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Gwen - GI and General surgery > Hepato-biliary: Acute pancreatitis > Flashcards

Hepato-biliary: Acute pancreatitis Flashcards

1
Q

What is acute pancreatitis?

A

Reversible inflammatory state of the pancreas

  • Mild (85%) - Mild form of interstitial edema of the gland
  • Severe (15%) - Patients with pancreatic, or peripancreatic, necrosis or acute fluid collections have severe pancreatitis
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2
Q

What are the clinical “phases” of acute pancreatits

A

Early: lasts for a week

Second: weeks to months

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3
Q

What are causes of acute pancreatitis?

A
  • Idiopathic
  • Gallstones
  • Ethanol
  • Trauma
  • Steroids
  • Mumps
  • Autoimmune
  • Scorpian venom
  • Hyperlipidaemia, hypothermia, hypercalcaemia
  • ERCP
  • Drugs
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4
Q

What is the pathophysiology of acute pancreatitis?

A

Self-perpetuating enzyme mediated autodigestion:

  • Enzymes cause leaky vessels, leading to tissue oedema and inflammation
  • Lipolytic enzymes -> fat necrosis
  • Released fatty acids bind calcium -> white precipitates in the necrotic fat
  • Proteolytic enzymes destroy aicnar tissue.
  • Destruction of blood vessels causes haemorrhage
  • Destruction of islet cells can result in hyperglycaemia
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5
Q

Why do individuals with pancreatitis get hypoglycaemia?

A

Due to destruction of islet cells

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6
Q

Why do those with pancreatitis have white patches in the necrotic fat?

A

Fatty acids produced by lipolytic enzyme breakdown of fat bind calcium, forming white deposits

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7
Q

What are symptoms of acute pancreatitis?

A
  • Gradual/sudden severe epigastric/central abdominal pain
  • Vomiting
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8
Q

What is characteristic of the pain experienced in acute pancreatitis?

A
  • Radiates to the back
  • Relieved by sitting forward
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9
Q

What are signs of acute pancreatitis?

A
  • Tachycardia
  • Pyrexia
  • Can be in profound shock
  • Jaundice - obstructive (oedema of the head of the pancreas compressing the lower end of CBD)
  • Ileus
  • Rigid abdomen +/- local/general tenderness
  • Cullen’s sign
  • Turner’s sign
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10
Q

What is Cullen’s sign?

A

Periumbilical ecchymoses (haemorrhagic discoloration)

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11
Q

What causes cullen’s sign?

A

Retroperitoneal haemorrhage - The retroperitoneum is connected to the gastro-hepatic ligament, then the falciform ligament, and finally to the round ligament (the obliterated umbilical vein), which tracks to the abdominal wall around the umbilicus. When a haemorrhage (from any cause) occurs, blood is able to move along these ligaments to the abdominal wall to produce ecchymoses

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12
Q

What is Grey Turner’s sign?

A

Ecchymoses or purple discolouration of the flanks.

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13
Q

What is the mechanism behind Grey-Turner’s sign?

A

A hole in the abdominal fascia. A defect in the transversalis fascia allows blood from the posterior pararenal space to move to the abdominal wall musculature and the subcutaneous tissue

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14
Q

What are other causes of Cullen’s sign, besides acute pancreatitis?

A
  • Retroperitoneal bleeding
  • Post surgery
  • Anticoagulation
  • Rectus sheath haematoma
  • Ectopic pregnancy
  • Ischaemic bowel
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15
Q

Why wouldnt there be rigidity on abdominal palpation

A

Because pancreas is retroperitoneal. Make sure you aren’t missing an itnra-peritoneal rigidity

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16
Q

Why might there be reduced bowel sounds?

