Acute Pancreatitis

Question 1

How can pancreatitis be classified?

Answer 1

Severity of organ injury

Question 2

What are the different patterns of lobule injury?

Answer 2

Periductal necrosis
Panlobular necrosis
Perilobular necrosis

Question 3

Describe periductal necrosis

Answer 3

Necrosis of acinal cells adjacent to ducts

Due to duct obstruction

Question 4

Describe panlobular necrosis

Answer 4

Necrosis of whole acinar lobule
Generally due to drugs/toxins/viruses/metabolic insults
Spread from periductal necrosis

Question 5

Describe perilobular necrosis

Answer 5

Necrosis of the peripheries of lobules

Due to poor vascular perfusion

Question 6

What are the potential early complications of pancreatitis?

Answer 6

Shock
ARDS
Renal failure
DIC
Hypocalcaemia
Hyperglycaemia

Question 7

Describe the aetiology of acute pancreatitis

Answer 7

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)

Question 8

What is the pathology underlying pancreatitis?

Answer 8

Original insult –> activated pancreatic enzymes –> acute inflammatory reaction –> local tissue necrosis –> ECF collects in gut/peritoneum/retroperitoneum

Question 9

What are the Sx of acute pancreatitis?

Answer 9

Gradual/sudden onset severe epigastric pain
Radiates to back/relieved by sitting fowards
NAUSEA/VOMITING

Question 10

What are the signs of acute pancreatitis?

Answer 10

Tachycardia
Fever
Ileus
Jaundice (30%)
Rigid abdomen
Cullen's sign
Grey-Turner's sign

Question 11

What is Cullen’s sign?

Answer 11

Periumbilical discolouration due to haemmorhage into peritoneal space

Question 12

What is Grey-Turner’s sign?

Answer 12

Discolouration in flanks

Question 13

What blood tests are appropriate when investigating suspected acute pancreatitis?

Answer 13

Baseline FBC, CRP, U&Es, LFT, glucose, Ca
Serum amylase (v. sensitive w/i 24 hrs)
Serum lipase
ABG

Question 14

What imaging is appropriate when investigating suspected acute pancreatitis?

Answer 14

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

Question 15

What scoring systems can be used to predict the prognosis for acute pancreatitis?

Answer 15

Modified Glasgow Criteria
APACHE II
Ranson criteria

Question 16

Describe the Modified Glasgow Criteria

Answer 16

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)

Question 17

Describe APACHE II

Answer 17

Allocates points for assessment of clinical parameters (A), age (B) and co-morbidities (C)
>9 indicates severe pancreatitis

Question 18

Describe the Ranson criteria

Answer 18

Includes age + lab scores on admission + clinical findings at 48 hrs to give mortality risk

Question 19

What are the potential late complications of acute pancreatitis?

Answer 19

Pancreatic pseudocyst
Abscesses
Bleeding (elastase eroding major vessel)
Fistulae
Thrombosis of splenic/gastroduodenal aa (bowel necrosis)

Question 20

What is the immediate management of acute pancreatitis?

Answer 20

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

Question 21

What additional management steps may be needed to treat the early complications of acute pancreatitis?

Answer 21

Antibiotics (severe cases)
Laparotomy/debridement (abscess/pancreatic necrosis)
Urgent ERCP (gallstones)

Question 22

What is the prognosis of acute pancreatitis?

Answer 22

Unpredictable condition

• 85% settle w/i 3-7 days
• 15% require ICU admission (50% of these die)

Question 23

What are the potential metabolic complications of acute pancreatitis?

Answer 23

Hyperglycaemia
Hypocalcaemia
Reduced serum albumin
Malabsorption (reduced vit levels)