Acute Pancreatitis Flashcards
How can pancreatitis be classified?
Severity of organ injury
What are the different patterns of lobule injury?
Periductal necrosis
Panlobular necrosis
Perilobular necrosis
Describe periductal necrosis
Necrosis of acinal cells adjacent to ducts
Due to duct obstruction
Describe panlobular necrosis
Necrosis of whole acinar lobule
Generally due to drugs/toxins/viruses/metabolic insults
Spread from periductal necrosis
Describe perilobular necrosis
Necrosis of the peripheries of lobules
Due to poor vascular perfusion
What are the potential early complications of pancreatitis?
Shock ARDS Renal failure DIC Hypocalcaemia Hyperglycaemia
Describe the aetiology of acute pancreatitis
I GET SMASHED idiopathic (20%) gallstones (40%) ethanol (35%) trauma (15%) steroids mumps (CMV/EBV) autoimmune scorpion venom hyper/hypos (lipids, calcium, thermia) ERCP drugs (thiazies, sulphonamides, ACEIs, NSAIDs)
What is the pathology underlying pancreatitis?
Original insult –> activated pancreatic enzymes –> acute inflammatory reaction –> local tissue necrosis –> ECF collects in gut/peritoneum/retroperitoneum
What are the Sx of acute pancreatitis?
Gradual/sudden onset severe epigastric pain
Radiates to back/relieved by sitting fowards
NAUSEA/VOMITING
What are the signs of acute pancreatitis?
Tachycardia Fever Ileus Jaundice (30%) Rigid abdomen Cullen's sign Grey-Turner's sign
What is Cullen’s sign?
Periumbilical discolouration due to haemmorhage into peritoneal space
What is Grey-Turner’s sign?
Discolouration in flanks
What blood tests are appropriate when investigating suspected acute pancreatitis?
Baseline FBC, CRP, U&Es, LFT, glucose, Ca
Serum amylase (v. sensitive w/i 24 hrs)
Serum lipase
ABG
What imaging is appropriate when investigating suspected acute pancreatitis?
AXR (sentinel loop/small bowel ileus) Erect CXR (perforations) CT (enlarged pancreas) MRCP Endoscopic USS REPEAT TEST AT 48/72 HRS TO ESTABLISH EXTENT OF NECROSIS
What scoring systems can be used to predict the prognosis for acute pancreatitis?
Modified Glasgow Criteria
APACHE II
Ranson criteria
Describe the Modified Glasgow Criteria
3 or more +ve factors w/i 48 hrs of onset suggests severe pancreatitis - PANCREAS
- PaO2 <8kPa
- Age >55
- Neutrophils (WBC >15*10^9/L)
- Calcium <2mmol/L
- Renal urea >16mmol/L
- Enzymes (LDH >600iu/L, AST >200iu/L)
- Albumin <32g/L
- Sugar (glucose >10mmol/L)
Describe APACHE II
Allocates points for assessment of clinical parameters (A), age (B) and co-morbidities (C)
>9 indicates severe pancreatitis
Describe the Ranson criteria
Includes age + lab scores on admission + clinical findings at 48 hrs to give mortality risk
What are the potential late complications of acute pancreatitis?
Pancreatic pseudocyst Abscesses Bleeding (elastase eroding major vessel) Fistulae Thrombosis of splenic/gastroduodenal aa (bowel necrosis)
What is the immediate management of acute pancreatitis?
A-E resus IV fluids, catheterise Hrly monitoring - BP, pulse, urine output Daily bloods - FBC, U&Es, Ca, glucose, ABG Analgesia NBM NG tube suction (if ileus/emesis) PPI (prevent stress ulcer) Anticoagulation Consider ITU admission
What additional management steps may be needed to treat the early complications of acute pancreatitis?
Antibiotics (severe cases) Laparotomy/debridement (abscess/pancreatic necrosis) Urgent ERCP (gallstones)
What is the prognosis of acute pancreatitis?
Unpredictable condition
- 85% settle w/i 3-7 days
- 15% require ICU admission (50% of these die)
What are the potential metabolic complications of acute pancreatitis?
Hyperglycaemia
Hypocalcaemia
Reduced serum albumin
Malabsorption (reduced vit levels)
