Pancreatic disorders Flashcards
What are the functions of the pancreas?
- Endocrine production:
- Insulin
- Glucagon
- Exocrine production:
- Pancreatic protease: trypsin; chymotrypsin
- Amylase
- Lipase
Name three causes of acute pancreatitis
- Gallstone (60%)
- Ethanol (30%)
- Trauma (1.5%)
- Steroids
- Mumps; malignancy
- Autoimmune
- Scorpion (Tityus trinitatis) sting
- Hyperlipidaemia, hypothermia, hypercalcaemia
- ERCP (5%); emboli
- Drugs: eg. azathioprine, oestrogen, thiazides, isoniazid
10-30%: Pregnancy, neoplasia, idiopathic
Which drugs are particularly associated with acute pancreatitis?
- NSAIDs
- Steroids
- Azathioprine
- Thiazides
- Isoniazid
- Oestrogen
How can acute pancreatitis be classified?
- Oedematous: simple or associated with phlegmon
- Severe/necrotising: sterile/infected necrosis; pseudocysts
- Haemorrhagic: Grey Turner’s and Cullen’s sign
Name four presenting features of acute pancreatitis
-
Sudden severe epigastric abdominal pain
- May radiate to back; worse with movement
- Alcohol-related: less sudden; poorly localised
- Severe NaV; anorexia
- Peritonism; rebound tenderness; guarding
- Abdominal distension; small bowel ileus
- Cullen’s (periumbilical); Grey Turner’s sign (flank)
- Tachycardia; hypotension
Name three differential diagnoses for acute pancreatitis
- Perforated peptic ulcer; bowel obstruction; ischaemic bowl
- Ruptured AAA
- MI
- Gallstones: biliary colic; acute cholecystitis; cholangitis
- Viral hepatitis
- Gastroenteritis
How is acute pancreatitis initially investigated?
-
Serum amylase: >1000U/ml or 3x upper limit of normal
- Does not correlate with severity of disease
- Levels begin to fall within 24-48hr
- Serum lipase: more sensitive and specific for pancreatitis
- Imaging:
- USS within 48hr admission: Gallstones in CBD
- AXR (non-specific)
- CT: assess extent and complications
- ABG; FBC; U+E; LFTs; glucose: assess severity
Name three non-pancreatitis causes of raised serum amylase
- Intestinal ischaemia
- Leaking AAA
- Perforated peptic ulcer
- Acute cholecystitis
- Acute appendicitis
- Ectopic pregnancy
- Pelvic inflammatory disease
- Renal failure
- DKA
- Head injury
How is severe acute pancreatitis determined?
Glasgow-Imrie criteria
3+ criteria within 48hr of admission ➔ ITU/HDU transfer
- PaO2 <8kPa
- Age >55
- Neutrophils/WCC >15,000 x109/L
- Corrected Ca2+ <2mmol/L
- Raised blood urea >16mmol/L
- Enzymes: AST >200U/L, LDH >600U/L
- Albumin <32g/L
- Sugar (CBG) >10mmol/L (secondary diabetes)
Outline the management of acute pancreatitis
- Fluid resuscitation
- Do not make NBM unless clear reason eg. vomiting
- Enteral nutrition if moderate-severe pancreatitis
- Consider parenteral nutrition
- Urgent ERCP + cholecystectomy: proven bile duct stones
- Consider debridement or aspiration if refractory necrosis
- Manage complications eg. insulin for type 3c diabetes
Name two early complications of acute pancreatitis
- Shock; Pre-renal AKI
- ARDS
- Sepsis; DIC
- Hypocalcaemia: soaponification of fats
- Hyperglycaemia
Name three late complications of acute pancreatitis
- Pancreatic necrosis
- Pseudocysts; abscess
- Haemorrhage; Thrombosis
- Fistula
- Oedematous pancreas; obstructive jaundice
- Pancreatic encephalopathy due to hypoperfusion
Give four presenting features of chronic pancreatitis
- Recurrent/persistent severe epigastric pain radiating into back
- Relieved by sitting forward; hot water bottles
- Worse with food and alcohol
- NaV; anorexia
-
Exocrine insufficiency:
- Malabsorption; weight loss
- Diarrhoea
- Steatorrhoea
- Protein deficiency
-
Endocrine insufficiency:
- Diabetes mellitus
- Impaired glucose regulation
Describe the histology of chronic pancreatitis
- Glandular atrophy
- Duct ectasia
- Microcalcification
- Intraductal stone formation
What sign may be seen as a result of conservative management of chronic pancreatitis?
Erythema ab igne (hot water bottle rash)
Chronic exposure to infrared radiation (heat) causing localised reticulated erythema and hyperpigmentation