the pancreas and the areas affected

Question 20

What are the early complications?

Answer 20

Hypovolemic shock, hypocalceamia, diabetes, DIC, respiratory failure, renal failure

Question 21

Late complications include? (After 1 week)

Answer 21

Pancreatic necrosis, pseudocyst with fever, abscesses, bleeding, thrombosis in splenic/gastroduodenal arteries causing bowel necrosis, fistula, recurrent oedematous pancreatitis

Question 22

What is the management? In mild patient

Answer 22

ABC assessment, oxygen, Severity assessment, nil by mouth, LOTS of IV saline (renal failure), urinary catheter, morphine, hourly monitoring, ITU if worsening

Question 23

If the patient is still worsening, what management would you do?

Answer 23

Antibiotics if >30% necrosis eg IV imipenem, pareneternal nutrition and necrosectomy, ERCP if there is progressive jaundice

Question 24

What differential would you consider?

Answer 24

Any acute abdomen but especially mesenteric infarction/perforated peptic ulcer

Question 25

What is the associated mortality of acute pancreatitis?

Answer 25

12%

Question 26

What does the PANCRES severity assessment stand corrected?

Answer 26

PaO2 (less than 8kPa), age (>55), neutrophillia, calcium low (most prognostic of death), renal function (urea above 16 (norm=1.8-7.1)), enzymes (raised LDH and AST), blood glucose above 10

Question 27

How many criteria must be met to be classed as severe?

Answer 27

3