Pancreatic Disease

Question 1

What is acute pancreatitis?

Answer 1

Acute inflammation of the pancreas characterised by upper abdominal pain and elevation of serum amylase to > 4x normal levels.

Question 2

How does Acute Pancreatitis present?

Answer 2

1) Severe, constant upper abdominal pain which increases in intensity over 15-60 minutes and radiates to the back
2) Nausea and vomitting
3) Epigastric tenderness

Question 3

What causes acute pancreatitis?

Answer 3

1) Gallstones
2) Alcohol
3) Post-ERCP
4) Idiopathic

Question 4

What are the investigations of acute pancreatitis?

Answer 4

Blood tests:

• Raised amylase/lipase
• FBC (raised WBC, raised CRP)
• U&E’s (raised urea)
• Ca2+
• Glucose
• ABG’s

Imaging:

AXR/CXR

Abdominal USS

CT scan - contrast enhanced

Question 5

How is severity of acute pancreatitis assessed?

Answer 5

Glasgow criteria - score >3 of the following criteria = Severe pancreatitis

• White cell count >15 x 109/l
• Blood glucose >10 mmol/l
• Blood urea >16mmol/l
• AST >200 iu/l
• LDH >600 iu/l
• Serum albumin <32 g/l
• Serum calcium <2.0 mmol/l
• Arterial PO2 <7.5 kPa

Question 6

What is the general management of acute pancreatitis?

Answer 6

• Analgesia
• IV fluids
• Blood transfusion
• Monitor urine output
• Naso-gastric tube
• Oxygen

Question 7

What are the surgical options for managing acute pancreatitis?

Answer 7

Pancreatic necrosis - CT guided aspiration with antibiotics and then possible surgery

Gallstones - Cholecystectomy

Question 8

What is Chronic Pancreatitis?

Answer 8

Continuing inflammatory disease of the pancreas characterised by irreversible glandular destruction and typically causing pain and/or permanent loss of function

Question 9

How does chronic pancreatitis present?

Answer 9

• Early disease is asymptomatic
• Abdominal pain
• Weight loss (protein malabsorption)
• Steatorrhoea (exocrine insufficiency causing malabsorption of fat)
• Diabetes (endocrine insufficiency)

Question 10

What are the investigations for chronic pancreatitis?

Answer 10

• AXR (calcification of pancreas)
• Ultrasound (size of pancreas, cysts, duct diameter, tumours)
• CT

- Blood tests:

• Raised serum amylase
• Lowered albumin, Ca2+, Vit B12
• Raised LFT’s, PT and Glucose

Question 11

How is chronic pancreatitis managed?

Answer 11

Pain control:

• avoid alcohol
• pancreatic enzyme supplements
• opiate analgesia (dihydrocodeine, pethidine)
• Coeliac plexus block
• referral to pain clinic/psychologist
• Endoscopic treatment of pancreatic duct stones and strictures
• Surgery in selected cases

Question 12

How are the exocrine and endocrine insufficiencies managed in acute pancreatitis?

Answer 12

• Low-fat diet (30-40 g/day)
• Pancreatic enzyme supplements (eg. Creon, Pancrex); may need acid suppression to prevent hydrolysis in stomach
• Vitamin supplements usually not required
• Insulin for diabetes mellitus (oral hypoglycaemics usually ineffective)