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CC: Gastro > Approach to pancreatitis > Flashcards

Approach to pancreatitis Flashcards

1
Q

When should acute pancreatitis be suspected?

A

When there is severe epigastric pain

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2
Q

Where does acute pancreatitis pain typically radiate to?

A

The back

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3
Q

How can you differentiate between gallstone pancreatitis, and other causes such as alcohol?

A

Time to onset

With a gallstone it will be 10-20 minutes, the others will normally be >1/24

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4
Q

Why would a patient with pancreatitis have dyspnoea?

A

Because of diaphragmatic irritation

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5
Q

Why would a patient with acute pancreatitis have no bowel sounds?

A

Because of ileus formation secondary to inflammation (adynamic ileus)

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6
Q

Why would a patient with acute pancreatitis present with jaundice?

A

If the pancreatitis is 2nd to choledocholithiasis

Or oedema of the head of the pancreas causing Mirizzi syndrome (external common bile duct obstruction)

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7
Q

What also comes with pain in acute pancreatitis normally?

A

Vomiting, nausea, fever, tachypnoea, hypotension

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8
Q

What is the sensitivity/specificity of serum lipase for acute pancreatitis?

A

Between 82-100% both sensitivity and specificity

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9
Q

What are the characteristics of serum lipase in acute pancreatitis?

A

Rises within 4-8 hours

Peaks at 24 hours

Elevated for 8-14 days

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10
Q

What enzymes other than lipase and amylase can be used to assess pancreatitis?

A

Trypsinogen activation peptide (TAP)

Trypsinogen-2 (poorly understood)

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11
Q

What is understood about trypsinogen activation peptide?

A

Elevated in acute pancreatitis

Marker of early acute pancreatitis

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12
Q

What level of CRP is associated with acute pancreatitis?

A

A CRP above 150 mg/dL at 48 hours, though this is a poorly sensitive test

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13
Q

What findings would you find on FBE in acute pancreatitis?

A

Leukocytosis

Elevated haematocrit

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14
Q

Why would you find an elevated haematocrit in acute pancreatitis on FBE?

A

Because of hemoconcentration due to extravasation of intravascular fluid into third spaces

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15
Q

What abnormal findings might you find on UEC in acute pancreatitis?

A

^ Blood urea nitrogen (BUN)

Hypocalcaemia

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16
Q

What findings might be present on AXR in acute pancreatitis?

A

May be unremarkable in mild disease

Localised ileus of a segment of small intestine (sentinel loop)

Colon cut off sign

Ground glass appearance

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17
Q

What findings might be present on CXR in acute pancreatitis?

A

Elevation of the hemidiaphragm

Pleural effusion

Basal atelectasis

Pulmonary infiltrates

ARDS

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18
Q

What is the colon cut off sign on AXR?

A

Reflects paucity of air in the colon distal to the splenic flexure due to functional spasm of the descending colon 2nd to pancreatic inflammation

Just looks like the colon has literally been cut off, due to air being trapped

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19
Q

What does a ground glass appearance on AXR in the context of acute pancreatitis represent?

A

The presence of an acute peripancreatic fluid collection

20
Q

How useful is abdominal U/S in the setting of acute pancreatitis?

A

Not all that useful.

Can show choledocholithiasis

However is there is an ileus, bowel gas may prevent ultrasound penetration

It also cannot detect extrapancreatic spread of inflammation or detect necrosis within the pancreas

21
Q

What would pancreatic necrosis appear on contrast CT?

A

As lack of enhancement with contrast

22
Q

What benefits does MRI have over CT in the setting of acute pancreatitis?

A

Better characterises pancreatic and bile ducts and complications of pancreatitis

MRCP is comparable to ERCP for diagnosis of choledocholithiasis

No radiation, gandolinium less nephrotoxic

23
Q

What disadvantages does MRI have over CT in the setting of acute pancreatitis?

A

Cost, availability, longer scanning time

Requires more operator expertise

24
Q

What criteria does the Dx of acute pancreatitis require?

