Acute pancreatitis additional info

Question 1

buzzwords for acute pancreatitis

Answer 1

epigastric abdominal pain
acute
nausea and vomiting
pain worse on eating and lying down
pain improves on leaning forward
pain radiates to back
history of gallstones
sweaty
large body habitus
scleral icterus
jaundice

Question 2

A 46-year-old female presents with a long history of severe upper abdominal pain which radiates to her back.

The patient’s abdominal radiograph is shown below. What does this show?
What is the most likely diagnosis?

Answer 2

pancreatic calcifications

There are punctate, speckled calcifications seen projected in the region of the pancreatic head. These are typical of chronic pancreatitis – they may involve the body and tail also.

Calcification in the pancreas is most commonly associated with chronic pancreatitis.

Question 3

complications of chronic pancreatitis

Answer 3

• diabetes mellitus
• malabsorption
• opiate addiction
• weight loss

Don’t forget that pancreatic cancer and chronic pancreatitis may co-exist and the clinical and imaging features may be very similar. Severe and unrelenting pain is a feature of chronic pancreatitis and can cause opiate addiction. Chronic pancreatitis can affect the exocrine (malabsorption & weight loss) and endocrine (diabetes mellitus) functions of the pancreas.

Question 4

A 64-year-old male patient is referred to your gastroenterology clinic with a six-month history of intermittent epigastric pain and diarrhoea. He has recently been diagnosed as diabetic (non-insulin dependent) and has also lost 1 stone in weight. He is a smoker and has a history of previous alcohol excess but now has reduced consumption to 15-20 units per week.

Clinical examination confirms he is under weight and pale. He is not jaundiced and cardiorespiratory examination confirms mild epigastric tenderness but no masses or organomegaly.

Which is the most likely diagnosis?

Answer 4

chronic pancreatitis

The most likely diagnosis is chronic pancreatitis. This type of pain is typical, often described as “boring” through to the back. Progressive pancreatic damage secondary to recurrent inflammation and subsequent fribrosis/gland atrophy leads to pancreatic insufficiency with diabetes and malabsorption. Weight loss is common. This patient probably has steatorrhoea.

Question 5

differentials for chronic pancreatitis

Answer 5

• Acute pancreatitis
• duodenal ulcer
• coeliac disease
• crohns disease
• primary billiary cirrhosis

Coeliac disease does cause malabsorption, although not pain/diabetes. The history also is not that of acute pancreatitis or duodenal ulcer and biliary cirrhosis tends to present with evidence of cholestasis, but not pain.

Question 6

list 6 investigations for initial assessment of a patient presenting with suspected chronic pancreatitis

Answer 6

1. chest x-ray - if patient is a smoker with a history of weight loss and a chest x-ray is also indicated (mostly to exclude lung cancer).
2. abdominal x-ray - Abdominal radiograph may be helpful to show calcifications associated with chronic pancreatitis.
3. FBC
4. LFTs
   Chronic pancreatitis is associated with malabsorption and this patient has an alcohol history also and a screen of blood investigations are indicated.
5. serum albumin/corrected calcium
6. Amylase - Amylase may also be elevated.

Question 7

Look at the image below. What does this show?

Answer 7

calicication in the pancreatic area

These appearances are pathognomonic for chronic pancreatitis and are not typical for the other options. Vascular calcification is curvilinear.

Question 8

2 further investigations helpful in confirming diagnsosi of chronic pancreatitis

Answer 8

1. CT

CT is the most accurate technique for demonstrating the gland calcification, atrophy and duct dilatation that occur in chronic pancreatitis. Chronic inflammatory masses may occur (pancreatic pseudocysts) and these can be very hard to differentiate from carcinoma.

2. MRCP

MRCP may be helpful as it is non-invasive and could give additional information about the pancreas and ducts.

ERCP should not be used as a purely diagnostic tool due to its significant complication rate. It is mostly a therapeutic procedure to retrieve retained common bile duct stones

Ultrasound is sometimes helpful but bowel gas my obscure the pancreas, making imaging unreliable.

