Acute Pancreatitis Flashcards
What is acute pancreatitis and how is it distinguished from chronic pancreatitis?
Inflammation of the pancreas
Limited damage to secretory function of the gland with no gross structural damage developing
What are causes of acute pancreatitis?
GET SMASHED Gallstones Ethanol Trauma Steroids Mumps Antoimmune disease (SLE) Scorpion venom Hypercalcaemia Endoscopic retrograde cholagio-pancreatography (ERCP) Drugs such as azathioprine, NSAIDs or diuretics
Also, pregnancy, neoplasia, no cause
What is the pathogenesis of acute pancreatitis?
Each cause triggers a premature and exaggerated activation of digestive enzymes within the pancreas.
This results in pancreatic inflammatory response causing an increase in vascular permeability and fluid loss into the third space (e.g. peritoneal cavity - trans cellular space)
Enzymes are released from pancreas into systemic circulation causing autidgestion of fats leading to fat necrosis and blood vessels, sometimes leading to haemorrhage. Fat necrosis can cause the release of free fatty acids reading with serum Ca to form chalky deposits, resulting in hypocalcaemia.
Severe end stage pancreatitis results in partial or complete necrosis of the pancreas.
What are the symptoms of pancreatitis?
Sudden onset of severe epigastric pain, which can radiate through the back - sitting forward may relieve
Nausea and vomiting
What are the signs of pancreatitis?
Epigastric tenderness
SNT bowel or
Guarding, rigid abdomen
Tachycardia, faves, jaundice, shock ileus, local/general tenderness
Grey Turner’s sign - bruising in the flanks from retroperitoneal haemorrhage
Cullen’s sign - bruising around the umbilicus from blood vessel auto digestion
Tetany from hypocalcaemia secondary to fat necrosis and any gallstone pathology
What are differentials for abdominal pain radiating to the back?
Ruptured AAA
Chronic pancreatitis
Aortic dissection
Duodenal ulcer
What biochemical investigations for pancreatitis?
Raised serum amylase (3x upper limit of normal >1000U/mL)
- Can be normal, starts to fall after 24-48 hours
- Also raised in bowel perforation, ectopic pregnancy, mesenteric ischaemia and DKA
Serum lipase is more sensitive and specific for pancreatitis and remains elevated for longer
LFT - assess for any cholestatic element - ALT>150
What imaging for pancreatitis?
Abdominal USS if cause is unknown - identify gallstone by showing dilation of ducts..
AXR can show sentinel loop sign - dilated proximal bowel loop adjacent to pancreas occurring due to secondary localised inflammation
CT scan may show pancreatic oedema/swelling
What score is used to assess severity of acute pancreatitis?
Glasgow criteria within 48 hours of admission PANCREAS pO2 < 8 kPa Age > 55 years Neutrophils > 15x109/L Calcium <2mmol/L Renal function - urea > 16mmol/L Enzymes LDH > 600U/: or AST > 200U/L Albumin < 32g/L Sugar >10mmol/L
If 3 or more within first 48 hours = severe pancreatitis and HDU referral is warranted
What is the management of acute pancreatitis?
Treat underlying causes
Supportive:
High flow O2
IV fluid resuscitation - 250-500ml crystalloid over 1 hour (Hartmann’s)
NG tube - make patient NBM
Catherisation - measure fluid output and start fluid balance chart - aim for UO > 0.5ml/kg/hr
Opioid analgesia
Hourl obs
Daily bloods
ERCP + gallstone removal if there is progressive jaundice
Refer to ITU/HDU
Prophylactic broad-spectrum abx
What are systemic complications of pancreatitis?
Disseminated Intravascular Coagulation
ARDS
Hypocalcaemia
Hyperglycaemia - secondary to insulin metabolism disturbance
Hypovolaemic shock and multiorgan failure
What are local complications of pancreatitis?
Pancreatic necrosis - ischaemic infarction of pancreatic tissue
- suspect in patients with persistent systemic inflammation for more than 7-10 days
Confirm by CT scan
Pancreatic necrosectomy
Pancreatic pseudocyst - collection of fluid within the pancreatic tissue
Typically formed weeks after initial episode
Inflammatory reaction produces a necrotic space in the pancreas that fills with pancreatic fluid surrounded by fibrous tissue.
Pseudocyst as it lacks epithelial cells surrounding collection
Treatment - surgical debridement or endoscopic drainage
What should you suspect if there is clinical deterioration associated with raised infection markers? How can this be confirmed
Infection of pancreatic necrosis
Fine needle aspiration of necrosis
