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#Phase 2.1: Peri Op > Pancreatitis > Flashcards

Pancreatitis Flashcards

1
Q

What is Acute Pancreatitis?

A

Inflamm. of pancreas –> extra-ductal release of pancreatic enzymes

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2
Q

What are the causes of Acute Pancreatitis?

A

Gall stones (35%)
Ethanol (35%)
Trauma
Steroids
Mumps (+ other viruses)
Autoimmune
Scorpion venom
Hypertriglyceridaemia / Hyperchylomicronaemia / Hypercalcaemia / Hypothermia
ERCP
Drugs (azathioprine / bendroflumethiazide / furosemide, pentamidine / steroids / sodium valproate)

GET SMASHED

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3
Q

What is the pathophysiology of Acute Pancreatitis? (6 steps)

A
  1. Causes will trigger premature + exagg activation of digestive enzymes in pancreas
  2. Pancreatic inflamm response
  3. Increase in vasc perm –> fluid shift
  4. Enzymes released from pancreas –> systemic circulation
  5. Autodigestion of fats (fat necrosis) + blood vessels (haemorrage in retroperitoneal space)
  6. Fat necrosis –> free F.A release –> reacts with serum Ca –> Chalky deposits in fatty tissue –> Hypocalcaemia
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4
Q

What are the clinical features of Acute Pancreatitis from the history? (3 main things / 8 total)

A
  1. Epigastric pain (radiates to back)
  2. Nausea + vomiting
  3. Jaundice

Other

  1. Beh alcohol
  2. Weight loss (pancreatic / biliary tumour = cause)
  3. Steroids use
  4. ERCP
  5. MUMPS
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5
Q

What are the clinical features of Acute Pancreatitis on examination? (6 things)

A
  1. Epigastric tenderness (+/- guarding)
  2. Haemodynamically unstable (severe cases bc inflamm response)
  3. Distension (ascites)
  4. Loss of bowel sounds (acute ileus)
  5. Cullen’s Sign = bruising @ umbilicus
  6. Grey Turner’s Sign = bruising @ flanks

5+6 = retroperitoneal haemorrhage

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6
Q

What are some other clinical features of Acute Pancreatitis?

A
  1. Tachycardia
  2. Hypotension
  3. Fever
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7
Q

What are the other differentials of abdominal pain that RADIATES TO BACK other than Acute Pancreatitis? (5 things)

A
  1. Abdominal aortic aneurysm
  2. Aortic dissection
  3. Chronic pancreatitis
  4. PUD
  5. Renal calculi
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8
Q

What are some abdominal conditions that present similarly to Acute Pancreatitis? (7 things)

A
  1. Perforated duodenal ulcer
  2. Acute Hepatitis
  3. Biliary tract pathology
  4. Bowel obstruction / ischaemia
  5. Obstructed / strangulated hernia
  6. Renal tract disease
  7. Gynae pathologies
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9
Q

What are some NON abdominal conditions that present similarly to Acute Pancreatitis? (3 things)

A
  1. Inferior MI
  2. Basal pneumonia
  3. Pericarditis
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10
Q

What are the SIMILARITIES between Acute Pancreatitis and Perforated duodenal ulcer? (3 things)

A
  1. Shock
  2. Epigastric pain
  3. Amylase rise
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11
Q

How do you DIFFERENTIATE between Acute Pancreatitis and Perforated duodenal ulcer? (2 things)

A
  1. Examination findings
  2. PDU = less amylase rise
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12
Q

What are the SIMILARITIES between Acute Pancreatitis and Acute hepatitis? (4 things)

A
  1. Shock
  2. Upper abdominal pain
  3. Jaundice
  4. Raised transaminase (ALT / AST) levels
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13
Q

What are the SIMILARITIES between Acute Pancreatitis and Biliary tract pathology? (3 things)

A
  1. Shock
  2. Upper abdominal pain
  3. Amylase rise (if obstructed)
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14
Q

How do you DIFFERENTIATE between Acute Pancreatitis and Biliary tract pathology?

A

Abdominal US for evidence of ductal obstruction

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15
Q

What are the SIMILARITIES between Acute Pancreatitis and Bowel obstruction / ischaemia?

A

Amylase rise (bc inflamm in mesenteric system –> inflamm mediators release –> pancreatic irritation –> amylase rise)

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16
Q

How do you DIFFERENTIATE between Acute Pancreatitis and Bowel obstruction / ischaemia? (2 things)

A
  1. Examination findings
  2. Bowel obstruction / ischaemia = less amylase rise
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17
Q

What are the SIMILARITIES between Acute Pancreatitis and Obstructed / strangulated hernia?