PTC will demonstrate the biliary tree only and so will not provide useful information about the pancreas.

Angiography is used to look at mesenteric vessels, small bowel contrast studies won’t add anything either.

Question 9

Which is the likely aetiological cause of chronic pancreatitis

Answer 9

Alcohol is the commonest cause of chronic pancreatitis (60-90%) . Continued alcohol consumption often worsens symptoms. Likewise smoking is a cause of chronic pancreatitis and worsens the disease course – it is important to advise patients to stop both.

Question 10

List 5 complications of late chronic pancreatitis

Answer 10

• carcinoma of the pancreas -* Carcinoma occurs in 2-3%.*
• opiate addiction - Intractable pain is a common feature of chronic pancreatitis and can cause problems with addiction to opiates prescribed for it.
• pseudocyst formation - Pseudocyst formation occurs due to destruction of the pancreatic parenchyma, resulting in fluid filled sacs containing blood, pancreatic enzymes and necrotic debris. They can increase in size over time
• malabsorption
• diabetes
• diarhoea - (loss of pancreatic exocrine function usually results in diarrhoea

Question 11

What is a drug used in crohns that can trigger acute pancreatitis

Answer 11

Azathioprine

It is important to stop the Azathioprine which is the most likely culprit and patient will never be able to have thiopurine medications again such as mercaptopurine (as this would inevitably cause a recurrence of the pancreatitis).

Question 12

blood result diagnostic of pancreatitis

Answer 12

very raised amylase

Question 13

differentials of acute pancreatitis presentation in crohns

Answer 13

perforation from crohns, perforated peptic ulcer due to steroid therapy, urinary sepsis due to dual immunosuppression, obstruction from stricture

The other differentials are possible and patient will require an urgent CT scan to ensure that there is no surgical emergency, such as perforation or obstruction . Similarly, it would be sensible to screen for sepsis with blood cultures, MSU and CXR

Question 14

treatments alternatives for azathioprine in crohns if it causes acute pancreatitis

Answer 14

The most likely next step would be to offer anti-TNF but Vedolizumab and Ustekinumab are also licensed for the treatment of Crohns

JAK inhibitors are only licensed for ulcerative colitis at the current time.

don’t give mercaptopurine as it is another thiopurine and will cause pancreatitis

Don’t give longterm steroids due to side effect profile

Longterm enteral nutrition isn’t wrong but is not acceptable to most patients.

Question 15

Give 3 of the most likely differential diagnosis

Answer 15

• acute pancreatitis
• alcoholic gastritis
• perforated duodenal ulcer

His alcohol excess makes him at risk for peptic ulcer disease, alcoholic gastritis and pancreatitis, all of which may present with epigastric pain. The abnormal blood tests may point to the severity of the pancreatitis. Appendicitis classically presents with at first central, and then right iliac fossa pain, making it less likely.

Acute cholecysitis classically presents with epigastric pain and vomiting but is less likely following a story of an alcoholic binge.

Question 16

two important tests for suspected acute pancreatitis in ED?

Answer 16

• ERECT CHEST X-RAY
• SERUM AMYLASE

Serum amylase can confirm pancreatitis if above 1000. Lower levels may also suggest pancreatitis, but other causes, such as a perforated duodenal ulcer must be ruled out. Serum lipase may also be useful as it remains elevated for longer so can be helpful with late presentations.

An erect chest x-ray should be sought to rule out a perforated viscus.

An abdominal ultrasound is seldom used in an acute setting to investigate epigastric pain, although it is sensitive for cholecystitis and gallstones, ultrasound is less useful particularly in obese patients who are in pain and does not reliably demonstrate free intraperitoneal air or air in the retroperitoneum. Nowadays patients may undergo a CT abdomen whilst in the ED as it generally provides a rapid diagnosis.

An abdominal X-ray is not likely to be helpful in this situation. A barium meal is unlikely to be helpful in this clinical situation and is not indicated.

MRCP is not indicated at this stage but may be needed later if the bile ducts are dilated to assess for possible duct calculus or ampullary lesion.

