Acute Pancreatitis COPY

Question 1

What are the two most common causes of acute pancreatitis?

Answer 1

Alcohol misuse and gallstones are the most common causes of acute pancreatitis.

Question 2

Alcohol misuse and gallstones are responsible for upwards of 75% of cases of … …. Other important causes include ERCP and hyperlipidaemia (e.g. hypertriglyceridaemia).

Answer 2

Alcohol misuse and gallstones are responsible for upwards of 75% of cases of acute pancreatitis. Other important causes include ERCP and hyperlipidaemia (e.g. hypertriglyceridaemia).

Question 3

The causes of acute pancreatitis may be remembered with the mnemonic I GET SMASHED.

Answer 3

Question 4

… are the most common cause of acute pancreatitis, they are responsible for around 40-50% of cases.

Answer 4

Gallstones are the most common cause of acute pancreatitis, they are responsible for around 40-50% of cases.

Question 5

… has toxic effects on the pancreas and is implicated in around 25-35% of cases of acute pancreatitis

Answer 5

Alcohol has toxic effects on the pancreas and is implicated in around 25-35% of cases.

Question 6

Alcohol commonly causes chronic pancreatitis with alcoholics suffering … attacks. It may also induce acute pancreatitis without pre-existing disease following a significant binge.

Answer 6

Alcohol commonly causes chronic pancreatitis with alcoholics suffering … attacks. It may also induce acute pancreatitis without pre-existing disease following a significant binge.

Question 7

Acute pancreatitis is a significant complication in those undergoing an … It is estimated 1-3% develop the condition following the procedure.

Answer 7

Acute pancreatitis is a significant complication in those undergoing an endoscopic retrograde cholangiopancreatography (ERCP). It is estimated 1-3% develop the condition following the procedure.

Question 8

Pancreatitis is caused by the abnormal release and activation of enzymes, which cause … of pancreatic tissue.

Answer 8

Pancreatitis is caused by the abnormal release and activation of enzymes, which cause autodigestion of pancreatic tissue.

Question 9

The pancreas has both endocrine and exocrine functions. Endocrine function is governed by the islets of … and the hormones produced include … and ….

Answer 9

The pancreas has both endocrine and exocrine functions. Endocrine function is governed by the islets of Langerhans and the hormones produced include insulin and glucagon.

Question 10

The pancreatic ductal cells are responsible for the … function. They produce the ‘pancreatic juice’ composed of bicarbonate and digestive enzymes. One of these enzymes, trypsin (helps with the breakdown and digestion of proteins), is key to the development of pancreatitis.

Answer 10

The pancreatic ductal cells are responsible for the exocrine function. They produce the ‘pancreatic juice’ composed of bicarbonate and digestive enzymes. One of these enzymes, trypsin (helps with the breakdown and digestion of proteins), is key to the development of pancreatitis.

Question 11

Under normal circumstances, the pancreas releases zymogens - inactive enzyme precursors (trypsinogen in the case of trypsin). In …, normal zymogen transport fails and trypsinogen is converted to trypsin within the pancreas leading to a cascade of zymogen activation. This triggers the recruitment of inflammatory cells and the release of inflammatory mediators.

Answer 11

Under normal circumstances, the pancreas releases zymogens - inactive enzyme precursors (trypsinogen in the case of trypsin). In pancreatitis, normal zymogen transport fails and trypsinogen is converted to trypsin within the pancreas leading to a cascade of zymogen activation. This triggers the recruitment of inflammatory cells and the release of inflammatory mediators.

Question 12

The presentation of pancreatitis may range from mild abdominal pain to life-threatening …

Answer 12

The presentation of pancreatitis may range from mild abdominal pain to life-threatening shock.

Question 13

Symptoms of pancreatitis

Answer 13

Abdominal pain (may radiate to the back)
Nausea
Vomiting
Anorexia
Diarrhoea

Question 14

Signs of acute pancreatitis

Answer 14

Abdominal tenderness
Abdominal distention
Tachycardia
Tachypnea
Pyrexia

Question 15

Cullen’s sign:

Answer 15

peri-umbilical bruising (first described in ruptured ectopic pregnancy)

Question 16

Grey-Turner’s sign: … …

Answer 16

Grey-Turner’s sign: flank bruising

Question 17

A serum … elevated 3 times above the reference range is considered diagnostic for acute pancreatitis

Answer 17

A serum amylase elevated 3 times above the reference range is considered diagnostic.

Question 18

When do amylase levels fall in acute pancreatitis?

Answer 18

Levels rise acutely before falling after 3 days (urinary amylase may remain elevated for a longer period).

