Acute Pancreatitis

Question 1

pathophysiology of acute pancreatitis

Answer 1

pancreatic enzymes released & activated in vicious circle

1. oedema + fluid shift + vomiting -> hypovolaemic shock & autodigestion by enzymes and fat necrosis
2. vessel autodigestion -> retroperitoneal haemorrhage
3. inflammation -> pancreatic necrosis
4. super-added infection (50% pts with necrosis)

Question 2

epidemiology of acute pancreatitis (age, mortality rate)

Answer 2

4th & 5th decades

10% mortality

Question 3

causes of acute pancreatitis

Answer 3

GET SMASHED
gallstones (45%)
ethanol (25%)
idiopathic (20%)
trauma
steroids
mumps 
autoimmune
scorpion
hyperlipidaemia
ERCP (5% risk)
drugs (thiazides, azathioprine)

Question 4

symptoms of acute pancreatitis

Answer 4

severe epigastric pain -> back (maybe relieved on sitting forward)
vomiting

Question 5

signs of acute pancreatitis

Answer 5

increase HR, increase RR
fever
hypovolaemia -> shock
epigastric tenderness
jaundice
ileus (absent bowel sounds)
ecchymoses 
- Grey Turners (flank)
- Cullens (periumbilical)

Question 6

Severity of acute pancreatitis

Answer 6

1 = mild
2 = mod
3 = severe
PaO2 <8kPa
Age >55yrs
Neutrophils >15 x109/L
Ca2+ <2mM
Renal function U>16mM
Enzymes LDH>600iu/L, AST>200 iu/L
Albumin <32g/L
Sugar >10mM

Question 7

blood tests for acute pancreatitis

Answer 7

FBC: ↑WCC
↑amylase (>1000 / 3x ULN) and ↑lipase
↑ in 80%
Returns to normal by 5-7d
U+E: dehydration and renal failure
LFTs: cholestatic picture, ↑AST, ↑LDH
Ca2+: ↓
Glucose: ↑
CRP: monitor progress, >150 after 48hrs = sev
ABG: ↓O2 suggests ARDS

Question 8

urine test for acute pancreatitis

Answer 8

Urine: glucose, ↑cBR, ↓urobilinogen

Question 9

imaging for acute pancreatitis

Answer 9

CXR: ARDS, exclude perfed DU
AXR: sentinel loop, pancreatic calcification
US: Gallstones and dilated ducts, inflammation
Contrast CT: Balthazar Severity Score

Question 10

conservative management of acute pancreatitis

Answer 10

constant reassessment 
fluid resus
pancreatic rest
analgesia
antibiotics

Question 11

interventional management of acute pancreatitis

Answer 11

ERCP

• if pancreatitis with dilated ducts secondary to gallstones
• ERCP + sphincterotomy → ↓ complications

Question 12

indication for surgical management of acute pancreatitis

Answer 12

Infected pancreatic necrosis
Pseudocyst or abscess
Unsure Dx

Question 13

surgical options for acute pancreatitis

Answer 13

Laparotomy + necrosectomy (pancreatic debridement)
Laparotomy + peritoneal lavage
Laparostomy: abdomen left open with sterile packs in ITU

Question 14

early complications of acute pancreatitis

Answer 14

Respiratory: ARDS, pleural effusion
Shock: hypovolaemic or septic
Renal failure
DIC
Metabolic (↓ Ca2+, ↑ glucose, Metabolic acidosis)

Question 15

late (>1 week) complications of acute pancreatitis

Answer 15

Pancreatic infection
Pancreatic abscess (May form in pseudocyst or in pancreas, Open or percutaneous drainage)
Bleeding: e.g. from splenic artery (May require embolisation)
Thrombosis (Splenic A., GDA or colic branches of SMA
May → bowel necrosis, Portal vein → portal HTN)
Fistula formation (Pancreato-cutaneous → skin breakdown)

Question 16

what is a pancreatic pseudocyst?

Answer 16

collection of pancreatic fluid in lesser sac surrounded by granulation tissue (occurs in 20%)

Question 17

presentation of pancreatic pseudocyst

Answer 17

4-6wks after acute attack
Persisting abdominal pain
Epigastric mass → early satiety

Question 18

complications of pancreatic pseudocyst

Answer 18

Infection → abscess

Obstruction of duodenum or CBD

Question 19

tests for pancreatic pseudocyst

Answer 19

Persistently ↑ amylase ± LFTs

US / CT

Question 20

treatment of pancreatic pseudocyst

Answer 20

<6cm: spontaneous resolution

>6cm (Endoscopic cyst-gastrostomy, Percutaneous drainage under US/CT)