FN: Acute Pancreatitis

Question 1

Pathophysiology

Answer 1

Pancreatic enzymes released and activated in vicous circle –> multi-stage process

Question 2

Pathophysiology linked to presentation

Answer 2

1. OEdema + fluid shift + vomiting–> hypovolamaemic shock while enzymes –> autodigestion and fat necrosis
2. Vessel autodigestion –> retroperitoneal haemorrhage
3. Inflammation - pancreatic necrosis
4. Super-added infection: 50% of pts/ w/ necrosis

Question 3

Epi

Answer 3

1% of surgical admission
2. 4th and 5th decades
10% mortality

Question 4

Aetiology

Answer 4

IGET SMASHED
Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Microbiology: infection
Autoimmune
Scorpion bite
Hyperlipidaemia
ERCP
Drugs:thiazides, azathioprine

Question 5

symptoms

Answer 5

Severe epigastric pain - radiating to the back -May be relived by sitting forward
Vomiting

Question 6

Signs

Answer 6

Raised HR, Raised RR
Fever
Hypovolaemia - shock
Epigastric tenderness
Jaundice
Ileus - absent bowel sounds
Ecchymoses
1. Grey turners: flank
Cullens periumbilical (tracks up falciform)

Question 7

differential

Answer 7

Perforated DU
Mesenteric infarction
MI

Question 8

Classifying criteria

Answer 8

Modified glasgow criteria

Ranson criteria

Question 9

Modified Glasgow Criteria

Answer 9

Valid for EtOH and Gallstones

Assess severity and predict mortality

Question 10

Ransons criteria

Answer 10

are only applicable to EtOH and can only be fully applied after 48hrs

Question 11

Investigations

Answer 11

Bloods
Urine
Imaging

Question 12

Bloods show

Answer 12

1. Raised WCC
2. Raised amylase and raised serum lipase - returns to nromal by 5-7days
3. U+E: dehydration and renal failure
4. LFTs: cholestatic picture, raised AST, raised LDH
   Calciu: reduced
   Glucose reduced
   CRP: monitor progress >150 after 48hrs = severe
   ABG: reduced oxygen sggest ARDS

Question 13

Urine show

Answer 13

Glucose,
Raised cBR
Reduced urobilinogen

Question 14

Imaging

Answer 14

CXR:ARDS, exlcude perfer DU
AXR: sentinel loop, pancreatic calcification
US: Gallstones and dilated ducts
Contrast CT: balthazar Severity Score

Question 15

conservative Management

Answer 15

Manage @ apprpriate levle: e.g TU if severe
Constant reassessment is key
1. Hrly TPR, UO
Dakly FBC, U+E, Calciu, glucose amylase ABG

Question 16

Fluid resus

Answer 16

Aggressive fluid resusL Keep UO >30 ml

Catheric ! CVP

Question 17

Pancreatitc rest

Answer 17

NBM

NGT if vomiting

Question 18

Conservative management

Answer 18

Fluid reses
Pancreatic rest
Analgesia
Antibiotics

Question 19

Antibiotics

Answer 19

Not routinely given if mild
Used if suspicion of infection of before ERCP
Penems often used: meropenem imipenem

Question 20

Management complications

Answer 20

ARDS: Oxygen therapy or ventilation
Raised glucose: insulin sliding scale
Raised or reduced Calcium
EtOH withdrawal: chlordiazepoxide

Question 21

Interventional Management

Answer 21

If pancreatitis with dilated ducts secondary to gallstones

ERCP + shpincterotomy - reduced surgical complications

Question 22

Surgical management indications

Answer 22

Infected pancreatic necrosis
Psuedocyst or abscess
Unsure diagnosis

Question 23

Operations available

Answer 23

Laparotomy + necrosectomy (pancreatic debridement)
Laparotomy + peritoneal lavage
Laparostomy: abdomen left open with sterile packs in ITU