Question 19

Aside from pancreatitis, there are a number of causes of elevated amylase. These include …

Answer 19

Aside from pancreatitis, there are a number of causes of elevated amylase. These include parotitis, bowel obstruction, intestinal inflammation, trauma, numerous malignancies and ruptured ectopic pregnancies - however, levels tend to only be mildly elevated.

Question 20

serum … is sometimes measured for suspected acute pancreatitis instead of amylase. Again, levels elevated 3 times above the reference range are indicative of pancreatitis. … has a longer half-life and as such levels remain elevated longer than amylase. Raised levels are also more specific for pancreatic disease than amylase.

Answer 20

Again, levels elevated 3 times above the reference range are indicative of pancreatitis. Lipase has a longer half-life and as such levels remain elevated longer than amylase. Raised levels are also more specific for pancreatic disease than amylase.

Question 21

Bedside tests for suspected acute pancreatitis

Answer 21

Observations
ECG
Blood sugar
Pregnancy test

Question 22

Bloods for suspected acute pancreatitis

Answer 22

Amylase/lipase
FBC
U&Es
CRP
LFTs (assess for any evidence of concomitant cholangitis)
Bone profile (hypocalcaemia is common, used in scoring)
LDH (used in scoring)
Serum glucose (particularly important in diabetics where blood glucose control often worsens, also used in scoring)
Lipids (hyperlipidaemia is a cause of pancreatitis)
Arterial blood gas (assess oxygenation and acid-base, pO2 is also used for scoring acute pancreatitis)

Question 23

Imaging for acute pancreatitis

Answer 23

Ultrasound: used to demonstrate gallstones or a dilated common bile duct. The pancreas may be visualised.

Computed tomography: used to confirm diagnosis when uncertainty remains and to exclude complications of disease.

MRCP: most commonly indicated in suspected gallstone pancreatitis to help evaluate for CBD stones.

Question 24

The … score, completed in the first 48hrs, helps to assess the severity of acute pancreatitis.

Answer 24

The Glasgow score, completed in the first 48hrs, helps to assess the severity of acute pancreatitis.

Question 25

A score of … or greater (Glasgow score) indicates severe pancreatitis, these patients have a high mortality and should receive HDU/ITU review. It is normally completed at admission and repeated at 48 hours.

Answer 25

A score of 3 or greater (Glasgow score) indicates severe pancreatitis, these patients have a high mortality and should receive HDU/ITU review. It is normally completed at admission and repeated at 48 hours.

Question 26

The majority of cases of acute pancreatitis are treated with supportive measures. This normally includes: (3)

Answer 26

IV fluids
Analgesia
Nutritional support

Question 27

Supportive care for acute pancreatitis involves … management

Answer 27

Pain is the most common complaint and patients should receive adequate analgesia. Morphine can be used, but may lead to spasm of the sphincter of Oddi. Pethidine and buprenorphine are alternatives.

Question 28

Acute pancreatitis - must monitor … balance

Answer 28

Patients require fluid resuscitation to compensate for third-space losses. They may need aggressive intravenous fluids, particularly in the first 24 hours. A careful fluid balance should be recorded and a urinary catheter is indicated in all but the mildest cases.

Question 29

Nutrition - acute pancreatitis

Answer 29

Our understanding of how to best manage nutrition in patients with acute pancreatitis continues to evolve. In mild cases, a low-fat diet may be reintroduced once tolerated by the patient (i.e. the pain has settled and they have an appetite).

In patients with severe disease where a normal diet is not tolerated other options must be explored. As a general rule enteral feeding is preferred to total parenteral nutrition (TPN). It is thought enteral feeding helps maintain the mucosa and prevents translocation of bacteria. Nasojejunal feeding is commonly used.

TPN should be used in patients with ileus or where nutritional requirements are not being met.

Question 30

Are antibiotics indicated in acute pancreatitis?

Answer 30

Antibiotics are not routinely indicated in acute pancreatitis and they should not be used prophylactically. Antibiotics should be commenced in patients with suspected/confirmed infected pancreatic necrosis, cholangitis or another infective source.

Question 31

Patients with gallstone pancreatitis need supportive management, biliary decompression where indicated and … when appropriate.

Answer 31

Patients with gallstone pancreatitis need supportive management, biliary decompression where indicated and cholecystectomy when appropriate.

Question 32

Following a diagnosis of acute pancreatitis an … is indicated in essentially all patients

Answer 32

Following a diagnosis of acute pancreatitis an USS is indicated in essentially all patients (may be omitted in those with an admission CT that is considered conclusive).

Question 33

In those with signs or blood tests indicative of an obstructed biliary system, or an inconclusive USS, an … will normally be arranged to assess for CBD stones.

Answer 33

In those with signs or blood tests indicative of an obstructed biliary system, or an inconclusive USS, an MRCP will normally be arranged to assess for CBD stones.

