Acute Pancreatitis

Question 1

Definition of Acute Pancreatitis?

Answer 1

A sudden inflammation of the exocrine pancreas, associated with local and systemic inflammatory responses

Question 2

Explain the risk factors of acute pancreatitis?

Answer 2

I GET SMASHED

I - Idiopathic

G - Gall stones

E - Ethanol

T - Trauma

S - Steroids

M - Measles/Mumps/HIV

A - Autoimmune

S - Scorpion Bites

H - Hyperlipidaemia/Hypercalcaemia (hypercalcaemia is a rare cause of pancreatitis)

E - Endoscopic retrograde cholangiopancreatography (ERCP)
* this technique is both for imaging/ physically removing stones/BIOPSY
​

D - Drugs (thiazides, sodium valproate)

Question 3

Explain the aetiology of Acute Pancreatitis

Answer 3

The inflammation of the exocrine pancreas causes the release of activated pancreatic enzymes which autodigest the pancreas

Question 4

Summarise the epidemiology of Acute Pancreatitis

Answer 4

• increasing in incidence
• incidence in the UK reported at approximately 56 per 100,000 per year.
• The overall mortality rate in the UK is reported as around 5%, rising to 25% for patients with severe disease
• In the UK, around:
  
  • 50% of cases are caused by gallstones
  • 25% by alcohol
  • 25% by other factors
• Gallstone pancreatitis is more common in white women >60 years of age
• Alcoholic pancreatitis is seen more frequently in men
  *

Question 5

Presenting complaints for Acute Pancreatitis

Answer 5

Upper abdominal pain - typically mid-epigastric or LUQ which radiates to the back (usually the lower thoracic area

• Usually constant and severe - may be described as “like being stabbed with a knife”
• Typically worsens with movement; some patients find it is eased by taking the fetal position.

Nausea and vomiting - vomiting may lead to dehydration and electrolyte abnormalities

Anorexia/Decreased appetite is common, usually secondary to nausea, pain, and general malaise.

Dyspnoea may be present, due to pleural effusion or acute respiratory distress syndrome (ARDS).

Question 6

Signs on physical examination

Answer 6

ABDOMINAL EXAMINATION:

• Tender abdomen in Epigastium/LUQ
• Voluntary guarding on palpation

VISUAL:

• Cullen’s (umbiliCus) ± Grey-Turners (flanks) ecchymoses on the skin
• Pancreatic Panniculitis (erythematous subcutaneous nodules) usually seen on legs due to focal fat necrosis

SIGNS OF FLUID LOSS/HYPOVOLAEMIA:

• Hypotension
• oliguria
• dry mucous membranes
• decreased skin turgor

LOOK FOR SIGNS OF Systemic Inflammatory Response Syndrome:

• Tachycardia
• Tachypnoea
• Febrile
• Neutrophilia

Question 7

Investigations for Acute Pancreatitis

Answer 7

BLOODS

• Serum lipase or amylase
  
  • usually ≥3x ULN
  • Lipase is preferred to amylase
  • They have similar specificity and sensitivity however lipase remains elevated for longer
• Elevated WBC (leukocytosis - especially neutrophils)
• Elevated CRP above 200 units/L
• LFTs: usually normal, slightly raised bili, raised GGT if alcoholic
• Triglyceride levels: Raised and can cause pancreatitis
• Calcium: High Ca causes pancreatitis whereas low Ca is a consequence of pancreatitis (due to saponification)

IMAGING

• Transabdominal ultrasound needed in ALL patients to confirm or exclude cholelithiasis
• CT Abdo with contrast can give additional information about complications of pancreatitis

Question 8

Glasgow scale for scoring pancreatitis

Answer 8

P A N C R E A S - A Glasgow score of 3 or more indicates severe pancreatitis

P - Partial Pressure of Oxygen below 60mmHg

A - Age over 55 years

N - Neutrophilia

C - Calcium below 2mM

R - Renal function (Urea > 16)

E - Enzymes (AST, LDH)

A - Albumin below 32g/dL (this is a prognostic feature, associated with

S - Sugar greater than 10mM

Question 9

Generate a management plan for pancreatitis

Answer 9

MANAGEMENT IS LARGELY SUPPORTIVE

• AGGRESSIVE IV Fluid Resuscitation
• Catheter to monitor urine output closely (aim for >0.5mL/kg/hr)
• Administer Oxygen
• Analgesia (IV opiates usually requried)
• Anti-emetics
• encourage oral feeding as soon as pain and N&V subsides
  
  • NBM to allow the pancreas to rest if N&V
  • in patients who cannot tolerate oral feeding use enteric methods (NG or NJ tubes rather than parenteral)
• NO ANTIBIOTICS

SURGICAL

• If due to gallstone disease, book patient for early lap chole
• Endoscopic/Percutaneous drainage of any pancreatic collections (e.g. pseduocyst)

Question 10

Complications

Answer 10

Long-term monitoring is not usually required as this will recover without further therapy

Complications:

• Acute renal failure (high chance)
• Sepsis
• Chronic Pancreatitis
• Pancreatic necrosis (treat with antibiotics)
• Pseudocyst
• ARDS
• Pancreatic abscess (drain and antibiotics)
• Pancreatic Ascites/Pleural Effusion may occur due to fistula between pancreatic duct and abdomen/chest or pseudocyst rupture

Question 11

Prognosis

Answer 11

• The majority of patients with acute pancreatitis have mild disease and will improve within 3 to 7 days of conservative management.
• Long-term prognosis is based on the aetiology and patient adherence to lifestyle modifications, a lack of adherence may lead to a recurrence of ACUTE PANCREATITIS
  
  • If gallstones were the cause then a cholecystectomy may be useful
  • Alcohol may need to be stopped/cutrailed