Acute Pancreatitis Flashcards
What are the causes of acute pancreatitis?
I GET SMASHED
Idiopathic
Gallstones
Ethanol (alcohol)
Trauma
Steroids
Mumps
Autoimmune (SLE)
Scorpion sting
Hyperlipidaemia, hypothermia, hypercalcaemia (metabolic disorders)
ERCP and emboli
Drugs (tetracyclines, furosemide, azathioprine, thiazides and many others)
IGET are the most common causes of pancreatitis
A 53 year old man presents to ED with severe mid-epigastric pain that radiates to his back. Leaning forward or curling into the foetal position both offer relief, while deep inspiration and movement make it worse.
He also complains of nausea, vomiting and anorexia and gives a history of heavy alcohol intake this past week.
He is tachycardic, tachypnoeic, and febrile with hypotension. He is slightly agitated and confused. He is diaphoretic with decreased breath sounds over the base of the left lung.
How would you decide if this is pancreatitis or not?
Satisfactory clinical story for alcohol pancreatitis: male, middle age, recent history of high alcohol intake. Hx of anorexia, nausea, vomiting. Classic mid-epigastric pain radiating to the back, worsens with movement, relieved in fetal position.
Examination: Epigastric tenderness; guarding and rigidity. Signs of hypovolaemia (reduced skin turgor, dry mucous membranes, hypotension etc). Cullen’s/Grey-Turner’s signs. Absent bowel sounds (paralytic ileus). Jaundice.
Check serum lipase or amylase (>3x upper limit of normal)
Imaging study: XR (abdo/CXR), CT to visualise pancreas
A 47-year-old overweight woman is admitted with generalised abdominal pain. She has been unable to eat or drink due to nausea and vomiting.
She states the pain started in the right upper quadrant, similar to previous episodes that she had been to the emergency department with over the past few months. An ultrasound obtained on her last visit to the emergency department revealed gallstones with no inflammation of the gallbladder, and she was told that she should see a surgeon.
She looks jaundiced and in distress. She has point tenderness under her ribs on the right, which is worsened with deep palpation. No mass is palpable.
How would you decide if this is pancreatitis or not?
Satisfactory clinical story for gallstone pancreatitis. The 5 F’s: fat, forty, female, fertile, family history.
Examination: Epigastric tenderness; guarding and rigidity. Signs of hypovolaemia (reduced skin turgor, dry mucous membranes, hypotension etc). Cullen’s/Grey-Turner’s signs. Absent bowel sounds (paralytic ileus). Jaundice.
Check serum lipase or amylase (>3x upper limit of normal)
Check LFTs: ALP and bilirubin raised
Imaging study: XR (abdo/CXR), CT to visualise pancreas, ERCP (due to suspected biliary obstruction), USS (identify dilated common bile duct and gallstones).
What investigations might you order for suspected pancreatitis?
Serum lipase (preferred) or amylase → 3x normal
LFTs: may suggest gallstones
Prognosis indicated by:
- FBC (leukocytosis, derranged haematocrit)
- CRP: >150 mg/L assoc. with pancreatic necrosis
Imaging: XR (chest and abdo) exclude other causes; CT to visualise pancreas; ERCP if suspected biliary obstruction; USS to look at CBD and gallstones.
12 hourly ABG to monitor O2
What differentials can be the cause of a raised amylase?
Pancreatitis Renal Failure DKA Perforated duodenal ulcer Mesenteric ischaemia
What other differentials may have a similar pain history to acute pancreatitis?
Small bowel perf or obstruction
AAA dissection
Atypical MI
What is the general treatment plan for acute pancreatitis?
1) Resuscitation: IV Fluids (consider catheter to monitor urine output)
Blood transfusion if indicated
2) Analgesia: Morphine or similar
3) Nutritional support: Oral nutrition when possible, consider NG tube (or similar) for enteral nutrition if required. Parenteral nutrition if NG/ND/NJ not tolerated or unsuccessful.
4) Manage associated conditions and complications
- Gallstones
- Alcohol
- Pancreatic necrosis
Possible adjuncts:
- supplemental O2
- Anti-emetics
- Ca and Mg replacement
- Insulin
How would you manage acute pancreatitis associated with gallstones?
Fluid resus
Analgesia
Nutritional support
Plus: cholecystectomy
When might you perform an ERCP on a patient with acute pancreatitis?
In cases of acute pancreatitis with gallstones AND cholangitis (Charcot’s triad: jaundice, fever and rigors, RUQ pain).
ERCP is not indicated for mild or severe gallstone pancreatitis without cholangitis in the absence of common bile duct obstruction. The risks of the procedure outweigh any potential benefits in this patient population.
How would you manage acute pancreatitis associated with alcohol abuse?
Fluid resus
Analgesia
Nutritional support
Plus:
- Counselling (+/- alcohol withdrawal prophylaxis)
- Vit and min replacement (thiamine, folate and B12 (cyanocobalamin))
How would you manage acute pancreatitis associated with pancreatic necrosis?
Fluid resus
Analgesia
Nutritional support
Plus:
- If sterile necrosis: +/- catheter drainage or necrostomy
- if infected necrosis: IV ABx +/- drainage; +/- debridement
