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yr 3 GI > acute pancreatitis > Flashcards

acute pancreatitis Flashcards

1
Q

definition of acute pancreatitis

A

acute inflammation of the pancreas

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2
Q

aetiology of acute pancreatitis

A

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

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3
Q

I GET SMASHED

A

idiopathic

gallstones

ethanol

trauma

steroids

mumps

autoimmune (PAN)

scorpian venom

hyperparathyroidism, hyperlipidaemia, hypercalcaemia, hypothemia

ERCP and emboli

drugs - azathioprine, thiazides, valproate

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4
Q

epidimiology of acute pancreatitis

A

common

annual UK incidence - 10/10000

60yrs

males - alcohol induced more

females - gallstones

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5
Q

sx of acute pancreatitis

A

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

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6
Q

signs of acute pancreatitis

A

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
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7
Q

pathology of acute pancreatitis

A

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

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8
Q

Ix for acute pancreatitis

A

bloods

USS
erect CXR

AXR

assessment of severity

ERCP if LFTs worsen

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9
Q

bloods for acute pancreatitis

A

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

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10
Q

USS for acute pancreatitis

A

for gallstones and biliary dilation, if high AST

pancrease difficult to visualise because of the overlying bowel gas

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11
Q

erect CXR for acute pancreatitis

A

mainly to exclude other causes of acute abdo

may be pleural effusion

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12
Q

AXR for acute pancreatitis

A

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

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13
Q

assessment of severity of acute pancreatitis

A

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

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14
Q

modified glasgow criteria - acute pancreatitis

A

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,
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15
Q

Ranson’s criteria

A

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.
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16
Q

Mx of acute pancreatitis

A

intensive supportive care

early detectuion and treatment of complications

surgical

17
Q

intensive supportive care for acute pancreatitis

A

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

18
Q

early detection and treatment of complications of acute pancreatitis

A

monitor resp function, renal function and clotting

management in ITU might be needed for severe cases

19
Q

surgical Mx for pancreatitis

A

for necrotosing pancreatitis

drainage and debridement of necrotic tissues

20
Q

local complications of acute pancreatitis

A

pancreatic necrosis (further complicated by infection)

pseudocyst

abscess

pancreatic ascites

in the long term - chronic pancreatitis with dm and malabsorption

21
Q

systemic complications of acute pancreatitis

A

multiorgan dysfunction

sepsis

renal failure

ARDS

22
Q

Px of acute pancreatitis

A

20% follow severe fulminating course with high mortality

pancreatic necrosis is associated with 70% mortality

80% run milder course - 5% mortality

23
Q

what ‘characterises’ acute pancreatitis

A

self-perpetuating pancreatic enzyme-mediated autodigestion, oedema and fluid shifts = hypovolaemia

extracellular fluid is trapped in gut, peritoneum, and retroperuitoneum (worsened by vomiting)

24
Q

purpose of giving fluids in acute pancreatitis

A

counter 3rd space sequestration

until vital signs are satisgfactory

and urine flow stays >30ml/hr

25
Q

early complications of acute pancreatitis

A

shock

ARDS
renal failure - give lots of fluids

DIC

sepsis

hypocalcaemia

hyperglycaemia - transient

26
Q

late complications of acute pancreatitis

A

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

27
Q
A

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

yr 3 GI (52 decks)

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