Acute Pancreatitis Flashcards by Don J

Epidemiology

Increasing incidence

30 per 100000 in UK

Mortality between 5-30%

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How can it be distinugished from chronic?

In acute tehre is limited damage to the secretory function of the gland

There is no gross structural damaged

However repeated episodes of acute pancreatitis can lead to chronic pancreatitis

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Aetiology

Commonly gallstone disease or excess alcohol

Less commonly GET SMASHED

Gallstones

Ethanol

Trauma

Steroids

Mumps

Autoimmune

Scorpion venom

Hypercalcaemia

ERCP

Drugs like azathioprine, NSAIDs or diuretics

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Pathogenesis of acute pancreatitis

There is a premature and exaggerated activation of digestive enzymes within the pancreas

The pancreatic inflammatory response leads to increase in vascular permeability and subsequent fluid shifts

Enzymes are released into systemic circulation and lead to autodigesetion of fats called fat necrosis

Blood vessels can also be digested leading to retriperitoneal space haemorrhage.

Fat necrosis can cause release of free fatty acids that react with serum calcium and causes hypocalcaemia.

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Clinical features

Sudden onset of severe epigastric pain that can radiate through to the back

N+V

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Examination findings

Epigastric tenderness +/- guarding

Can have haemodynamic instability

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Less common signs

Cullen’s sign (Bruising around umbilicus)

Grey Turner’s sign (bruising in the flank)
These are due to retroperitoneal haemorrhage

There might also be tetany from hypocalcaemia.

Can also have obstructive jaundice if there are gallstones

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AAA

Renal calculi

Chronic pancreatitis

Aortic dissection

Peptic ulcer disease

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Lab tests

Routine bloods

Serum amylase

LFTs

Serum lipase

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Lab test findings

Serum amylase 3x the upper limit of normal (does not correlate with severity)

LFTs with ALT >150U/L has a positive predictive value of 85% for gallstones as underlying cause

Serum lipase is more accurate for acute pancreatitis as it remains elevated longer than amylase.

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When else might serum amylase be elevated?

Bowel perforation

Ectopic pregnancy

DKA

However usually not 3x the upper limit

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Risk scoring

modified Glasgow criteria

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Explain modified glasgow criteria

Assesses the severity within the first 48h of admission

3 or more positive factors should be considered to have severe pancreatitis and a high-dependency care referral is warranted.

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Mnemonic for modified glasgow criteria

PANCRES

pO2 <8kPa

Age >55

Neutrophils >15x10^9/L

Calcium <2mmol/L

Renal function (Urea >16mmol/L)

Enzymes LDH>600U/L or AST >200U/L

Albumin <32g/L

Sugar (serum) >10mmol/L

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Other risk scorers

APACHE II Score

Ranson criteria

Balthazar score

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Imaging

Abdo USS might be done if cause is unknown

AXR can be done but is not routinely done so

CT may be required if initial assessment and ix prove inconclusive.

AXR findings

CAn show a sentinel loop sign = Dilated proximal bowel loop adjacent to the pancreas

This is secondary to localised inflammation

What can contrast-enhanced CT show?

If performed within 48h of initial presentation it can show…

Pancreatic oedema and swelling

Non-enhancing areas suggestive of pancreatic necrosis

When should CT scan for assessment of severity be done?

Only performed 6-10 days after admission in patients with features of persistent infalmmatory response or organ failure.

Mainstay treatment

There is no curative management

Mainstay is supportive measures and treating any underlying cause

What does supportive tx include?

IV fluid resus + O2 if needed (balanced crystalloid should be used)

NG tube if a lot of vomit

Catheterisation to accurately monitor urine output and start a fluid balance shart.

Opioid analgesia

Where should all patients with severe acute pancreatitis be managed?

In a high dependency unit or intensive therapy unit

What might be used as prophylaxis vs infection?

Broad-spectrum antibiotics like imipenem,

This is in cases of confirmed pancreatic necrosis

Treatment of gallstones in acute pancreatitis

Once condition has stabilised

Early laparoscopic cholecystectomy

Systemic complications

Tend to occur within days of initial onset DIC ARDS Hypocalcaemia Hyperglycaemia

Local complications

Pancreatic necrosis Pancreatic pseudocyst

Explain pancreatic necrosis

The ongoing inflammation can lead to ischaemic infarction. This should be suspected in persistent systemic inflammation for more than 7-10 days after onset.

Confirmation of diagnosis of pancreatic necrosis

CT imaging

Treatment of pancreatic necrosis

Pancreatic necrosectomy either open or endoscopic However the intervention should be delayed until walled-off necrosis has developed which is generally 3-5 weeks after onset of symptoms.

When should pancratic necrosis be suspected?

Persistent systemic inflammation for more than 7-10 days Since pancreatic necrosis is prone to infection -\> Clinical deterioration and raised infection markers should warrant suspicion of pancreatic necrosis as well.

Diagnosis of infected pancreatic necrosis

Fine needle aspiration of the necrosis

What is a pancreatic pseudocyst

A collection of fluid containing pancreatic enzymes, blood and necrotic tissue. They can occur anywhere within or adjacent to the panceares. Most commonly seen in **the lesser sac** and **obstructing the** **gastro-epiploic foramen** by inflammatory adhesions.

Why are they called pseudocysts?

Because they lack an epithelial lining, instead they have a vascular and fibrotic wall. They typically form weeks after AP episode.

When are pseudocysts found?

Usually incidentally on imaging They can also present with symptoms of mass effect like biliary obstruction or gastric outlet obstruction. They are also prone to haemorrhage or rupture and can become infection

Treatment of pseudocysts

50% will resolve by themselves so conservative is usually first line If they have been present for long than 6 weeks they are unlikely to resolve by themselves. Treatment is then surgical debridment or endoscopic drainage often into the stomach.

When should antibiotics be used in acute pancreatitis

As prophylaxis in cases of **confirmed** pancreatic necrosis