acute pancreatitis Flashcards
definition of acute pancreatitis
acute inflammation of the pancreas
aetiology of acute pancreatitis
most common - gallstones, EToH
drugs - steroids, azathioprine, thiazides, valproate
trauma
ERCP or abdo surgery
infective - mumps, EBV, CMV, Coxsackie B, mycoplasma
hyperlipidaemia
hyperparathyroidism
anatomical - pancreas divisum, annular pancreas
idiopathic
pregnancy
neoplasm
I GET SMASHED
idiopathic
gallstones
ethanol
trauma
steroids
mumps
autoimmune (PAN)
scorpian venom
hyperparathyroidism, hyperlipidaemia, hypercalcaemia, hypothemia
ERCP and emboli
drugs - azathioprine, thiazides, valproate
epidimiology of acute pancreatitis
common
annual UK incidence - 10/10000
60yrs
males - alcohol induced more
females - gallstones
sx of acute pancreatitis
epigastric pain
- radiating through to back,
- better when sat forward, worse lying down because retroperitoneal
- aggrevated by movement
anorexia
nausea and vom
pale stool, dark urine - bile is excreted in urine because not getting into the colon
history of gallstones/alcohol intake
signs of acute pancreatitis
epigastric tenderness
rigid abdo
fever
shock, tachycardia, tachypnoea
jaundice
reduced bowel sounds - due to ileus
from blood vessel autodigestion and retroperitoneal haemorrhage:
- Turner’s sign - flank bruising
- cullens - periumbilical bruising
pathology of acute pancreatitis
insult = activation of proenzymes in the duct/acini = tissue damage and inflammation
varies in severity from mild glandular and interstitial oedema ->
to frank parenchymal necrosis and haemorrhage with release of inflamm mediators into the systemic circulation
saponification (foaming) see due to action of lipases and proteasaes on pancreatic tissue
Ix for acute pancreatitis
bloods
USS
erect CXR
AXR
assessment of severity
ERCP if LFTs worsen
bloods for acute pancreatitis
high amylase - normally >3x normal or >1000u/mL (fall after 24-48hrs, excreted renally so renal failure will increase levels)
high serum lipase - rises earlier and falls later, better than amylase esp when alcohol
FBC - high WCC and haematocrit
UE
high glucose
high CRP >100 at 48hr is prognostically severe
low ca
LFT - deranged if due to gallstones or alcohol
ABG - for hypoxia or metabolic acidosis
USS for acute pancreatitis
for gallstones and biliary dilation, if high AST
pancrease difficult to visualise because of the overlying bowel gas
erect CXR for acute pancreatitis
mainly to exclude other causes of acute abdo
may be pleural effusion
AXR for acute pancreatitis
exclude other causes of acute abdo
psoas shadow may be lost - because of high retroperitoneal fluid
‘sentinal loop’ of prox jejunum from ileus - solitary air filled dilatation
CT scanning for severe cases and assess severity and complicatioons
assessment of severity of acute pancreatitis
modified Glasgow criteria - gallstones and EToH
or Ranson’s criteria after 48hr (for alcohol induced pancreatitis)
CRP
Acute physiology and Chronic Health examination (APACHE)-II
Bedside Index for Severity in Acute Pancreatitis (BISAP)
amylase doesnt correlate with severity
modified glasgow criteria - acute pancreatitis
3 or more +ve factors within 48hr of onset suggest severe pancreatitis = HDU/ITU
PANCREAS
- pO2 < 8 kPa,
- Age >55yrs
- Neutrophilia - WCC >15 x10(9)/L,
- Ca2+ < 2 mmol/L,
- Renal function - urea >16 mmol/L,
- Enzymes - AST > 200 unit/L, LDH >600.
- albumin > 32 g/L,
- Sugar - glucose >10 mmol/L,
Ranson’s criteria
On admission:
- WCC >16x10(9)/L,
- age > 55,
- AST > 250,
- LDH > 350,
- glucose > 11 mmol/L.
During first 48 h:
- pO2 < 8kPa,
- Ca2+ < 2mmol/L,
- urea > 16 mmol/L,
- base deficit > 4,
- haematocrit fall > 10%,
- fluid sequestration > 600 ml.
Mx of acute pancreatitis
intensive supportive care
early detectuion and treatment of complications
surgical
intensive supportive care for acute pancreatitis
fluid (crystalloids) and electrolyte resus and close monitoring
NBM
urinary catheter and NG tube
consider CVP monitoring
analgesia - pethidine or morphine
hourly pulse, BP, UO
daily FBC, UE, Ca, glucose, amylase, ABG
oxygen if low PaO2
later - nutritional support to decrease panc stimulation. if suspected abscess or necrosis - parenteral
phrophylactic AB dont reduce mortality but are given
if gallstone - ERCP in severe cases or if cholestatic jaundice
early detection and treatment of complications of acute pancreatitis
monitor resp function, renal function and clotting
management in ITU might be needed for severe cases
surgical Mx for pancreatitis
for necrotosing pancreatitis
drainage and debridement of necrotic tissues
local complications of acute pancreatitis
pancreatic necrosis (further complicated by infection)
pseudocyst
abscess
pancreatic ascites
in the long term - chronic pancreatitis with dm and malabsorption
systemic complications of acute pancreatitis
multiorgan dysfunction
sepsis
renal failure
ARDS
Px of acute pancreatitis
20% follow severe fulminating course with high mortality
pancreatic necrosis is associated with 70% mortality
80% run milder course - 5% mortality
what ‘characterises’ acute pancreatitis
self-perpetuating pancreatic enzyme-mediated autodigestion, oedema and fluid shifts = hypovolaemia
extracellular fluid is trapped in gut, peritoneum, and retroperuitoneum (worsened by vomiting)
purpose of giving fluids in acute pancreatitis
counter 3rd space sequestration
until vital signs are satisgfactory
and urine flow stays >30ml/hr
early complications of acute pancreatitis
shock
ARDS
renal failure - give lots of fluids
DIC
sepsis
hypocalcaemia
hyperglycaemia - transient
late complications of acute pancreatitis
pancreatic necrosis and pseudocyst (fluid in lesser sac) - fever, mass +- persistent high amylase/LFT. mar resolve/need drainage
abscess - drain
bleeding - elastase erode major vessel eg splenic artery, embolisation may be lifesaving
thrombososis - in splenic/gastroduodenal arteries, or colic branches of SMA = bowel necrosis
fistulae - normally close spontaneously, if purely pancreatic they dont irritate the skin
recurrent odematous pancreatitis -some pts get so often that near-total pancreatectomy considered
pancreatic pseudocyst - occupies the lesser sac of the abdomen posterior to stomach
not true cyst because lined by the lesser sac not epi/endothelium
develops at >=6wks