A

Amylase rise

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18
Q

How do you DIFFERENTIATE between Acute Pancreatitis and Obstructed / strangulated hernia? (2 things)

A
  1. Examination findings
  2. Obstructed / strangulated hernia = less amylase rise
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19
Q

What are the SIMILARITIES between Acute Pancreatitis and Renal tract disease?

A

Amylase rise

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20
Q

How do you DIFFERENTIATE between Acute Pancreatitis and Renal tract disease?

A
  1. Examination findings
  2. Renal tract disease = less amylase rise
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21
Q

What are the SIMILARITIES between Acute Pancreatitis and Gynae pathologies? (2 things)

A
  1. Abdominal pain
  2. Amylase rise
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22
Q

How do you DIFFERENTIATE between Acute Pancreatitis and Gynae pathologies? (2 things)

A
  1. Urine / serum hCG test (if ectopic preg suspected)
  2. Less amylase rise
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23
Q

How do you DIFFERENTIATE between Acute Pancreatitis and Inferior MI? (2 things)

A
  1. Inferior MI = ECG changes
  2. Inferior MI = Serum troponin rise
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24
Q

What are the SIMILARITIES between Acute Pancreatitis and Basal pneumonia?

A

Amylase rise

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25
How do you DIFFERENTIATE between Acute Pancreatitis and Basal pneumonia? (2 things)
1. Basal pneumonia = focal changes in CXR 2. Basal pneumonia = less amylase rise
26
What are the SIMILARITIES between Acute Pancreatitis and Pericarditis?
Amylase rise
27
How do you DIFFERENTIATE between Acute Pancreatitis and Pericarditis? (2 things)
1. Pericarditis = Pericardial thickening in ECG 2. Pericarditis = less amylase rise
28
What lab tests should be done for suspected Acute Pancreatitis? (2 things)
1. Serum amylase / lipase 2. LFTs
29
What level of serum amylase is diagnostic of Acute Pancreatitis?
3x upper limit of normal
30
What is the purpose of LFT's in suspected Acute Pancreatitis?
If ALT level high (150+) suggests gall stones is cause If gamma-GT high by itself suggests alcohol is cause
31
Why is serum lipase more accurate for Acute Pancreatitis than serum amylase?
Stays elevated longer than amylase
32
What is the score used to assess the severity of Acute Pancreatitis within 48 hours of admission?
Glasgow criteria
33
What are the factors in the Glasgow criteria score for Acute Pancreatitis?
``` P = pO2 : less than 8 kPa A = age : 55+ N = neutrophilia : WBC 15+ C = calcium : less than 2 R = uRea 16+ E = enzymes : LDH 600+ / AST 200+ A = albumin : less than 32 S = sugar : BG 10+ ``` Each scores 1 Score of 3+ = severe pancreatitis --\> transfer to ITU
34
When would an abdominal US be requested for suspected Acute Pancreatitis?
If underlying cause unknown --\> US identifies gallstones + evidence of duct dilatation
35
What may an abdominal XR show in Acute Pancreatitis?
Sentinal loop sign = dilated large bowel loop adj to pancreas (occurs 2ndary to localised inflamm.)
36
What may a CXR show in Acute Pancreatitis? (3 things)
1. Pleural effusion 2. Signs of ARDS (Acute Respiratory Distress Syndrome) 3. Pulmonary infiltrates These would suggest need for higher level of care
37
What is a CT scan used for in Acute Pancreatitis?
To assess severity
38
What may be seen in a CT scan in Acute Pancreatitis 48 hours after initial presentation?
Pancreatic oedema
39
What is the immediate management of Acute Pancreatitis?
1. No curative management available so supportive managament to stabilise patient 2. Treat underlying cause once stabilised (ERCP / sphincterectomy if gallstones)
40
What are the supportive management options for Acute Pancreatitis? (8 things)
1. IV fluid resuscitation 2. Oxygen 3. NG tube if vomiting 4. Antiemetics (IV) 5. Opioid analgesia 6. Broad spec abx (e.g imipenem) if pancreatic necrosis 7. Catheter = monitor urine output + start fluid balance chart (aim for 0.5+ ml / kg / hr) 8. Monitor BG + insulin infusions if hyperglycaemic
