GI - Acute Pancreatitis

Question 1

Acute pancreatitis: pathophysiology

Answer 1

• pancreatic enzymes released and activated in vicious circle —> multi stage process
  1. Oedema + fluid shift + vomiting = hypovolaemia
  2. Vessel auto-digestion —> Retroperitoneal haemorrhage (Cullen’s + Grey Turner signs)
  3. Inflammation —> pancreatic necrosis
  4. Super-added infection: 50% of pts have necrosis

Question 2

Acute pancreatitis: aetiology

Answer 2

• Idiopathic
• Gallstones
• Ethanol
• Trauma
• Steroids
• Mumps
• Autoimmune
• Scorpion bites
• Hyperlipidaemia, hyperthermia
• ERCP
• Drugs: thiazides, azathiprine

Question 3

Acute pancreatitis: symptoms

Answer 3

• Severe epigastric pain radiating to back (may be relieved by sitting forward)
• vomiting

Question 4

Acute pancreatitis: signs

Answer 4

• raised HR and RR
• fever
• hypovolaemia leading to shock
• epigastric tenderness
• jaundice
• ileus (absent bowel sounds)
• Ecchymoses: Grey Turner (flank) and Cullens (peri-umbilical, tracks up falciform)

Question 5

Acute pancreatitis: differential

Answer 5

• Perforated DU
• Mesenteric infarction
• MI

Question 6

What is the scale and name of criteria

Answer 6

Glasgow Criteria (spell out pancreas)

• PaO2 <8kPa
• Age: >55years
• Neutrophils: >15x10^9/L
• Ca2+ (uncorrected): <2mM
• Renal function: Urea >16mM
• Enzymes: LDH>600iu/L and AST>200iu/L
• Albumin: <32g/l
• Sugar: >10mM
• If scores on 1 (mild), 2 (mod) and 3 (severe)

Question 7

Acute pancreatitis: Ix - bloods and urine

Answer 7

• FBC: raised WCC
• U+E: dehydration and renal failure
• LFT: cholestatic picture with raised AST and raised LDH
• low calcium, high glucose
• CRP: raised
• ABG: low PaO2 suggests ARDS
• Urine: glucose, amylase, low urobilinogen

Question 8

Acute pancreatitis: Ix - imaging

Answer 8

• CXR: ARDS and exclude perf DU
• AXR: pancreatic calcification
• US: gallstones and dilated ducts + inflammation

Question 9

Acute pancreatitis: Mx - conservative

Answer 9

• Manage at appropriate level (may need ITU)
• Daily bloods, hourly obs/input-output monitoring
• Analgesia: morphine or pethidine
• Antibiotics: used if suspicion of infection (penems preferred)
• O2 therapy (for ARDS Mx), sliding scale (rising glucose), Ca2+ (ca falls)

Question 10

Acute pancreatitis: Mx - interventional

Answer 10

• Main option is ERCP if pancreatitis is associated with dilated ducts secondary to gallstones (do US first to prove this)
• Rx: ERCP + sphincterotomy

Question 11

Acute pancreatitis: Mx -surgical (indications and options)

Answer 11

Indications:

• Infected pancreatic necrosis
• Pseudocyst or abscess
• unsure of Dx

Options

• Laparotomy + necrosectemy (panic debridement)
• Laparotomy + peritoneal lavage
• Laparostomy: abdomen left open with sterile packs in ITU