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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
Q

How do you DIFFERENTIATE between Acute Pancreatitis and Basal pneumonia? (2 things)

A
  1. Basal pneumonia = focal changes in CXR
  2. Basal pneumonia = less amylase rise
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26
Q

What are the SIMILARITIES between Acute Pancreatitis and Pericarditis?

A

Amylase rise

27
Q

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

A
  1. Pericarditis = Pericardial thickening in ECG
  2. Pericarditis = less amylase rise
28
Q

What lab tests should be done for suspected Acute Pancreatitis? (2 things)

A
  1. Serum amylase / lipase
  2. LFTs
29
Q

What level of serum amylase is diagnostic of Acute Pancreatitis?

A

3x upper limit of normal

30
Q

What is the purpose of LFT’s in suspected Acute Pancreatitis?

A

If ALT level high (150+) suggests gall stones is cause
If gamma-GT high by itself suggests alcohol is cause

31
Q

Why is serum lipase more accurate for Acute Pancreatitis than serum amylase?

A

Stays elevated longer than amylase

32
Q

What is the score used to assess the severity of Acute Pancreatitis within 48 hours of admission?

A

Glasgow criteria

33
Q

What are the factors in the Glasgow criteria score for Acute Pancreatitis?

A 
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
Q

When would an abdominal US be requested for suspected Acute Pancreatitis?

A

If underlying cause unknown –> US identifies gallstones + evidence of duct dilatation

35
Q

What may an abdominal XR show in Acute Pancreatitis?

A

Sentinal loop sign

= dilated large bowel loop adj to pancreas (occurs 2ndary to localised inflamm.)

36
Q

What may a CXR show in Acute Pancreatitis? (3 things)

A
  1. Pleural effusion
  2. Signs of ARDS (Acute Respiratory Distress Syndrome)
  3. Pulmonary infiltrates

These would suggest need for higher level of care

37
Q

What is a CT scan used for in Acute Pancreatitis?

A

To assess severity

38
Q

What may be seen in a CT scan in Acute Pancreatitis 48 hours after initial presentation?

A

Pancreatic oedema

39
Q

What is the immediate management of Acute Pancreatitis?

A
  1. No curative management available so supportive managament to stabilise patient
  2. Treat underlying cause once stabilised (ERCP / sphincterectomy if gallstones)
40
Q

What are the supportive management options for Acute Pancreatitis? (8 things)

A
  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
Q

What are the early complications of Acute Pancreatitis? (7 things)

A
  1. Shock
  2. Hyperglycaemia
  3. Hypocalcaemia
  4. ARDS (Acute Respiratory Distress Syndrome)
  5. Renal failure (GIVE FLUIDS)
  6. DIC
  7. Sepsis

SHHARDS

42
Q

What causes the complication of Hypocalcaemia in Acute Pancreatitis?

A

Lipase release –> fat necrosis –> free F.A –> F.A react with serum calcium –> chalky deposits in fatty tissue

43
Q

What causes the complication of Hyperglycaemia in Acute Pancreatitis?

A

Islets of Langerhans destruction –> disturbance to insulin metabolism

44
Q

What are the late complications of Acute Pancreatitis?

A
  1. Pancreatic necrosis
  2. Pancreatic pseudocyst
  3. Abscesses
  4. Bleeding
  5. Thrombosis
  6. Fistulae
  7. Recurrent oedematous pancreatitis
45
Q

How should a diagnosis of suspected Pancreatic necrosis be confirmed?

A

CT

46
Q

What is the treatment of Pancreatic necrosis?

A

Pancreatic necrosectomy (open / endoscopic)

47
Q

What is Pancreatic necrosis prone to and how can this be confirmed?

A

Infection
Suspected if raised infection markers

Confirmed w fine needle aspiration of necrosis

48
Q

What is a Pancreatic pseudocyst?

A

Collection of fluid w pancreatic enzymes, blood, necrotic tissue

49
Q

Where are Pancreatic pseduocysts usually seen?

A

Lesser sac, obstructing gastro-epiploic foramen by inflamm adhesions

50
Q

How long after the initial Acute Pancreatitis episode will a Pancreatic pseudocyst form?

A

Several weeks after

51
Q

Why are Pancreatic Pseudocysts called PSEUDOcysts?

A

Bc they don’t have an epithelial lining,

They instead have a vasc + fibrotic wall around the collection

52
Q

How are Pancreatic pseudocysts managed?

A

50% will resolve

  1. Surgical removal
  2. Endoscopic drainage (into stomach)
53
Q

What are the causes of Chronic Pancreatitis? (4 things)

A
  1. Alcohol (80%)
  2. CF
  3. Haemochromatosis
  4. Ductal obstruction (tumours / stones)
54
Q

What are the clinical features of Chronic Panreatitis? (7 things)

A
  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
Q

What is the diabetes in Chronic Pancreatitis patients caused by? (3 steps)

A

Endocrine insuffiency

  1. Damage to ENDOCRINE tissue of pancreatic gland (islets of Langerhans)
  2. No insulin prod
  3. Impared glucose reg / DM
56
Q

What is the steatorrhoea / malabsorption / weight loss in Chronic Pancreatitis patients caused by? (4 steps)

A

Exocrine insufficiency

  1. Damage to EXOCRINE acinar cells
  2. No digestive enzymes prod
  3. Malabsorption
  4. Steatorrhoea / Diarrhoea / Weight loss
57
Q

What may a AXR show in Chronic Pancreatitis?

A

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
Q

What is the most sensitive scan for detecting Pancreatic calcification in Chronic Pancreatitis?

A

CT

59
Q

What functional tests should be done if imaging is inconclusive in suspected Chronic Pancreatitis?

A

Faecal elastase test

Measures amount of elastase in faeces to assess pancreas exocrine function

60
Q

What is the difference in lab test results between Acute and Chronic Pancreatitis?

A

Serum amylase and lipase are NOT raised in CHRONIC pancreatitis

61
Q

What should be looked for in a CT scan of suspected Chronic Pancreatitis? (2 things)

A
  1. Pancreatic atrophy / calcification
  2. Causes of disease: Malignancy / Congenital abnormalities
62
Q

What is the only ways that Chronic Pancreatitis can be managed definitively? (2 things)

A

Treating reversal underlying cause

  1. Alcohol cessation
  2. Statin therapy for hyperlipidaemia
63
Q

What is the management strategies for Chronic Pancreatitis? (5 things)

A
  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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