A

Secondary to ileus in small bowel loop or transverse colon nect to pancreas

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17
Q

Differentials of acute pancreatits

A
  • Perforated PU - sudden pain then levels off compared to AP (gradual reaching max due to inflammatory process),
    • Erext CXR
  • Acute cholecystitis/biliary colic
    • AUS
  • High intestinal obstruction
    • AXR
    • CT
  • Inferior MI
    • Bloods - troponin
    • ECG
  • Ruptured AAA
    • CT
    • AUS
  • Mesenteric ischaemia
    • CT angiogram
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18
Q

What investigations would you do if you thought someone had acute pancreatitis?

A
  • Bloods - Amylase/lipase, FBC, U&Es, LFTs, Ca2+, Glucose, ABG, Lipids, Coagulation screen, CRP
  • Urinary amylase
  • Abdominal XR/Erect CXR
  • Abdominal USS
  • Contrast-enhanced spiral CT
  • MRI/MRCP
  • ERCP
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19
Q

What bloods would you do in someone with suspected acute pancreatitis?

A
  • FBC, U&Es, LFTs
  • Amylase/lipase
  • LDH
  • Albumin
  • Ca2+
  • Glucose
  • ABG
  • Lipids
  • Coagulation screen
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20
Q

Why would you perform an erect CXR in someone with suspected acute pancreatitis?

A

To exclude a gastroduodenal perforation/pleural effusion. May also see signs of calcification

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21
Q

Why might you do an abdominal ultrasound in someone with acute pancreatitis?

A

1st line

Used to screen for possible biliary causes of pancreatitis. This is mainly used to exclude gallstones

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22
Q

Why would you consider doing a CT in someone with acute pancreatitis?

A

To assess extent/severity of pancreatic necrosis and for complications, including:

  • Abscess development
  • Fluid collection
  • Pseudocyst

Indicated in those with

  • uncertain diagnosis
  • a severe attack
  • clinical deterioration
  • suspected local complications
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23
Q

Why would you do an ERCP in someone with acute pancreatitis?

A

Used to look at pancreatic duct for inflammatory fibrosis, tumours, gallstones. Can also be used to remove stones.

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24
Q

Why might you do an abdominal X-ray in someone with suspected acute pancreatitis?

A

Look for signs of fluid collection - retroperitoneal fluid.

Also look for ielus - sentinel loop next to inflamed organ, colon cut off sign inflammed colond ue to associated pancreas.

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25
Q

Why might you perform a glucose in someone with suspected pancreatitis?

A

Look for signs of hypo/hyperglycaemia

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26
Q

Why might you look at LFTs in someone with suspected acute pancreatitis?

A

Obstructive jaundice pattern

Look for signs of liver dysfunction caused by blockage of biliary system - e.g. gallstones which could cause pancreatitis

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27
Q

Why might you perform a coagulation screen in someone presenting with features of acute pancreatitis?

A

Look for causes of cullen’s/Grey-turner’s sign - clotting disorders

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28
Q

Why would you do an ABG in someone with acute pancreatitis?

A

Look for signs of acid/base disturbance and monitor oxygenation (to assess severity - Modified glasgow criteria)

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29
Q

How is amylase excreted?

A

Renally - renal failure will lead to accumulation

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30
Q

What are causes of raised serum amylase?

A
  • Upper GI perforation
  • Biliary peritonitis
  • Intestinal infarction
  • Macroamylasaemia
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31
Q

Why is a serum calcium measured in acute pancreatitis?

A

Look for hypocalcaemia & to assess severity - Modified glasgow criteria

Due to deposition of calcium in fat necrosis

Appears 3-8 days after acute attack

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32
Q

Why would you assess U+E’s in someone with suspected acute pancreatitis?

A

Assess severity - Modified glasgow criteria

Concernad about 3rd space fluid loss - ARF

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33
Q

How would you manage gallstones as a cause of acute pancreatitis?

A

ERCP - can remove gallstones if progressive jaundice

If mild AP then during same admission

If severe then should be delayed until inflammatory process settled

If local complications - done when these have resolved or dealt with seperately

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34
Q

Why might you do a CRP in someone with suspected acute pancreatitis?