Question 17

Initial management of acute pancreatitis

Answer 17

• Blood gas analysis - A blood gas analysis is fundamental to pancreatitis severity scoring, which in turn guides management.
• IV anti-emitics
• IV fluids - Intravenous fluids are critical in pancreatitis. Large amounts of fluid may be lost in third spaces, and patients often require over 5 litres in 2-3 hours, however titrate fluids carefully to fluid status.
• IV analgesia - Analagesia is paramount as pain in pancreatitis is considerable, causing splinting of the diaphragm and possible respiratory compromise.
• start oral feeding - Nutrition is essential in the management of pancreatitis and establishment of oral /enteral nutrition within the first 24 hours has been shown to ameliorate the course of the pancreatitis. However, at this early stage patients are often vomiting a lot and unable to tolerate standard oral nutrition. Consider insertion of an NG tube and slow enteral feeding. Whilst there are theoretical advantages to insertion of an NJ tube bypassing the pancreas, in practice these can take time to arrange missing the vital window of early feeding and NG feeding has been as successful in clinic trials.

Intravenous antibiotics are not indicated if there are no features to suggest sepsis and no features suggestive of acute severe pancreatitis.

An ERCP is only indicated if gallstone pancreatitis is suspected, and again, is not indicated at presentation until a patient is stabilised.

Question 18

He improves steadily and is discharged a few days later with normal liver function tests and serum amylase. He is strongly cautioned against further alcohol use. 2 weeks after his discharge he is readmitted with upper abdominal pain. He denies any further alcohol use. On examination his abdomen is distended. In addition he is very tender in the epigastric region. His WCC is 22 x109/L and amylase is 210 IU/L. A CT scan abdomen shows a cystic lesion in the tail of the pancreas. What is the most likely diagnosis?

Answer 18

pancreatic pseudocyst

A pancreatic pseudocyst is a common complication of acute pancreatitis. Most consist of a collection of fluid, debris and pancreatic juices. Such cysts usually results from a disruption of pancreatic ducts as a consequence of acute pancreatitis.

Such patients may also develop ascites (so called pancreatic ascites), this diagnosis is made by a very high amylase content in the ascitic fluid.

Question 19

complications of acute pancreatitis

Answer 19

• intraductal pancreatic mucinous neoplasm
• pancreatic abscess
• pancreatic cancer
• pancreatic haemorrhage
• pancreatic pseudocyst

A pancreatic pseudocyst is a common complication of acute pancreatitis. Most consist of a collection of fluid, debris and pancreatic juices. Such cysts usually results from a disruption of pancreatic ducts as a consequence of acute pancreatitis.

A cancer in the pancreatic tail may be completely asymptomatic ( it will not cause obstructive jaundice) .

Pancreatic haemorrhage would present with shock, and blood results suggesting blood loss. It is unlikely to present 2 weeks after an initial bout.

A pancreatic abscess would present with pain, and features of sepsis.

IPMN is a benign tumour of the pancreatic ducts although it does have malignant potential.

Question 20

Which technique would be the first line method for draining a pseudocyst?

Answer 20

endoscopic ultrasound (EUS)

The pseudocyst can be drained percutaneously (usually via the left flank) or through the stomach wall at EUS, a blind attempt at gastroscopy is not generally advocated due to the increased risks.

Surgical drainage is thankfully rarely required.

Thought needs to also be given as to why this pseudocyst arose – this is often due to significant ductal disruption and an ERCP can be used to identify any leak and insert stents to reduce the progression of the pseudocyst.

Question 21

An ERCP reveals a leak in the pancreatic duct and a temporary stent is placed in the pancreatic duct to help seal the leak. The patient settles clinically and radiologically and repeat imaging 4 months later shows almost complete resolution of the pseudocyst. The patient is unfortunately lost to follow up and re-presents 10 years later, again with severe abdominal pain, weight loss and loose stools. He started drinking alcohol again 5 years ago and is currently drinking about 4-5 units/day. On examination he is cachetic. There are no stigmata of chronic liver disease. Initial lab work reveals: Blood glucose 12 mmol/l Amylase 45 IU/L Bilirubin 21 mmol/L Alkaline phosphatase 150 IU/L An abdominal x-ray shows calcification in the upper abdomen. What is the most likely cause of the elevated blood glucose and loose stools?

