Acute Pancreatitis

Question 1

What is acute pancreatitis?

Answer 1

Acute inflammatory process of the pancreas with variable involvement of other regional tissues or remote organ systems.

Question 2

Describe the classification of acute pancreatitis

Answer 2

Mild: minimal organ dysfunction + uneventful recovery
Severe: organ failure +/or local complications such as necrosis, abscesses + pseudocysts

Question 3

Explain the aetiology of pancreatitis

Answer 3

Insult results in activation of pancreatic proenzymes within the pancreatic duct/ acini leading to tissue damage + inflammation

Question 4

Describe the pain presenting in pancreatitis

Answer 4

Severe epigastric pain 
Radiating to the back  
Relieved by sitting forward 
Aggravated by movement  
Associated with anorexia, N+V

Question 5

What are the conventional causes of pancreatitis?

Answer 5

Gallstones  
Ethanol 
Trauma 
Steroids 
Mumps/ HIV/ Coxsackie 
Autoimmune 
Scorpion Venom 
Hypercalcaemia/ hyperlipidaemia/ hypothermia 
ERCP 
Drugs (e.g. sodium valproate, thiazides + azathioprine)

Question 6

Summarise the epidemiology of pancreatitis

Answer 6

COMMON 
UK Annual Incidence: 10/10,000 
Peak age: 60 yrs  
Most common cause in: 
Young Males = alcohol  
Middle age Females = gallstones

Question 7

List 4 signs of pancreatitis on physical examination

Answer 7

Epigastric tenderness
Fever
Shock (inc tachycardia + tachypnoea)
Decreased bowel sounds (due to ileus)

Question 8

What bloods results are seen in acute pancreatitis?

Answer 8

VERY HIGH SERUM AMYLASE (NO correlation with severity)
High WCC
U+Es (to check for dehydration)
High glucose
High CRP
Low Calcium (saponification: calcium binds to digested lipids from pancreas)
LFTs (deranged if gallstones or alcohol)

Question 9

Other than bloods, what investigations are performed for acute pancreatitis?

Answer 9

ABG (for hypoxia or metabolic acidosis)
USS: identify gallstones in biliary tree
Erect CXR: may be pleural effusion/ check for bowel perforation
AXR: exclude ddx
CT Scan: if dx uncertain or if persisting organ failure

Question 10

What are the 2 main scores for assessing severity of pancreatitis? What scoring system is used in the US?

Answer 10

Modified Glasgow Score (combined with CRP (> 210 mg/L)
APACHE-II Score
US: Ranson score (specific for alcoholic pancreatitis)

Question 11

Describe the medical management of acute Pancreatitis

Answer 11

Fluid + electrolyte resuscitation  
Urinary catheter + NG tube if vomiting  
Analgesia  
Blood sugar control  
HDU + ITU care

Question 12

When are ERCP and Sphincterotomy used for treating acute pancreatitis?

Answer 12

Used for gallstone pancreatitis
Ideally within 72 hours
All those with gallstone pancreatitis should undergo definitive management of gallstones during the same admission or within 2 weeks

Question 13

When and what surgical methods are used in acute pancreatitis?

Answer 13

Necrotising pancreatitis

Necresectomy (drainage + debridement of necrotic tissue)

Question 14

What 6 local complications may arise from acute pancreatitis?

Answer 14

Pancreatic necrosis  
Pseudocyst (peripancreatic fluid collection lasting > 4 weeks)  
Abscess  
Ascites  
Pseudoaneurysm 
Venous thrombosis

Question 15

What 8 systemic complications may arise from acute pancreatitis?

Answer 15

Multiorgan dysfunction  
Sepsis  
Renal failure  
ARDS  
DIC  
Hypocalcaemia  
Diabetes  
Long-Term: chronic pancreatitis

Question 16

What is the prognosis for patients with acute pancreatitis?

Answer 16

20% follow severe fulminating course with high mortality
Infected pancreatic necrosis has a 70% mortality
80% follow a milder course (still has 5% mortality)

Question 17

What should you check about the patient’s PMH?

Answer 17

Hx of high alcohol intake

Hx of gallstones

Question 18

What is involved in early detection + treatment of complications of acute pancreatitis?

Answer 18

If persistent symptoms or > 30% pancreatic necrosis or signs of sepsis –> image guided FNA for culture