A

Assess disease severity and prognosis

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35
Q

What level would you expect amylase to reach?

A

400 units is suggestive

>1000 is diagnostic

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36
Q

How long does it take amylase to intially rise?

A

Within 6 hours

NON SPECIFIC AND NON PROGNOSTIC

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37
Q

How long does it take amylase levels to fall back to normal after initial presentation of acute pancreatitis?

A

3-5 days - Late presentation may give false negative result

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38
Q

Other causes of raised amylase

A

Acute cholecystitis, CBD stone, perofrated PI, mesenteric ischaemia, pancreatic cancer

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39
Q

More specific test other than amylase that isn’t readily availble but would be ideal

A

Lipase

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40
Q

Diagnostic criteria for acute pancreatitis

A
  1. Abdominal pain consistent with acute pancreatitis
  2. Serum lipase (or amylase) levels at least 3x greater than the upper limit
  3. Characteristic findings on contrast, CT or less commonly MRI/AUS
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41
Q

Difference between mild/moderate/secere AP

A

Mild - no organ failure, no local or systemic complications

Moderate - transient organ failure (resolves<48 hours)

Severe - persistant organ failure (>48 hours)

42
Q

How would you assess the severity of pancreatitis in someone with acute pancreatitis?

A

Modified glasgow severity score

  • PaO2 < 8kPa
  • Age > 55
  • Neutrophilia > 15x109
  • Calcium < 2mmol/L
  • Renal function - Urea > 16 mmol/L
  • Enzymes - LDH > 600iu/L; AST > 200iu/L
  • Albumin < 32g/L
  • Sugar - >10 mmol/L
43
Q

In the glasgow criteria for severity of pancreatitis, what threshold is used for PaO2?

A

<8kPa

44
Q

In the glasgow criteria for severity of pancreatitis, what threshold is used for WBC?

A

>15x109

45
Q

In the glasgow criteria for severity of pancreatitis, what threshold is used for Age?

A

55 yrs

46
Q

In the glasgow criteria for severity of pancreatitis, what threshold is used for Calcium?

A

<2 mmol/L

47
Q

In the glasgow criteria for severity of pancreatitis, what threshold is used for Urea?

A

>16 mmol/L

48
Q

In the glasgow criteria for severity of pancreatitis, what threshold is used for LDH?

A

>600 iu/L

49
Q

In the glasgow criteria for severity of pancreatitis, what threshold is used for AST?

A

> 200iu/L

50
Q

In the glasgow criteria for severity of pancreatitis, what threshold is used for serum Albumin?

A

<32g/L

51
Q

In the glasgow criteria for severity of pancreatitis, what threshold is used for blood glucose?

A

>10 mmol/L

52
Q

Whats merits “severe pancreatitis” using the glasgow criteria for severity?

A

>3 positive factors within 48 hours of onset

53
Q

How would you initially manage severe acute pancreatitis?

A

HDU/ITU

  • Oxygen
  • Nil by mouth - Consider NG/NJ or TPN
  • IV fluids
  • Invasive monitoring with hourly obs - vital signs, urine output (catheter), central venous pressure & blood gases
  • Analgesia
  • Consider Prophylactic ABx - may decrease local/systemic complications in severe AP (pancreatic necrosis)
  • Daily bloods - FBC, U+E’s, LFTs, clotting, serum calcium & blood glucose, amylase, consider ABG
  • NJ tube if inflammation around pancreas/duodenum is too large
54
Q

What analgesia would you use in someone with acute pancreatitis?

A
  • Tramadol
  • Pethidine
  • Indomethacin
55
Q

Why would you give IV fluids in someone with acute pancreatitis?

A

To counter third-space sequestration -> give until vital signs are satisfactory and urine flow > 30ml/h

56
Q

If someone was having problems with controlling their blood sugars, what might you consider giving them?