Answer 21

PANCREATIC INSUFFICIENCY

This patient has developed chronic pancreatitis due to on-going alcohol use.

This is supported by the pancreatic calcification on the abdominal film.

Serum amylase may be normal in chronic pancreatitis.

Diabetes mellitus and malabsorption are common sequelae of chronic pancreatitis.

Question 22

How can you establish the diagnosis of pancreatic exocrine insufficiency?

Answer 22

• clinical judgement
• faecal elactase

Faecal elastase measures pancreatic exocrine function, however it is a fairly blunt instrument to determine pancreatic insufficiency. Clinical judgement is just as good.

wrong options:
- Calprotectin is a measure of gastrointestinal inflammation (think of it like CRP for the bowel)
- ERCP, CT scan and MRCP will give us pictures of what the pancreas looks like but not how it is functioning.
- the SeHCAT scan measures bile salt reabsorption, and is a test used to investigate chronic diarrhoea but does not give information about pancreatic exocrine function and is not relevant here.

Question 23

What is the treatment for pancreatic exocrine insufficiency?

Answer 23

oral pancreatic enzyme replacement eg. creon, pancreas V, nutrizyme.

Pancreatic exocrine insufficiency can ameliorated by oral enzyme replacement. Patients with chronic pancreatitis need expert dietary advice and are at high risk of malnutrition. Enzyme replacement therapy is essential and, if used properly can allow the patient to eat a normal diet. Dietetic input is very important.

Question 24

A 38-year-old man attends the ED with a 3-day history of epigastric pain. The pain has become increasingly severe but eases on sitting upright. The patient has been vomiting bilious liquid and has not eaten or opened his bowels normally for several days. The patient is not taking any medication but does have a history of alcohol misuse spanning several years.

On examination, he looks unwell and is in pain, his temperature is 37.8°C, heart rate 100 bpm, and blood pressure 120/70 mmHg. His abdomen is mildly distended and bowel sounds are quiet and there is diffuse tenderness with guarding in the upper abdomen. Chest and cardiovascular examination are otherwise unremarkable.

What differential diagnoses would you consider?

Answer 24

• acute cholecystitis
• acute pancreatitis
• perforated duodenal ulcer

if patient clinically has an ileus/small bowel obstruction, the severe upper abdominal pain could relate to acute pancreatitis or cholecystitis, a perforated duodenal ulcer or possibly a myocardial infarction.

Question 25

list 4 investigations in helping to make a diagnosis of acute pancreatitis

Answer 25

• CT scan abdomen
• Erect chest x-ray
• serum amylase
• ultrasound of the upper abdomen

In practice, most patients presenting with peritonitis would have a CT scan, followed by an USS if there was a query regarding gallstones, which are not routinely demonstrated on CT due to their cholesterol content. This is because a CT is easier and quicker to arrange, particularly out of hours.

An USS is helpful particularly to exclude gallstones and acute cholecystitis as a cause of pain and will confirm normal calibre bile ducts, making a bile duct calculus unlikely as a cause of pancreatitis also.

Chest X-ray (erect) is helpful to look for free intraperitoneal air.

MRCP/ERCP may be needed later if gallstones are a likely aetiology, especially of the biliary tree is dilated and stones need to be demonstrated (MRCP) and removed (ERCP).

Question 26

describe these findings of an erect chest X-ray and an abdominal X-ray.

Answer 26

there is air in normal large bowel vsiisble beneath the right hemidiaphragm and dilated small bowel loops are present
Normal large bowel can be seen interposed between liver and right hemidiaphragm. This is a normal variant and is known as Chilaiditi’s sign, do not confuse this appearance with free intraperitoneal air. Dilated small bowel loops are present on the abdominal radiograph – in keeping with small bowel obstruction/ileus.

