Acute pancreatitis

Question 1

What is the definition of acute pancreatitis?

Answer 1

Inflammation of the pancreas due to acute injury

Question 2

What is the incidence of acute pancreatitis?

Answer 2

Incidence of 150 to 420 cases per million population and is currently rising

Question 3

What is the pathology of acute pancreatitis?

Answer 3

• Gallstones – obstruction of drainage of pancreas leads to a build up of trypsin and Ca leading to acinar cell damage
• Alcohol – interferes with calcium homeostasis causing damage to cells. Also activates pancreatic stellate cells to produce collagen and matrix proteins

Question 4

What are the risk factors/aetiology of acute pancreatitis?

Answer 4

• Gallstones
• Alcohol
• Iatrogentic e.g. surgery
• Infection (mumps, coxsackie B)
• Pancreatic tumour
• Hyperlipidaemias
• Idiopathic
• Drugs (azathioprine, oestrogens, corticosteroids, didanosine = HIV/AIDS treatment)

Question 5

What are the signs and symptoms of acute pancreatitis?

Answer 5

• Sudden onset upper abdomen pain – as inflammation spreads the pain becomes more intense and can go to the back
• Pyrexia
• Hypotension
• Tachycardia
• ↑ white cell count
• Reduce/absent bowel sounds
• Oliguria - ↓ urine output
• Nausea/Vomiting
• Cullens and Grey Turners sign – necrotizing pancreatitis
• Jaundice, cholangitis – if caused by gallstones

Question 6

What other diseases does acute pancreatitis present similarly to?

Answer 6

• Cholecystitis – inflammation of the gallbladder
• Cholangitis – inflammation of the bile duct
• Hepatitis
• Pancreatic malignancy
• Pancreatic pseudocysts

Question 7

What investigations are carried out for suspected acute pancreatitis?

Answer 7

• Bloods – FBC, U&E’s, glucose, LFT’s, Ca, ARB, ECR, C-Reactive protein, serum amylase (3x normal level with 24h of pain diagnostic), serum lipase
• Urinary amylase
• CXR – rules out gastroduodenal perforation
• Abdominal US – gallstones
• Contrast enhanced CT – should be routinely performed 72h after attack
• MRI – assess between fluid and solid inflammatory masses

Question 8

What are the surgical treatments for acute pancreatitis?

Answer 8

• ERCP (Endoscopic retrograde cholangio-pancreatography) – removes gallstones from the bile duct
• Nasogastric suction
• Nil by mouth
• Cholecystectomy
• Positive pressure ventilation – if severe
• Kidney support – if severe

Question 9

What are the pharmacological treatments for acute pancreatitis?

Answer 9

• Fluids – with urinary catheter to monitor fluid loss
• Anticoagulants
• Prophylaxis antibiotics
• Parenteral nutrition
• Analgesia – tramadol/other opiates
• H2 receptor antagonists/PPI

Question 10

What are the non- pharmacological treatments for acute pancreatitis?

Answer 10

• APACHE II multiple factor scoring system