Acute pancreatitis

Question 1

How can acute pancreatitis be distinguished from chronic?

Answer 1

Limited damage to secretory function

Question 2

What are the causes of Acute pancreatitis?

Answer 2

• I GET SMASHED
  
  • Idiopathic
  • Gallstones
  • Ethanol
  • Trauma
  • Steroids
  • Mumps
  • Autoimmune disease (SLE)
  • Scorpion venom
  • Hypercalcaemia
  • ERCP
  • Drugs

Question 3

What drugs can cause acute pancreatitis?

Answer 3

• NSAIDs
• Azathioprine
• Diuretics
• Steroids

Question 4

Describe the pathogenesis of acute pancreatitis?

Answer 4

• Premature and excess digestive enzyme release
• Inflammatory response causes increased vascular permeability and fluid loss
• Enzymes cause autodigestion of fats and blood vessels
• FFAs then react with calcium causing chalky deposits and hypocalcaemia

Question 5

What are the features of Acute pancreatitis?

Answer 5

• Epigastric pain -> back
• Vomiting
• Tenderness, ileus and low grade fever
• Cullens and grey turners sign

Question 6

What is cullens sign?

Answer 6

• Periumbilical discolouration
• Present in ectopic pregnancy and acute pancreatitis

Question 7

What is grey turners sign?

Answer 7

• Flank bruising / discolouration
• Can predict a severe attack of acute pancreatitis

Question 8

What are the invesitgations for acute pancreatits?

Answer 8

Raised serum amylase

Question 9

Name a scoring system for pancreatitis?

Answer 9

Glasgow scale of pancreatitis severeity (PANCREAS)

Question 10

Features of the Glasgow scale of pancreatitis severity?

Answer 10

• PANCREAS
  
  • PaO2 <7.9
  • Age >55
  • Neutrophils (WBC >15)
  • Calcium (hypocalcaemia)
  • Renal function (Urea > 16)
  • Enzymes LDH > 600
  • Albumin <32
  • Sugar (blood glucose > 10)
• More than 3 features indicates severe pancreatitis

Question 11

Differentials for acute pancreatitis?

Answer 11

• Sympatomatic/ruptured AAA
• Chronic pancreatitis
• Aortic dissection
• Duodenal ulcer

Question 12

What investigations should be performed for someone with a suspected acute pancreatitis?

Answer 12

• Serum amylase (3x upper limit of normal)
• LFTs (ALT>150 predicts gallstones are the cause)
• Serum lipase (raised)
• Imaging
  
  • Abdo US
  • Contrast-enhanced CT

Question 13

What other factors can cause a raised serum amylase?

Answer 13

• Bowel perforation
• Ectopic pregnancy
• Mesenteric ischaemia
• DKA

Question 14

Describe risk scoring for Acute pancreatitis?

Answer 14

• Modified Glasgow Criteria
  
  • Assesses severity within 48hours of admission
• PANCREAS
  
  • pO2<8kPa
  • Age>55
  • Neutrophils: WCC>15x10⁹/L
  • Calcium <2mmol/L
  • Renal function: Urea >16mmol/L
  • Enzymes: LDH>600U/L
  • Albumin <32g/L
  • Sugar: glucose >10mmol/L

Question 15

Describe the use of abdominal ultrasound for acute pancreatitis?

Answer 15

• If underlying cause is unknown
• Identifies gallstones through dilation of bile ducts

Question 16

Describe the use of AXR in diagnosing acute pancreatitis?

Answer 16

• Not routinely performed
• Can show sentinal loop sign
  
  • Dilated proximal bowel loop adjacent to pancreas
  • Secondary to localised inflammation

Question 17

Describe the use of a contrast-enhanced CT scan in the diagnosis of acute pancreatitis?

Answer 17

• Performed within 48hrs of presentation if bloods are inconclusive
• Can show areas of pancreatic oedema and necrosis

Question 18

Describe the managment of Acute pancreatitis?

Answer 18

• Most people settle with supportive treatments
  
  • Oxygen, fluids
  • NG tube if vomiting, opioid analgesia
• Treat underlying cause
  
  • Gallstones
    
    • ERCP, sphincterotomy

Question 19

What are the systemic complications of Acute pancreatitis?

Answer 19

• Disseminated intravascular coagulation (DIC)
• ARDS
• Hypocalcaemia
• Hyperglycaemia

Question 20

What are the local complications of Acute pancreatitis?

Answer 20

• Pancreatic necrosis
• Pancreatic pseudocyst

Question 21

Describe pancreatic necrosis as a complication of acute pancreatitis?

Answer 21

• Suspect in patients with persistent systemic inflammation >7 days
• Confirmed by CT scan
• Fine needle aspiration of the necrosis if infection develops

Question 22

Describe a pancreatic pseudocyst as a complication of acute pancreatitis?

Answer 22

• Collection of fluid containg enzymes, blood and necrotic tissue
• Usually seen in the lesser sac
• Best visualised using MRI
• Treatment with surgical debridement or endoscopic drainage into stomach

Question 23

What are the two different functions of the pancreas?

Answer 23

• Endocrine
• Exocrine

Question 24

Describe the exocrine function of the pancreas?

Answer 24

• Digestion of fats, protein asnd carbohydrate
• 1L of alkaline enzymne-rich fluid is produced every day
• Trypsin, lipase and amylase

Question 25

Describe the endocrine function of the pancreas?

Answer 25

* Islets of langerhans * α cells - glucagon * β cells - insulin * D cells - somatostatin * PP cells - pancreatic polypeptide

Question 26

What is ileus?

Answer 26

* Lack of movement of somewhere in the intestine * Leads to build up and potential blockage

Question 27

Describe the symptomatic stratification of mild acute pancreatitis?

Answer 27

* No organ failure * No local or systemic complications

Question 28

Describe the symptomatic stratification of moderately severe acute pancreatitis?

Answer 28

* Organ failure which resolves wtihin 48 hours and/or * Local or systemic complications without persistent organ failure

Question 29

Describe the symptomatic stratification of severe acute pancreatitis?

Answer 29

* Persistent organ failure \> 48 hours * Single organ failure * Multiple organ failure

Question 30

Label the pancreas

Answer 30

Question 31

Describe the blood supply of the pancreas?

Answer 31

* Pancreatic branches of the splenic artery * Head is additionally supplied by the superior and inferior pancreaticoduodenal arteries * Superior pancreaticoduodenal is from coeliac trunk * Inferior pancreaticoduodenal is from the superior mesenteric arteries

Question 32

Describe the venous drainage of the pancreas?

Answer 32

* Head of pancreas * Superior mesenteric branches of the hepatic portal vein * Rest of the pancreas * Pancreatic veins to splenic veins

Question 33

What regions of the abdomen does the pancreas lie in?

Answer 33

Epigastric and left hypochondrium

Question 34

What is the only part of the pancreas that is intraperitoneal?

Answer 34

Tail