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z - Gastrointestinal > Acute Pancreatitis > Flashcards

Acute Pancreatitis Flashcards

1
Q

What is acute pancreatitis characterised by?

A

Self-perpetuating pancreatic enzyme-mediated autodigestion

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2
Q

What can cause hypovolaemia in acute pancreatitis?

A

Oedema and fluid shifts

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3
Q

What fluid shifts cause hypovolaemia in acute pancreatitis?

A

Extracellular fluid gets trapped in the gut, peritoneum, and retroperitoneal space

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4
Q

What % of acute pancreatitis cases are mild?

A

80%

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5
Q

What will 20% of acute pancreatitis cases develop to?

A

Serious and life threatening disease

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6
Q

How fast does the progression of acute pancreatitis occur?

A

May be rapid

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7
Q

What can severe cases of acute pancreatitis develop into?

A

Necrotising pancreatitis

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8
Q

What may cases of necrotising pancreatitis be further complicated by?

A

Infection

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9
Q

What % of cases of necrotising pancreatitis are further complicated by infection?

A

50%

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10
Q

When does acute pancreatitis occur?

A

When there is abnormal activation of digestive enzymes within the pancreas

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11
Q

What causes the abnormal activation of digestive enzymes in acute pancreatitis?

A

Inappropriate activation of inactive enzyme precursors called zymogens inside the pancreas, most notably trypsinogen

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12
Q

What normally happens to trypsinogen?

A

It is converted to it’s active form (trypsin) in the duodenum

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13
Q

What is the physiological role of trypsin?

A

To aid in the digestion of proteins

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14
Q

What happens to trypsinogen during an episode of acute pancreatitis?

A

Trypsinogen comes into contact with cathpepsin, which is a lysosomal enzyme, which activates it

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15
Q

What does the inappropriate activation of trypsinogen to trypsin in acute pancreatitis cause?

A
  • Inflammation
  • Oedema
  • Vascular injury
  • Cell death via necrosis or apoptosis
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16
Q

What can pancreatitis be classified into?

A

Mild and severe

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17
Q

What is the classification of pancreatitis based on?

A

Wether the predominant response to cell injury is inflammation (mild) or necrosis (severe)

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18
Q

What happens in mild pancreatitis?

A

There is inflammation and oedema of the pancreas

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19
Q

What happens in severe pancreatitis?

A

There is necrosis of the pancreas, and nearby organs may become injured

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20
Q

What are the causes of acute pancreatitis?

A
  • Gallstones
  • Alcohol
  • Trauma
  • Steroids
  • Mumps
  • Autoimmune
  • Scorpion venom
  • Hyperlipidaemia
  • Hypothermia
  • Hypercalcaemia
  • ERCP
  • Emboli
  • Drugs
  • Pregnancy
  • Neoplasia
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21
Q

What are the symptoms of acute pancreatitis?

A
  • Pain
  • Nausea and vomiting
  • Diarrhoea
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22
Q

Describe the pain in acute pancreatitis?

A

It is gradual or sudden onset severe epigastric or central abdominal pain, which radiates o the back

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23
Q

What might relieve the pain in pancreatitis?

A

Sitting forwards

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24
Q

What are the signs of acute pancreatitis?

A
  • Increased HR
  • Fever
  • Jaundice
  • Shock
  • Ileus
  • Rigid abdomen, with local or general tenderness
  • Periumbilical bruising, or bruising in flanks
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25
Q

What investigations can be done into acute pancreatitis?

A
  • Serum amylase and lipase
  • ABG
  • AXR
  • Other imaging
  • CRP
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26
Q

What is considered to be raised serum amylase?

A

>1000u/mL

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27
Q

Is the degree of elevation of serum amylase related to the severity of the disease in acute pancreatitis?

A

No

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28
Q

Why may serum amylase be misleading in acute pancreatitis?

A

It can be normal, even in severe pancreatitis

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29
Q

How is amylase secreted?

A

Renally

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30
Q

What is the result of amylase being excreted renally?