Question 27

Can a serum amylase measurement of 380 iU/L (normal range 0-150 iU/L) be associated with acute pancreatitis?

Answer 27

yes

In acute pancreatitis the amylase level may be very high (>1000 U/ml). If the pancreatitis has been going on for a few days the level may drop however and moderate elevation may also be seen occasionally in other conditions e.g. duodenal perforation, mesenteric infarction, acute cholecystitis.

Question 28

what is the Glasgow-Imrie criteria and what is another scoring system for acute pancreatitis

Answer 28

Worsening pancreatitis may be associated with hypoxia, hyperglycaemia, reduced serum calcium and albumin, rising white cell count, C-reactive protein and renal failure.

The Glasgow-Imrie criteria for the severity of acute pancreatitis is scored once, 48 hours after admission and uses the following parameters:

PaO2
WCC
Serum calcium
urea
LDH
Albumin
Glucose
Ranson criteria is another scoring system but requires measurement on admission and 48 hours later and uses age, change in haematocrit, fluid loss, change in urea and base deficit as well as measurements of glucose, WCC, LDH and calcium

Question 29

The patient recovers from this acute episode. It is thought that it is likely to relate to alcohol misuse but he returns to accident and emergency 6 weeks later with recurrence of upper abdominal pain. On this occasion there is fullness in the epigastrium although the symptoms and signs are less pronounced than at his initial presentation. His amylase is mildly elevated, having previously returned to normal What is the likely diagnosis?

Answer 29

pancreatic pseudocyst

This is the typical presentation of a pancreatic pseudocyst – US/CT will confirm and drainage is needed endoscopically, percutaneously or surgically.

Question 30

causes of acute pancreatitis

Answer 30

GETSMASHED

Gallstones
Ethanol (alcohol)
Trauma
Steroids
Mumps
Autoimmune disease (e.g. systemic lupus erythematosus, Sjogren’s syndrome)
Scorpion stings
Hypercalcaemia, hypertriglyceridemia, hypothermia
ERCP
Drugs (e.g. thiazides, azathioprine, sulphonamides)

Hypercalcaemia e.g. secondary to hyperparathyroidism can precipitate acute pancreatitis as can instrumentation such as an ERCP. Hypertriglyeridaemia is associated with an increased risk of acute pancreatitis. Certain drugs can also cause acute pancreatitis including steroids and azathioprine.

Question 31

immediate investigation for suspected gallstone induced pancreatitis

Answer 31

Early ultrasound imaging in acute pancreatitis is important to determine the aetiology as this may affect management (e.g. patients with gallstones/biliary obstruction)

Question 32

does amylase give prognostic value

Answer 32

While amylase is an important investigation in the diagnosis of pancreatitis, it does not offer prognostic value.

Amylase is a vital investigation in the diagnosis of acute pancreatitis but the level does not correlate with severity and it is therefore not useful as a prognostic marker. An amylase level >3x the upper limit of normal is diagnostic of acute pancreatitis in a patient with upper abdominal pain.

Question 33

how are calcium levels related to pancreatitis prognosis

Answer 33

indicates poor prognosis. The mechanism of hypocalcaemia in this context is unclear but there is a demonstrated increased mortality rate in patients presenting with hypocalcaemia compared to those with normal calcium levels.Hypocalcaemia is part of the Glasgow pancreatitis score, which predicts the severity of pancreatitis. The Glasgow-Imrie criteria are indicators of severity. Having three or more of the criteria is an indicator of severe acute pancreatitis, and would warrant intensive care review.

note: Whilst hypercalcaemia can cause pancreatitis, hypocalcaemia is an indicator of pancreatitis severity

Question 34

which is more sensitive for acute pancreatitis. amylase or lipase

Answer 34

lipase

The serum amylase may rise and fall quite quickly and lead to a false negative result. Should the clinical picture not be concordant with the amylase level then serum lipase or a CT Scan should be performed.