GI - pancreatitis

Question 1

causes of acute pancreatitis?

I GET SMASHED

Answer 1

I - idiopathic

G - gallstones (50%)
E - ethanol (20%)
T - trauma

S - steroids
M - mumps and malignancy
A - AI (PAN)
S - scorpion
H - ↑lipids, ↑Ca+, ↓T
E - ERCP
D - DHx (valproate, azathioprine, thiazides)

Question 2

why are patients with acute pancreatitis so ill?

Answer 2

intra-pancreatic activation of pancreatic enzymes and auto-digestion, oedema, fluid shifts, hypovolaemia

in severe disease there is erosion of blood vessel walls and intra-abdominal bleeding

Question 3

patient with sudden onset epigastric or LUQ pain radiating to back, V +/- pain relieved with sitting forward?
often with N, anorexia, +/- septic or jaundiced (if GS)?

may have plueral effusions and ascites if severe

Answer 3

acute pancreatitis

Question 4

Ex: bruising over both flanks and peri-umbilical bruising?

Answer 4

Grey-Turners sign (flanks)
Cullens sign (peri-umbilical)

in haemorrhagic pancreatitis there is autodigestion of BV and resultant retroperitoneal haemorrhage

Question 5

signs to find on Ex acute pancreatitis?

Answer 5

↑HR + T
jaundice
shock
ilues
rigid abdo
signs - GTs and Cullens

Question 6

Ix acute pancreatitis?

Answer 6

• ↑ **AMYLASE! (>1000 or 3x normal)
  (Nb amylase ↑ in renal failure and falls after 48 hours)
• ↑ lipase (alcohol espec)
• bloods: ↑wbc, ↑rbc (dehydr), ↓rbc (bleed), ↑LFTs (↑↑GS), ↓Ca+
• if ↑↑↑CRP (severe)
• ABG: +/- lactic acidosis
• ECG (always MI)

imaging:

• AXR (“sentinel” loop of dilated gut next to pancreas and no psoas shadow)
• CXR (plueral effusions, perforation)
• US (if GS + ↑AST)
• ***CT contrast or MRCP gold standard (use if uncertain)

Question 7

GOLD standard Ix for acute pancreatitis?

Answer 7

CT with contrast or MRCP

Question 8

Tx acute pancreatitis?

Answer 8

• fluids LOTS <4L (third space loss)
• antiemetics, analgesia, Abx if need, obs, bloods
• Glasgow score (risk)
• NBM if severe (NG/NJ) +/- ITU
• Ca+ if needed
• Tx cause (alcohol - benzos + vit B)

surgery/drainage if necrosis/abscess

offer lap chole or ERCP if GS/jaundice

Question 9

complications of acute pancreatitis?

Answer 9

infection ↑CRP
sepsis DIC
↑glucose ↓Ca+
***MOF (AKI, ARDS, paralytic ileus)

20% mortality if severe
bleeding (embolise)
necrosis + pseudocyst
abscess (drain)
chronic pancreatitis
insufficiency

Question 10

what mostly causes chronic pancreatitis?

Answer 10

alcohol

Question 11

how do Sx of chronic differ from acute pancreatitis?

Answer 11

(exocrine and endocrine dysfunction in chronic)

• epigastric pain which bores through to the back, relieved by sitting forward or hot water bottle on epigastrium/back
• steatorrhoea + bloating
• malnutrition + ↓weight
• DM

Question 12

Ix suspected chronic pancreatitis

Answer 12

blood glucose (DM)
CT/US (***calcifications confirm diagnosis)

Question 13

Tx chronic pancreatitis?

Answer 13

analgesia, enzyme supplements - creon, diet, DM Tx

surgery if unremitting pain

Question 14

can chronic pancreatitis lead to pancreatic CA?

Answer 14

yes

Question 15

how to assess if acute pancreatitis is severe?

Answer 15

modified glasgow criteria; >3 in 48hrs = severe

P - paO2 <8
A - age >55
N - neutrophilia
C - ↓Ca+
R - ↓renal function
E - enzymes (↑LDH, AST)
A - ↓albumin
S - sugar ↑