A

Renal failure will increase levels

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31
Q

Is serum amylase a specific test for acute pancreatitis?

A

No

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32
Q

What other conditions can cause raised serum amylase?

A
  • Cholecystitis
  • Mesenteric infarction
  • GI perforation
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33
Q

How does serum amylase rises in cholecystitis, mesenteric infarction, and GI perforation compare to in acute pancreatitis?

A

These conditions cause the levels to rise less than in acute pancreatitis

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34
Q

How does testing serum lipase compare to serum amylase in acute pancreatitis?

A

It is more sensitive and specific for pancreatitis, especially when related to alcohol, rises earlier, and falls later

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35
Q

What may be shown on an AXR in acute pancreatitis?

A
  • No psoas shadow
  • ‘Sentinel loop’ of proximal jejunum from ileus
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36
Q

Why is there no psoas shadow on AXR in acute pancreatitis?

A

Due to increased retroperitoneal fluid

37
Q

Other than AXR, what imaging modalities can be used in suspected acute pancreatitis?

A
  • CT
  • Erect CXR
  • Ultrasound
38
Q

How is CT used in acute pancreatitis?

A

It is the standard choice of imaging to assess severity and for complications

39
Q

What are erect CXR used for in acute pancreatitis?

A

Rule out other causes, e.g. bowel perforation

40
Q

What are ultrasounds used for in acute pancreatitis?

A

May be used if there is suspected gallstones or increased AST

41
Q

What can CRP be used for in acute pancreatitis?

A

As an indicator of severity

42
Q

What CRP is an indicator of severe pancreatitis?

A

>150mg/L at 36 hours after admission

43
Q

How is the Modified Glasgow Criteria used in acute pancreatitis?

A

It is used to predict the severity of acute pancreatitis

44
Q

What suggests severe pancreatitis in the Modified Glasgow criteria?

A

Three or more positive factors detected within 48 hours of onset

45
Q

What are the factors in the Modified Glasgow Criteria for acute pancreatitis?

A
  • PaO2 <8kPa
  • Age >55years
  • WBC >15x109/L
  • Calcium <2mmol/L
  • Urea >16mmol/L
  • Albumin <32g/L
  • Blood glucose >10mmol/L
46
Q

Where are mild cases of acute pancreatitis managed?

A

General ward

47
Q

What is involved in the management of mild acute pancreatitis?

A
  • Pain relief
  • IV fluids with NBM
  • Antibiotics for specific infections
  • NG tubes
48
Q

What pain relief should be given in acute pancreatitis?

A

Buprenorphine, with or without IV benzodiazepines

49
Q

Is morphine used in the management of acute pancreatitis?

A

No, it is relatively contraindicated

50
Q

Why is morphine relatively contraindicated in acute pancreatitis?

A

Due to possible spastic effect on the sphincter of Oddi

51
Q

When might NSAIDs be effective in acute pancreatitis?

A

In the recovery phase

52
Q

When should a NG tube be used in acute pancreatitis?

A

Only for severe vomiting

53
Q

Is a CT scan necessary in mild acute pancreatitis?

A

No

54
Q

When can oral fluids be resumed in acute pancreatitis?

A

When pain and other symptoms have resolved and blood tests are normal

55
Q

Should oral fluids and solids be resumed at the same time following acute pancreatitis?

A

No, solids should be resumed a bit after

56
Q

What can be considered in the management of mild acute pancreatitis when gallstones are the cause?

A

Common bile duct clearance and cholecystectomy after recovery

57
Q

Where should severe cases of acute pancreatitis be treated?

A

ITU, or in high dependency unit

58
Q

What treatment should be given in severe acute pancreatitis?

A
  • Antibiotics
  • Enternal nutrition via NG tube
  • Fluid replacement and pain relief
  • Early ERCP if co-existing cholangitis or biliary obstruction
59
Q

When should IV antibiotics be given in severe acute pancreatitis?

A

When there is evidence of significant pancreatic necrosis

60
Q

Why should patients with severe acute pancreatitis be fed with enternal nutrition via a NG tube?