Question 34

General management of gallstone pancreatitis

Answer 34

The general management is as described above. Appropriate IV fluids, analgesia and nutritional support are key.

Antibiotics should be commenced in any patient with suspected cholangitis or other infective source.

Question 35

ERCP - when is this indicated in pancreatitis?

Answer 35

In patients with gallstone pancreatitis, CBD stones and cholangitis urgent decompression is required. ERCP should also be promptly organised for those with stones obstructing the CBD. This can be achieved with ERCP and stone extraction (+/- sphincterotomy, +/- stent).

Question 36

In patients with … pancreatitis, CBD stones and … urgent decompression is required. ERCP should also be promptly organised for those with stones obstructing the CBD. This can be achieved with ERCP and stone extraction (+/- sphincterotomy, +/- stent).

Answer 36

In patients with gallstone pancreatitis, CBD stones and cholangitis urgent decompression is required. ERCP should also be promptly organised for those with stones obstructing the CBD. This can be achieved with ERCP and stone extraction (+/- sphincterotomy, +/- stent).

Question 37

… is recommended following recovery from gallstone pancreatitis. Ideally, in cases that are relatively mild, this can be completed during the index admission.

Answer 37

Cholecystectomy is recommended following recovery from gallstone pancreatitis. Ideally, in cases that are relatively mild, this can be completed during the index admission.

Question 38

Local complications of acute pancreatitis include pancreatic … and pancreatic pseudocyst formation.

Answer 38

Local complications of acute pancreatitis include pancreatic necrosis and pancreatic pseudocyst formation.

Question 39

Local complications of acute pancreatitis include pancreatic necrosis and pancreatic … formation.

Answer 39

Local complications of acute pancreatitis include pancreatic necrosis and pancreatic pseudocyst formation.

Question 40

Pancreatic necrosis - what is this?

Answer 40

In certain cases, continued inflammation leads to localised thrombosis, haemorrhage and necrosis within the pancreas. Though initially sterile, there is a 30-70% chance of infection. This is a major cause of mortality in those with acute pancreatitis.

Patients with suspected infected necrosis should have a CT guided fine needle aspiration and culture. Culture positive patients are generally managed with appropriate antibiotics guided by microbiology. Drainage or surgical debridement may be required

Question 41

Pancreatic pseudocyst - what is this?

Answer 41

These are organised peripancreatic collections of pancreatic fluid, normally defined as being present for four or more weeks after an acute episode. The term ‘pseudo’ reflects the absence of an epithelial lining around the cyst, instead being surrounded by fibrotic granulation tissue.

If small and asymptomatic these can be monitored, but they frequently cause pain and the feeling of fullness. In addition, they can be complicated by rupture, haemorrhage or cause bowel/gastric outlet obstruction. Pseudocysts that are symptomatic or large require endoscopic, radiological or surgical management.

Question 42

What vascular complications may arise in acute pancreatitis?

Answer 42

Pseudoaneurysm: these are rare but when they occur life-threatening haemorrhages may result. It can affect any local vessel but it is often seen in the splenic and hepatic arteries. They normally occur in association with pancreatic pseudocysts. When haemorrhage occurs, interventional radiology intervention is normally the mainstay of management after appropriate resuscitation.

Venous thrombosis: a relatively common and likely under recognised complication, venous thrombosis may affect the portal, splenic and superior mesenteric veins. It is often diagnosed incidentally on repeat CT in patients with severe pancreatitis. Optimal management of the underlying pancreatitis is key, anticoagulation decisions should be made following discussion between surgeons and haematology.

Question 43

Severe acute pancreatitis can result in A…, renal failure and distributive …

Answer 43

Severe acute pancreatitis can result in ARDS, renal failure and distributive shock.

Question 44

Systemic complications of severe acute pancreatitis (3)

Answer 44

Severe acute pancreatitis can result in ARDS, renal failure and distributive shock.

Question 45

In some individuals a cascade of inflammatory mediators leads to systemic complications including:

Answer 45

Acute respiratory distress syndrome
Renal failure
Shock (multifactorial but often distributive in nature)
In those with single or multiple organ failure mortality is greatly increased. These patients need HDU/ITU care with organ support and close monitoring.

Question 46

Patients with mild pancreatitis (no organ failure or complications) have a mortality of approximately …%. This rises significantly in those with severe pancreatitis:

Sterile pancreatic necrosis: …% mortality
Infected pancreatic necrosis: …% mortality

Answer 46

Patients with mild pancreatitis (no organ failure or complications) have a mortality of approximately 1%. This rises significantly in those with severe pancreatitis:

Question 47

… pancreatic necrosis: 10% mortality

… pancreatic necrosis: 25% mortality

Answer 47

Sterile pancreatic necrosis: 10% mortality

Infected pancreatic necrosis: 25% mortality