A

Insulin

57
Q

What daily boods would you perform in someone with acute pancreatitis?

A

FBC, U+E’s, LFTs, Ca2+, clotting screen, glucose, amylase, ABG

58
Q

What are early complications of acute pancreatitis?

A
  • Shock
  • ARDS
  • Renal Failure
  • DIC
  • Sepsis
  • Hypocalcaemia/Hyperglycaemia
  • Ileus
  • Confusion/encephalopathy
59
Q

What are late complications of pancreatitis?

A

>1 week

  • Acute fluid collection/Pancreatic ascites - foramen of winslow connects lesser and greater sac so fluid can move into greater sac leading to 3rd space loss
  • Pancreatic necrosis (sterile or infective) -
  • Pancreatic Pseudocyst
    • ​Acute collection of pancreatic juice enclosed in a wall of fribrous/granulation tissue that arises following an attack of acute pancreatitis
    • Chronic if the cyst persists for >6 weeks
  • Pancreatic Abscess - circumscribed intra-abdominal colelction of pus, usually in close priximity to the pancreas
  • Bleeding - from elastase eroding vessels
  • Portal/splenic vein thrombosis
  • Fistulae
  • Pleural effusion
60
Q
A
61
Q

What is a acute pancreatic pseudocyst?

A

Collection of pancreatic juice enclosed in a wall of fibrous or granulation tissue that arises following an attack of acute pancreatitis

62
Q

What are features of someone with a pancreatic pseudocyst?

A

Persistent hyperamylasaemia and/or pain

63
Q

How would you investigate someone for a pancreatic pseudocyst?

A
  • CT
  • Amylase
64
Q

Indications for manageming pancreatic psuedocyst

A

Cyst> 6cm and >12 weeks in duration are unlikely to resolve

Offered only for symptomatic cysts or onset of complications

65
Q

How would you manage someone with a pancreatic pseudocyst?

A

Consider any of:

  • Percutaneous US/CT guided drainage
  • Endoscopic/Laproscopic/open cystogastrostomy
66
Q

What are complications associated with pancreatic pseudocyst formation?

A
  • Jaundice
  • Infection
  • Haemorrhage
  • Rupture
  • Pressure effect
67
Q

How would you treat someone with a pancreatic abscess?

A

Antibiotics and analgesia

68
Q

Why can individuals with pancreatitis get bowel necrosis?

A

Thrombosis can occur in the splenic/gastroduodenal arteries, or colic branches of SMA

69
Q

What score do individuals need to get on glasgow severity scale for pancreatitis to be determined to have severe acute pancreatitis?

A

Score >3

70
Q

What is the definition of mild pancreatitis?

A
  • No organ failure
  • No local or systemic complications
71
Q

What is classed as moderate acute pancreatitis?

A

Organ failure that resolves within 48 hrs +/- local/systemic complications without persistent organ failure

72
Q

What is classed as severe acute pancreatitis?

A

Persistent organ failure > 48 hrs (single or multiple)

73
Q

When is a psuedocyst classed as chronic?

A

When it persists >6 weeks

74
Q
A
75
Q

What is a pancreatic abscess?

A

Circumscribed intra-abdominal collection of pus, usually in a proximity to the pancreas, containing little or no pancreatic necrosis, which arises as a consequence of acute pancreatitis

76
Q

What is pancreatic necrosis?

A

Diffuse or focal area(s) of non-viable pancreatic parenchyma

  • Sterile necrosis
  • Infected necrosis
77
Q

Management of pancreatic necrosis

A

Sterile necorisis - treated conservatively

Infected necrosis - necrosectomy guided by CT findings

78
Q

What is meant by walled off necrosis?

A

A mature, encapsulated collection of pancreatic and/or peripancreatic necrosis that has developed a well-defined inflammatory wall

Usually occurs after 4 weeks

79
Q

What is an acute necrotic collection?

