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HPB - Surgery > Acute Pancreatitis > Flashcards

Acute Pancreatitis Flashcards

1
Q

What is acute pancreatitis?

A

Inflammation of the pancreas due to acinar cell injury and necrosis.

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2
Q

What mneumonic details causes of acute pancreatitis?

A

GET SMASHED

  • Gallstones
  • Ethanol
  • Trauma
  • Steroids
  • Mumps
  • Autoimmune
  • Scorpion bite
  • Hyperlipidaemia, Hyperchylomicronaemia, Hypercalcaemia, Hypothermia
  • ERCP
  • Drugs
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3
Q

What are the 2 most common causes of acute pancreatitis?

A
  • Gallstone
  • Alcohol
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4
Q

What drugs are most commonly responsible for causing acut pancreatitis?

A
  • Azathioprine
  • Mesalazine
  • Didanosine
  • Bendroflumethiazide
  • Furosemide
  • Pentamidine
  • Steroids
  • Sodium valproate
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5
Q

What is the pathogenesis of acute pancreatitis?

A

Autodigestion of pancreatic tissue by the pancreatic enzymes, leading to necrosis. Pancreatic enzymes also released into circulation causing autodigestion of blood vessels (leading to retroperitoneal abscess) and fat (leading to fat necrosis).

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6
Q

Why can hypocalcaemia develop in acute pancreatitis?

A

Fat necrosis causes the release of free fatty acids, that react with serum calcium to form chalky deposits in fatty tissue.

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7
Q

What is tetany?

A
  • A sign of hypocalcaemia
  • Sustained muscle contraction with periods of intermittent relaxation.
  • Usually occurs in hands and feet
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8
Q

What are the features of acute pancreatitis?

A
  • Severe epigastric pain radiating to back
  • Association with vomiting
  • Low grade fever
  • Ileus
  • History of gallstones / excessive alcohol consumption
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9
Q

What signs may be found on examination?

A
  • Poorly localised tenderness
    • +/- Guarding
  • Haemodynamic instability (Severe cases)
  • Cullen’s sign = Periumbilical discolouration
  • Grey-Turner’s sign = Flank discolouration
  • Tetany
    • Indicates hypocalcaemia
  • Jaundice
    • Indicates obstructive cause (e.g. gallstones, mass)
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10
Q

What signs are seen here?

A

A = Cullen’s sign

B = Grey Turner’s sign

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11
Q

Why do Cullen’s & Grey Turner’s present in acute pancreatitis?

A

Due to retroperitoneal haemorrhage

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12
Q

Give some differential diagnoses

A
  • Abdominal aortic aneurysm
  • Chronic pancreatitis
  • Aortic dissection
  • Peptic ulcer disease
  • Hepatitis
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13
Q

What bloods would you request?

A
  • Serum amylase / lipase
  • FBC
    • Looking for elevated infection markers & haematocrit
  • CRP
  • U&Es
    • To assess volaemic state and kidney function
  • LFTs
    • To investigate gallstones as a cause
  • Serum calcium
    • Hypercalcaemia is a rare cause of AP
    • Hypocalcaemia is a complication of AP
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14
Q

What imaging might you want to request when investigating a presentation of acute pancreatitis?

A
  • CXR
    • To exclude/confirms differentials
  • Transabdominal USS of RUQ
    • To investigate biliary pathology
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15
Q

What investigations do you need to diagnose acute pancreatitis?

A
  1. Serum Lipase / Amylase > 3 x upper limit
    * Can also use urinary amylase as it is more accurate than serum amylase
  2. CT abdo-pelvis (ONLY if amylase/lipase result inconclusive but acute pancreatitis still suspected)
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16
Q

What is the most sensitive blood test for diagnosis of acute pancreatitis?

A

Serum lipase

  • Stays elevated longer than amylase
  • More sensitive & specific than serum amylase
17
Q

What other conditions can present with elevated amylase?

