Acute pancreatitis

Question 1

what is acute pancreatitis?

Answer 1

inflammation on a background of a normal anatomical and functional pancreas.

Pancreas returns to normal

Question 2

What is chronic pancreatitis?

Answer 2

inflammation of the pancreas that is recurrent and leads to irreversible structural changes,

Question 3

What are the causes of acute pancreatitis?

I GET SMASHED

Answer 3

I GET SMASHED
I - idiopathic
G - gall stones (40%)
E - alcohol excess
T - trauma
S - steroids
M- mumps (coxsackie B)
A - autoimmune (tumour)
S - scorpion stings
H - hyperlipidaemia / Hypercalcaemia
E - ERCP
D - drugs (azathioprine, diuretics like furosemide, oestrogens, corticosteroids, didanosine, Abx like tetracycline)

Question 4

What are the symptoms of acute pancreatitis?

Answer 4

SOCRATES
S - epigastric pain
O - after alcohol binge
C - severe, agonising
R - bores through to back
A - gallstones, nausea, vomiting, retching, fever
T - constant
E - aggravated by eating fatty food.
S - SEVERE.

(peritonitis as inflammation spreads through abdo)

Question 5

What are the signs of acute pancreatitis on examinationʔ

Answer 5

• swollen , tender abdo
• gaurding
• decreased or absent bowel sounds
• fever
• increased heart rate
• hypotension
• oliguric (decreased urine ouput)

ɴecrotising pancreatitisː

• Cullen’s (periumbical bruising
• ɢrey-turner’s sign (flank bruising)

-jaundice or cholangitis (gallstone obstruction)

Question 6

What Blood investigations are done for suspected acute pancreatitis

Answer 6

1) BʟOODSː
- serum amylase (raised 3X)
- urinary amylase (raised)
- serum lipase (raised)
- CʀP
- FBC, U&E, ʟFT,
- ɢlucose
- Plasma Calcium
- ABɢ at 24hs and 48hrs

Question 7

What does the serum amylase show in acute pancreatitisʔ

Answer 7

• serum amylase will be 3X the normal upper limit when measured within 24hrs of onset of pain ( 300+ is deffo acute pancreatitis), they then fall over the next 3 to 5 days.

Question 8

What are the other causes of elevated serum amylase other than pancreatitisʔ

Answer 8

• upper ɢɪ perforation
• biliary peritonitis
• intestinal infarction
• congenital macroamylasaemia

Question 9

What radiological invx are done for acute pancreatitisʔ

Answer 9

1) CXʀ (to exclude gastroduodenal perforation as the cause of raised serum amylase)
2) Abdo USS (gallstoneʔ bile duct obstructionʔ)
3) contrast enhanced CT (essential for all but mild attacks of pancreatitis to assess pancreatic necrosis)
4) MʀCP (Mʀɪ to asses pancreatic damage and gallstones in biliary tree)
5) ECʀP (to remove bile duct stones)

Question 10

Why do we do CXʀ for acute pancreatitisʔ

Answer 10

• to exclude gastrodudoenal perforation as the cause of raised amylase.
• gallstone / pancreatic calcifation

Question 11

Why is essential to do contrast enhanced spiral CT for acute pancreatitisʔ

Answer 11

Contrast enchanced spiral CT is necessary for all but mild attacks.

Do after 72hrs to asses pancreatic necrosis and complications.

Question 12

What are the complications of pancreatitisʔ

Answer 12

• haemodynamic instability

- multiple organ failure

Question 13

What is the assessment for predicting severity of acute pancreatitisʔ

Answer 13

Modified ranson and glasgow criteriaː
ɪf 3 or more of the following within the 1st 48hours than send to ɪTU.

PAɴCʀEAS

P - PaO2 <8KPa

A - Age >55

ɴ - ɴeutrophils WCC > 15 x 10^9

C - Calcium < 2mmol/ʟ

ʀ - ʀenal function urea > 16mmol/ʟ

E - enzymes ʟDɢ > 600ɪU/ʟ, AST > 200 ɪU/ʟ

A - albumin < 32g/ʟ

S - sugar blood glucose > 10mmol/ʟ

Question 14

What is the APACʜE scoreʔ

Answer 14

APACʜE score = acute physiology and chronic health evalutation score it is used to predict severity in a number of diseases. ɪt is adjusted fo age and other chronic health problems.

ɪt is very sensitive even in the 1st 24hrs of acute pancreatitis presentation

Question 15

ɢallstones cause 40% of acute pancreatitis.

ɪf no gallstone is found on USS , what other test can indicate its prescence and cause of acute pancreatitisʔ

Answer 15

AʟT (alanine transminase ) will be elevated 2X the upper limit - this is highly suggestive of a gallstone cause of acute pancreatitis.

Question 16

ʜow is a patient with acute pancreatitis managedʔ

Answer 16

VACCɪɴESː

V - vital signs monitoring (hourly pulse, bp, sats, urine output, is Oxygen necessaryʔ give anticoagulant lmw heparin)

A - Analgesia (tramadol - don’t give morphine as risk of sphincter of oddi spasm)
- Antibiotic prophylaxis (imipenem - reduces incidence of necrosis)

C - catheter to monitor urine output

C - calcium gluconate if hypocalcaemic

ɪ - ɪV acccess and fluids

ɴ - ɴBM + ɴɢ tube parental feeding

E - emptying gastric contents (ɴɢ tube suction reduces risk of vomiting and aspiration)

S - surgery if required

Question 17

What are the differential diagnosis of acute pancreatitisʔ

Answer 17

• Mɪ
• leaking AAA
• pneumonia

Acute Abdoː

• rupture of organ (spleen /colon / oesophagus)
• peritonitis
• colic (biliary colic)
• peptic ulcer
• acute cholecystitis
• ɪBS
• mesenteric ischaemia
• rupture spleen
• gastric ulcer
• duodenal ulcer
• hepatitis

Question 18

how long does it take for pancreatitis to resolveʔ

Answer 18

80% acute pancreatitis is self limiting within 48-72 hours

Question 19

What is the prognosis of acute pancreatitis associated withʔ

Answer 19

Prognosis after 7 days correlates with the extent of pancreatic necrosis which is assessed by CT.

Question 20

What are the complications of Acute pancreatitisʔ

Answer 20

PAɪɴ ː

P- peripancreatic fluid collections / Pseudocysts

A - abscesses

ɪ - ɪnfection (sepsis)

ɴ - necrosis

Question 21

what is cullen’s and grey-tuner’s brusing a sign ofʔ

Answer 21

pancreatic necrosis

cullens = periumbical bruising

ɢrey-turners = flank bruising