A

Two of three criteria, of:

Acute onset of persistent, severe, epigastric pain often radiating to the back

Elevation in serum lipase or amylase to three times or greater than the upper limit of normal

Characteristic findings of acute pancreatitis on imaging (CT, MRI or U/S)

25
Q

Is imaging necessary in a patient that has a diagnostic clinical picture and elevations in serum lipase/amylase to three times normal?

A

No

Treat for acute pancreatitis

26
Q

What should be in your DDxs if the patient is a woman of child bearing age presenting with a clinical picture suggesting acute pancreatitis?

A

bHCG, to rule out an uncommon presentation of ectopic pregnancy

Or, indeed, a normal pregnancy that they have not been aware of

27
Q

What should be in the DDxs for a pt presenting with sudden onset, severe epigastric pain?

A

Peptic ulcer disease

Choledocholithiasis, cholecystitis, cholangitis

Perforated viscus

Intestinal obstruction

Mesenteric ischaemia

Hepatitis

28
Q

What is an examination finding that should make you think of mesenteric ischaemia?

A

Patient reporting a lot of pain, but there being no tenderness on palpation of the abdomen

29
Q

Is routine CTabdo recommended at initial presentation in patients with ?acute pancreatitis?

A

No, unless there is uncertainty in diagnosis

No evidene that CT improves outcomes

Extent of necrosis only visible around 72 hours after onset

30
Q

What are some indications for ICU admission in acute pancreatitis?

A

APACHE II score >8 in first 24 hours

Peristent (>48 hours) SIRS

Elevated haematocrit, BUN or creatitine

Age>60yrs

Underlying cardiac or pulmonary disease, obesity

31
Q

What are the APACHE scoring systems?

A

Acute Physiologic and Chronic Health Evaluation scores

There are three scores, APACHE II, III, and IV

IV is the most accurate

32
Q

When should you pursue aggressive fluid resuscitation in acute pancreatitis?

A

In the first 24-48 hours

Associated with improved morbidity/mortality/outcomes

33
Q

Why is fluid resuscitation important in acute pancreatitis?

A

Necrotising pancreatitis results in vascular leak syndrome leading to increased third space loss and worsening of pancreaetic hypoperfusion

34
Q

What are the two most important things to consider in the very acute management of acute pancreatitis?

A

Pain and fluid resuscitation

35
Q

How can you manage the pain of acute pancreatitis?

A

Opioids are safe and effective

Fentanyl is increasingly used because of its better safety profile, especially in renal impairment

36
Q

Can you use morphine in acute pancreatitis?

A

No – it causes increased Sphincter of Oddi pressure

Use merperidine instead if you don’t use fentanyl

37
Q

How can you remember which of the ducts is the Santorini duct?

A

Santorini = Small duct (the two S’s)

Wirsung is the larger duct

38
Q

Why do you have to remove the duodenum if the head of the pancreas must be removed?

A

They share the same blood supply, the gastroduodenal artery

39
Q

What is the mnemonic for the causes of acute pancreatitis?

A

I GET SMASHED

Idiopathic

Gallstones
Ethanol
Trauma

Scorpion bite
Mumps (viruses)
Autoimmune
Steroids
Hyperlipidaemia
ERCP
Drugs
40
Q

What are some signs of acute pancreatitis?

A 
Epigastric tenderness
Diffuse abdominal tenderness
Decreased bowel sounds (adynamic ileus)
Fever
Dehydration/shock
41
Q

What lab tests should you order with ?acute pancreatitis?

A

FBE, LFT, ABG, UEC, coags

Amylase, lipase

Serum lipids (hyperlipidaemia major cause of acute pancreatitis)

42
Q

Aside from pain and fluid resuscitation, what other management should you be considering in an acute pancreatitis pt?

A

NPO
NGT if vomiting
Correction of coags/electrolytes

43
Q

Why does acute pancreatitis cause hypercalcaemia?

A

Fat saponification, where fat necrosis binds to calcium

44
Q

What pancreatic tumour is associated with gallstone formation?

A

Somatostatinoma

Inhibits gallbladder contraction

45
Q

What is the triad of symptoms associated with somatostatinoma?

A

Gallstones

Diabetes

Steatorrhoea

CC: Gastro (6 decks)

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