A
  • Mesenteric ischaemia
  • Ectopic pregnancy
  • Bowel perforation
  • DKA
  • Pancreatic pseudocyst
  • Acute cholecystitis
18
Q

How do you investigate gallstones as a cause for acute pancreatitis?

A
  • Transabdominal USS of RUQ
    • To see if gallstones are present
  • MRCP
    • To confirm exact location of stones
19
Q

What is the modified Glasgow criteria used for?

A

To assess the severity of acute pancreatitis within the first 48 hours of admission

20
Q

What are the criteria for the Glasgow scoring system for acute pancreatitis?

A

PANCREAS

  • PO2 < 8 kPa
  • Age > 55yrs
  • Neutrophils (/WCC) > 15×109/L
  • Calcium < 2mmol/L
  • Renal function (Urea) > 16mmol/L
  • Enzymes LDH > 600U/L or AST > 200U/L
  • Albumin <32g/L
  • Sugar (blood glucose) >10mmol/L
21
Q

What score deems a patient to have severe pancreatitis & in need of a high-dependency care referral?

22
Q

Aside from the Glasgow scoring system for acute pancreatitis, what other scoring systems exist to assess the severity of acute pancreatitis?

A

Ranson Criteria

APACHE II

23
Q

How do you treat acute pancreatitis?

A

Supportive measures:

  • Opioid analgesia
  • IV fluids
    • Balanced crystalloid (e.g. Hartmann’s soln)
  • O2 (as required)
  • Consider NG tube w profuse vomiting
  • Catheterisation & fluid balance monitoring
  • Refer to high dependency unit
  • Treat underlying cause​
    • Remove gallstones
    • Refer to services for alcoholics

In cases of confirmed pancreatic necrosis, consider broad spectrum Abx prophylaxis.

24
Q

What are the systemic complications of untreated acute pancreatitis?

A
  • DIC
  • ARDS
  • Hypocalcaemia
    • Secondary to fat necrosis
  • Hyperglycaemia
    • Secondary to destruction of islets of Langerhans
25
Q

What are the local complications of untreated acute pancreatitis?

A
  • Pancreatic necrosis
  • Pseudocysts
26
Q

What is a pancreatic pseudocyst?

A

A collection of fluid containing pancreatic enzymes, blood, and necrotic tissue surrounded by a vascular & fibrotic wall (instead of an epithelial wall characteristic of cysts)

These usually form in the lesser sac where they obstruct the gastro-epiploic foramen, however, they can form anywhere within or adjacent to the pancreas.

27
Q

How do pseudocysts present?

A

Can be:

  • An incidental finding on imaging

OR

  • Symptoms of mass effect
    • Biliary obstruction
    • Obstruction of gastric outlet
28
Q

What complications can arise from pancreatic pseudocysts?

A

Prone to:

  • Haemorrhage
  • Rupture
  • Infection
29
Q

How do you treat pancreatic pseudocysts?

A

Usually conservative management (50% resolve spontaneously within 6 weeks)

After 6 weeks, treatment options include:

  • Surgical debridement
  • Endoscopic drainage
30
Q

What is pancreatic necrosis?

A

Ischaemic infarction of pancreatic tissue

31
Q

When would you begin to suspect pancreatic necrosis?

A

With evidence of persisent systemic inflammation for 7-10 days after onset of pancreatitis.

  • Clinical deterioration of patient
  • Elevated infection markers
  • Positive blood culture
  • CT changes
32
Q

How do you confirm a diagnosis of pancreatic necrosis?

A
  • CT imaging
  • Fine needle aspiration of necrosis
33
Q

What is the treatment of pancreatic necrosis?

A
  • Broad-spectrum Abx prophylaxis
  • Pancreatic necrosectomy (Open/Endoscopic)
34
Q

How are chronic and acute pancreatitis differentiated clinically?

A
  • Different time course
  • Typically serum amylase / lipase levels aren’t elevated as dignificatly

HPB - Surgery (2 decks)

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