A

A collection containing variable amounts of both fluid and necrosis associated with necrotizing pancreatitis

Usually occurs < 4 weeks

80
Q

Why can those with acute pancreatitis present with profound shock?

A

Caused by hypovolaemia & circulating cytokines

81
Q

How long after initial insult does it take for amylase to start to rise in acute pancreatitis?

A

Within 6 hours

82
Q

Wich stays elevated for longer in acute pancreatitis; serum amylase or serum lipase?

A

Serum Lipase

83
Q

Why can someone get hypocalcaemia in acute pancreatitis?

A

Due to deposition of calcium in fat necrosis - appears 3-8 days after attack

84
Q

When is CT indicated for in acute pancreatitis?

A
  • All patients with severe attacks - 3-10 days after admission
  • Diagnosis uncertain - within 24 hours
  • Clinical deterioration
  • Patients with organ failure/signs of sepsis
  • Suspected local complications
85
Q

What criteria need to be met to make the diagnosis of acute pancreatitis?

A

Diagnosis requires two of the following three features:

  1. Abdominal pain consistent with acute pancreatitis
  2. Serum lipase/amylase activity at least 3x greater than upper normal limits
  3. Characteristic findings on contrast-enhanced CT or less commonly MRI /abdominal US
86
Q

What would your differential diagnosis be for someone with symptoms of acute pancreatitis?

A
  • Perforated peptic ulcer
  • Acute cholecystitis / Biliary colic
  • High intestinal obstruction
  • Myocardial infarction
  • Rupture abdominal aortic aneurysm
  • Mesenteric ischemia
87
Q

Name the different scoring systems which are used to assess pancreatitis severity?

A
  • Ranson’s criteria
  • Glasgow Scoring System
  • APACHE II score
  • Modified Marshall scoring system
88
Q

When would you consider CT scanning someone with severe acute pancreatitis?

A

Between days 3-10 - look for evidence of local complications

89
Q

How would you manage mild pancreatitis?

A
  • Ward management with basic observations
    • ​Oxygen
    • IV fluids
    • Analgesia
    • Blood transfusion
    • Diet - nutrition, NG tube
    • Monitor urine output - risk of renal failure
    • Blood sugar control
  • Analgesia
  • Fluids
90
Q
A
91
Q

When would you consider an early ERCP in someone with severe acute pancreatitis?

A
  • Severe gallstone pancreatitis
  • Signs of cholangitis
92
Q

How would you manage infected pancreatic necrosis?

A

Necrosectomy guided by CT findings

93
Q

How would you manage non-infected pancreatic necrosis?

A

Treat conservatively

94
Q

What complications can occur with a pancreatic pseudocyst?

A
  • Infection
  • Rupture
  • Pressure effect
  • Erosion into a blood vessel
95
Q

When is treatment for a pancreatic pseudocyst offered?

A

Only if symptomatic or onset of complications

96
Q

How would you manage acute fluid collections

A

50% resolve spontaneously

Percutaneous aspiration may introduce infection

Aspiration only if infection suspected or symptomatic

97
Q

Prognosis of acute pancreatitis

A

Most will recover with general supportitive care

25% develop severe acute pancreatits with multi-organ faulure

98
Q

Local complications acute pancreatitis

A

Acute fluid colelction

Pseudocyst

Abscess

Pancreatic necorisis -sterile, infected

Pancreatic ascites

Pleural effusion

Portal/splenic vein thrombosis - splenic vein is just above pancreas

Pseudoaneurysm - can weaken splenic artery wall

Chronic pancreatitis

99
Q

Systemic complications of acute pancreatitis

A

Shock - cause of most deaths

ARDS

Renal failure

DIC

Hypocalcaemia/Hyperglycaemia

Ileus

Confusion/encephalopathy

100
Q

When do you re-evaluate those with acute pancreatits

A

24hr

48hr

7 days

Gwen - GI and General surgery (44 decks)

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