Acute Pancreatitis Flashcards
What classifies pancreatitis as mild or severe?
mild = interstitial oedema inflammatory infiltrate no haemorrhage or necrosis minimal/organ dysfunction
severe = severe infiltrate necrosis of parenchyma severe gland dysfunction multi-organ failure
What are some short term complications of pancreatitis?
acute renal failure - circulating toxins, rhabdomyolysis, hypovolaemia, inflammatory mediators
pancreatic abscess - can become colonised and infected
necrotising pancreatitis - secondary to inadequate fluid resus + vasoactive + toxic substances
What are some long term complications of pancreatitis?
pancreatic insufficiency chronic pancreatitis portal vein/splenic thrombosis enteric fistulas intestinal obstruction
What is chronic pancreatitis? How does this differ from acute pancreatitis?
= continuing chronic inflamation –> irreversible morphological changes + permanent damage
AP has reversible damage. The pain in acute pancreatitis often has a sudden onset. It starts as a dull, steady ache which gradually becomes more severe
What is the classic acute pancreatitis presentation?
abdo pain - dull, boring, steady N&V diarrhoea fever tachycardia hypotension abdo tenderness jaundice (28%) dyspnoea (10%) bloating curled up
List the causes of pancreatitis
Gallstones Ethanol Trauma Steroids Mumps Autoimmune Scorpion sting Hyperlipidaemia ERCP Drugs (valproate, azathioprine, opiates)
Describe the pathophysiology of acute pancreatitis
trigger eg gallstones –> acinar cell injury –> zymogen secretion
extracellular - neural and vascular response
intracellular - intracellular digestive enzymes activated
increased calcium signalling
heat shock protein activation
trypsinogen –> trypsin –> cascade which activated zymogen
chemoattraction of inflammatory cells
activated neutrophils –> superoxide
macrophages –> cytokines
increased pancreatic vascular permeability –> haemorrhage, oedema, pancreatic necrosis
Why can systemic complications occur as a result of pancreatitis?
leaky vessels –> translocation of gut flora –> ARDS, AKI, pleural effusions, GI haemorrhage, renal failure
What enzymes are released as a result of the trypsin cascade? What are their effects?
Chymotrypsin - oedema, vascular damage
Elastase - vscular damage, haemorrhage
Phospholipase A2 - coagulation, necrosis
Lipase - fat necrosis
List some DDx for acute pancreatitis
peptic ulcer disease perforated viscus oesophageal spasm intestinal obstruction cholangitis/choledocholithiasis AAA
How is acute pancreatitis diagnosed?
lab: serum lipase serum amylase AST/ALT FBC + differential CRP HCT lipase:amylase arterial blood gas
Ix:
AXR + CXR
transabdominal US
CT - for complications
Diagnosis = 2/3 of;
typical symptoms
pancreatic enzymes >3x upper limit
radiographic evidence
What might be seen on an US when looking for pancreatitis?
gallstones? pancreatic inflammation peri-pancreatic stranding calcification fluid collections
What might be seen on an ERCP when looking for pancreatitis?
(endoscopic retrograde cholangiopancreatography)
identifies stones + allows for retrieval
identify duct filling defects and strictures
What might be seen on a CT when looking for pancreatitis?
cannot be visualised within the first 48hrs
CT with IV contrast most sensitive test
diffuse/segmental pancreatic enlargement irregular contour obliteration of peri-pancreatic fat necrosis pseudocysts
What is the Atlanta criteria for grading pancreatitis?
mild = no organ failure, no local or systemic complications moderate = organ failure which resolves <48hrs, local or systemic complications severe = persistent single/multiple organ failure >48hrs