41
What are the early complications of Acute Pancreatitis? (7 things)
1. Shock 2. Hyperglycaemia 3. Hypocalcaemia 4. ARDS (Acute Respiratory Distress Syndrome) 5. Renal failure (GIVE FLUIDS) 6. DIC 7. Sepsis SHHARDS
42
What causes the complication of Hypocalcaemia in Acute Pancreatitis?
Lipase release --\> fat necrosis --\> free F.A --\> F.A react with serum calcium --\> chalky deposits in fatty tissue
43
What causes the complication of Hyperglycaemia in Acute Pancreatitis?
Islets of Langerhans destruction --\> disturbance to insulin metabolism
44
What are the late complications of Acute Pancreatitis?
1. Pancreatic necrosis 2. Pancreatic pseudocyst 3. Abscesses 4. Bleeding 5. Thrombosis 6. Fistulae 7. Recurrent oedematous pancreatitis
45
How should a diagnosis of suspected Pancreatic necrosis be confirmed?
CT
46
What is the treatment of Pancreatic necrosis?
Pancreatic necrosectomy (open / endoscopic)
47
What is Pancreatic necrosis prone to and how can this be confirmed?
Infection Suspected if raised infection markers Confirmed w fine needle aspiration of necrosis
48
What is a Pancreatic pseudocyst?
Collection of fluid w pancreatic enzymes, blood, necrotic tissue
49
Where are Pancreatic pseduocysts usually seen?
Lesser sac, obstructing gastro-epiploic foramen by inflamm adhesions
50
How long after the initial Acute Pancreatitis episode will a Pancreatic pseudocyst form?
Several weeks after
51
Why are Pancreatic Pseudocysts called PSEUDOcysts?
Bc they don't have an epithelial lining, They instead have a vasc + fibrotic wall around the collection
52
How are Pancreatic pseudocysts managed?
50% will resolve 1. Surgical removal 2. Endoscopic drainage (into stomach)
53
What are the causes of Chronic Pancreatitis? (4 things)
1. Alcohol (80%) 2. CF 3. Haemochromatosis 4. Ductal obstruction (tumours / stones)
54
What are the clinical features of Chronic Panreatitis? (7 things)
1. Chronic epigastric + back pain (worse 15 to 30 mins after meal) 2. Soft abdomen @ examination 3. Nausea + vomiting 4. Steatorrhoea (5-25 years after pain onset) 5. Malabsorption 6. Cachexia (muscle wasting --\> weight loss) 7. Diabetes (develops in most patients, and develops after 20 years)
55
What is the diabetes in Chronic Pancreatitis patients caused by? (3 steps)
Endocrine insuffiency 1. Damage to ENDOCRINE tissue of pancreatic gland (islets of Langerhans) 2. No insulin prod 3. Impared glucose reg / DM
56
What is the steatorrhoea / malabsorption / weight loss in Chronic Pancreatitis patients caused by? (4 steps)
Exocrine insufficiency 1. Damage to EXOCRINE acinar cells 2. No digestive enzymes prod 3. Malabsorption 4. Steatorrhoea / Diarrhoea / Weight loss
57
What may a AXR show in Chronic Pancreatitis?
Pancreatic calcification (30% of cases) CT is more sensitive at detecting pancreatic calcification. Sensitivity is 80%, specificity is 85% functional tests: faecal elastase may be used to assess exocrine function if imaging inconclusive
58
What is the most sensitive scan for detecting Pancreatic calcification in Chronic Pancreatitis?
CT
59
What functional tests should be done if imaging is inconclusive in suspected Chronic Pancreatitis?
Faecal elastase test Measures amount of elastase in faeces to assess pancreas exocrine function
60
What is the difference in lab test results between Acute and Chronic Pancreatitis?
Serum amylase and lipase are NOT raised in CHRONIC pancreatitis
61
What should be looked for in a CT scan of suspected Chronic Pancreatitis? (2 things)
1. Pancreatic atrophy / calcification 2. Causes of disease: Malignancy / Congenital abnormalities
62
What is the only ways that Chronic Pancreatitis can be managed definitively? (2 things)
Treating reversal underlying cause 1. Alcohol cessation 2. Statin therapy for hyperlipidaemia
63
What is the management strategies for Chronic Pancreatitis? (5 things)
1. Analgesia 2. Pancreatic enzyme replacement 3. Vitamins (fat soluble ones A,D,E,K) 4. Insulin regimes (if DM) 5. Steroids (if autoimmune, reduces symptoms)

#Phase 2.1: Peri Op (24 decks)

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