A

It has been shown to significantly reduce mortality, multiple organ failure, systemic infections, and the need for operative interventions

61
Q

When is surgery required in severe acute pancreatitis?

A

Only when there is infection and necrosis

62
Q

What was the original surgical treatment for severe acute pancreatitis?

A

Open surgical debridement

63
Q

What is open surgical debridement be largely replaced by in severe acute pancreatitis?

A

Newer, minimally invasive techniques such as transgastric endoscopy

64
Q

What procedure can sometimes avoid surgery in acute severe pancreatitis?

A

Percutaneous catheter drainage wtih saline irrigation

65
Q

What are the early complications of acute pancreatitis?

A
  • Shock
  • ARDS
  • Renal failure
  • DIC
  • Sepsis
  • Hypocalcaemia
  • Hyperglycaemia
66
Q

What are the late complications of acute pancreatitis?

A
  • Pancreatic necrosis and pseudocyst
  • Abscess
  • Bleeding
  • Thrombosis
  • Fistulae
67
Q

What causes pancreatic necrosis as a complication of acute pancreatitis?

A

Ongoing inflammation eventually leads to ischeamic infarction of the pancreatic tissue

68
Q

When should pancreatic necrosis be considered in an acute pancreatitis patient?

A

When patients have evidence of persistent systemic inflammation for more than 7-10 days after the onset of pancreatitis

69
Q

How should any suspected pancreatic necrosis be confirmed?

A

By CT scan

70
Q

What will treatment of pancreatic necrosis often warrant?

A

Pancreatic necrosectomy (open or endoscopic)

71
Q

What is pancreatic necrosis prone to?

A

Infection

72
Q

When should pancreatic necrosis be suspected, related to it being prone to infection?

A

If there is a clinical deterioration in the patient associated with raised infection markers

73
Q

How can definitive diagnosis of pancreatic necrosis be made?

A

By fine needle aspiration of the necrosis

74
Q

What is the problem with fine needle aspiration of pancreatic necrosis?

A

It can be associated with a risk of seeding infection, therefore must be performed with care

75
Q

What is the general consensus for intervention in cases of confirmed pancreatitis?

A

That it should be delayed until walled-off necrosis has been developed, typically 3-5 weeks after the onset of symptoms

76
Q

What is a pancreatic pseudocyst?

A

A collection of fluid within the pancreatic tissue

77
Q

When is a pancreatic pseudocyst typically formed?

A

Weeks after the initial acute pancreatitis episode

78
Q

How does a pancreatic pseudocyst form?

A

The inflammation reaction produces a necrotic space in the pancreas that fills with pancreatic fluid, surrounding by fibrous tissue

79
Q

Why is a pancreatic pseudocyst so named, rather than a pancreatic cyst?

A

Because it lacks epithelial or endothelial cells surrounding the collection

80
Q

How do pseudocysts present?

A

They may present incidentally on imaging, or can prsent with symptoms of mass effects

81
Q

What symptoms of mass effects might pancreatic pseudocysts present with?

A
  • Biliary obstruction
  • Gastric outlet obstruction
82
Q

What can complicate pancreatic pseudocysts?

A
  • Haemorhage
  • Rupture
  • Infected
83
Q

When are cysts unlikely to resolve spontaneously?

A

When they have been present for longer than 6 weeks

84
Q

What are the treatment options for pancreatic pseudocysts?

A
  • Surgical debridement
  • Endoscopic drainage (often into the stomach)
85
Q

What causes bleeding in acute pancreatitis?

A

Elastases eroding into a major vessel, e.g. the splenic artery

86
Q

How is bleeding in acute pancreatitis managed?

A

Embolisation - may be life-saving

87
Q

Where can thrombosis occur in acute pancreatitis?

A
  • Splenic or gastroduodenal arteries
  • Colic branches of the SMA
88
Q

What can thrombosis in acute pancreatitis cause?

A

Bowel necrosis

z - Gastrointestinal (6 decks)

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