Acute pancreatitis

Question 1

Define

Answer 1

• An acute inflammatory process of the pancreas with variable involvement of other regional tissues or remote organ systems.
• A disorder of the exocrine pancreas, and is associated with acinar cell injury with local and systemic inflammatory responses.

Question 2

What are the 3 types?

Answer 2

o Mild: minimal organ dysfunction and uneventful recovery in the first week
o Moderate: transient organ failure (resolves in 48hrs)/ local complications or exacerbation of comorbid disease
o Severe: persistent organ failure (>48hrs) and/or local complications such as necrosis, abscesses and pseudocysts

Question 3

What are the causes?

Answer 3

•	Causes of Pancreatitis: GET SMASHED
o	Gallstones 
o	Ethanol
o	Trauma
o	Steroids
o	Mumps/HIV/Coxsackie
o	Autoimmune
o	Scorpion Venom
o	Hypercalcaemia/hyperlipidaemia/hypothermia
o	ERCP
o	Drugs (e.g. sodium valproate, steroids, thiazides and azathioprine)
•	Causes of Pancreatitis: GET SMASHED
o	Gallstones 
o	Ethanol
o	Trauma
o	Steroids
o	Mumps/HIV/Coxsackie
o	Autoimmune
o	Scorpion Venom
o	Hypercalcaemia/hyperlipidaemia/hypothermia
o	ERCP
o	Drugs (e.g. sodium valproate, steroids, thiazides and azathioprine)

Question 4

Explain aetiology

Answer 4

Ethanol-induced pancreatitis has different pathophysiological mechanisms. Studies have described that ethanol is a direct toxic insult to the acinar cell, causing inflammation and membrane destruction. Other mechanisms include sphincter of Oddi dysfunction, induction of hypertriglyceridaemia, or formation of free oxygen radicals. [15] Some studies have demonstrated that ethanol causes an increase in ductal pressures secondary to protein deposition within the pancreatic duct, favouring retrograde flow and intra-pancreatic enzymatic activation.

Question 5

Epidemiology

Answer 5

•	COMMON
•	UK Annual Incidence: 10/10,000
•	Peak age: 60 yrs
•	Middle aged women 
•	Most common cause in:
o	Males = alcohol 
o	Females = gallstones

Question 6

What are the presenting symptoms?

Answer 6

• Severe epigastric pain
• Radiating to the back
• Relieved by sitting forward
• Aggravated by movement
• Associated with anorexia, nausea and vomiting
• IMPORTANT: check whether the patient has a history of high alcohol intake or gallstones

Question 7

What are the signs?

Answer 7

•	Epigastric tenderness 
•	Tachycardia
•	Fever 
•	Shock (includes tachycardia and tachypnoea) 
•	Decreased bowel sounds (due to ileus) 
•	In severe pancreatitis: 
o	Cullen's sign (periumbilical bruising)
o	Grey-Turner sign (flank bruising) 

•	Epigastric tenderness 
•	Tachycardia
•	Fever 
•	Shock (includes tachycardia and tachypnoea) 
•	Decreased bowel sounds (due to ileus) 
•	In severe pancreatitis: 
o	Cullen's sign (periumbilical bruising)
o	Grey-Turner sign (flank bruising)

Question 8

What are the 1st investigations?

Answer 8

• Blood:
o VERY HIGH SERUM AMYLASE and lipase (x3 upper limit, this does not correlate with severity)
o High WCC
o U&Es (to check for dehydration)
o High glucose
o High CRP (if >200units/l, pancreatic necrosis) and haematocrit (>44%, pancreatic necrosis)
o Low Calcium (saponification - calcium binds to digested lipids from the pancreas to form soap)
o LFTs / AST/ALT(may be deranged if gallstone pancreatitis or alcohol)
o ABG (for hypoxia or metabolic acidosis)
• USS: check for evidence of gallstones in biliary tree
• Erect CXR: may be pleural effusion of lung collapse. Also to check for bowel perforation
• AXR: exclude other causes of acute abdomen

Question 9

What are some investigations to consider?

Answer 9

• CT Scan: if diagnosis is uncertain or if persisting organ failure
• MRCP or ERCP
• Fine needle aspiration (if pancreatic necrosis suspected)

Question 10

How would you manage?

Answer 10

o Fluid and electrolyte resuscitation
o Nutritional support – nil by mouth
o Urinary catheter and NG tube if vomiting
o Analgesia
o Antiemetic (ondasterone)
o Replace calcium and magnesium
o Blood sugar control
o HDU and ITU care
o Prophylactic antibiotics may be useful in reducing mortality
• ERCP and Sphincterotomy:
o Used for gallstone pancreatitis, cholangitis, jaundice or dilated common bile duct
o Ideally performed within 72 hours
o All patients presenting with gallstone pancreatitis should undergo definitive management of gallstones during the same admission or within 2 weeks
• Early detection and treatment of complications:
o For example if there are persistent symptoms or > 30% pancreatic necrosis or signs of sepsis –> image guided fine needle aspiration for culture
• Surgical:
o Necrotising pancreatitis should be managed by specialists
o Necresectomy (drainage and debridement of necrotic tissue) may be necessary

Question 11

What scales are used to assess severity?

Answer 11

o Modified Glasgow Score (combined with CRP (> 210 mg/L)

o APACHE-II Score

Question 12

What are the possible complications?

Answer 12

•	Local:
o	Pancreatic necrosis 
o	Pseudocyst (peripancreatic fluid collection lasting > 4 weeks) 
o	Abscess 
o	Ascites 
o	Pseudoaneurysm
o	Venous thrombosis 
•	Systemic:
o	Multiorgan dysfunction 
o	Sepsis 
o	Renal failure 
o	ARDS 
o	DIC 
o	Hypocalcaemia 
o	Diabetes 
•	Long-Term: could result in chronic pancreatitis

Question 13

What’s the prognosis?

Answer 13

• 20% follow severe fulminating course with high mortality
• Infected pancreatic necrosis has a 70% mortality
• 80% follow a milder course (but this still has 5% mortality)
• Long-term prognosis is based on the aetiological factor and patient compliance to lifestyle modifications. Acute pancreatitis generally resolves and leaves pancreatic function intact. May progress to recurrent acute pancreatitis or chronic pancreatitis, and the risk is higher among people who smoke, alcoholics, and men.