Acute Pancreatitis

Question 1

What is it?

Answer 1

A disorder of the exocrine pancreas, and is associated with acinar cell injury with local and systemic inflammatory responses

Question 2

Causes of pancreatitis + mmemonic?

Answer 2

GET SMASHED

Gallstones  
Ethanol 
Trauma 
Steroids 
Mumps/HIV/Coxsackie 
Autoimmune 
Scorpion Venom 
Hypercalcaemia/hyperLIPIDAEMIA/hypothermia 
ERCP 
Drugs (e.g. sodium valproate, steroids, thiazides and azathioprine)

Question 3

Most common cause in males/females?

Answer 3

Most common cause in:

Males = alcohol  
Females = gallstones

Question 4

Recognise the presenting symptoms of pancreatitis

Answer 4

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 5

Signs of acute panc on examination?

Answer 5

Epigastric tenderness

Fever

Shock/ signs of hypovolaemia (includes hypotension, tachycardia and tachypnoea)

Decreased bowel sounds (due to ileus)

In severe pancreatitis:
Cullen’s sign (periumbilical bruising)
Grey-Turner sign (flank bruising)

Question 6

Invx for acute panc?

Answer 6

Blood:

VERY HIGH SERUM AMYLASE (this does not correlate with severity) usually at least 3x normal limit

High WCC
High CRP
U&Es (to check for dehydration)
High glucose
Low Calcium (saponification - calcium binds to digested lipids from the pancreas to form soap)
LFTs (may be deranged if gallstone pancreatitis or alcohol)
ABG (for hypoxia or metabolic acidosis)

USS: check for evidence of gallstones in biliary tree

Erect CXR: may be pleural effusion. Also to check for bowel perforation

AXR: exclude other causes of acute abdomen

CT Scan: if diagnosis is uncertain or if persisting organ failure

Question 7

1st line Treatment for ac panc?

Answer 7

1st line
1A. Resus; Hartman’s or saline
- catheter to monitor urine output for sever cases
- blood transfusion if haemmorhage

1B. Analgesia ; Morphine sulphate iv
1C. Nutrition;
- parenteral if cant do oral

consider empirical ABX

Some patients may also need;
antiemetic; ondansetron
calcium replacement; calcium gluconate
mg replacement
insulin

this is done for all patients regardless of aetiology

Question 8

Treatment for ac panc with gallstones?

Answer 8

If with gallstones;

- cholecystectomy; remove gbladder

Question 9

Treatment for ac panc with gallstones and cholangitis?

Answer 9

ercp

Question 10

Treatment for ac panc , alcohol induced?

Answer 10

councelling

alcohol withdrawal prophylaxis ; Lorezapam

vitamin n mineral replacement;

• thiamine
• folic acid
• cyanocobalamin

Question 11

Treatment for ac panc , infected and necrotic?

Answer 11

iv abx

catheter drainage

necrosectomy, debridement

Question 12

some scores used to grade SEVERITY of acute pancreatitis?

Answer 12

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

APACHE-II Score

Ranson score

Balthazar score - based on CT

Question 13

why can acute pancreatitis cause a pleural effusion?

Answer 13

a blocked pancreatic duct can lead to a leak and formation of a pancreaticopleural fistula

effusion usaully left sided