Pancreatitis

Question 1

What is pancreatitis

Answer 1

Inflammation of the pancreas

Question 2

What is acute pancreatitis

Answer 2

Rapid onset inflammation and symptoms.

Normal function usually returns after an episode

Question 3

What is chronic pancreatitis

Answer 3

Longer term inflammation and symptoms with progressive and permanent deterioration in pancreatic function. Results in fibrosis

Question 4

Causes of pancreatitis

Answer 4

I GET SMASHED:
Idiopathic 
Gallstones*
Ethanol*
Trauma 
Steroids 
Mumps
Autoimmune
Scorpion sting
Hyperlipidaemia 
ERCP
Drugs (Furosemide, Thiazide diuretic, azathioprine)

Question 5

How does alcohol cause pancreatitis

Answer 5

It is directly toxic to pancreatic cells, resulting in inflammation.

Question 6

How do gallstones cause pancreatitis

Answer 6

Gallstones become trapped in at the end of the biliary system (ampulla of Vater), blocking the flow of bile and pancreatic juices into the duodenum.
The build up of these results in inflammation of the pancreas

Question 7

Acute pancreatitis presentation

Answer 7

Acute onset:
Severe epigastric pain - may radiate through the back
Associated vomiting
Abdominal tenderness
Systemically unwell (low grade fever and tachycardia)

Question 8

Acute pancreatitis investigations

Answer 8

Raised amylase levels - more than 3x upper limit of normal indicative of acute. May not rise in chronic due to reduced pancreatic function 
FBC - WCC
U&E's - Urea
LFT - transaminases and albumin
Calcium
ABG (for PaO2 and blood glucose)
CRP
USS to check for gallstones 
CT abdo for complications e.g. necrosis, abscesses, fluid collections... (only if patient becoming more unwell)

Question 9

Acute pancreatitis scoring system

Answer 9

Glasgow score to assess severity:

PANCREAS pneumonic - 1 point for each
0-1 = mild pancreatitis
2 = moderate pancreatitis
3 or more = severe pancreatitis

P - PaO2 < 8KPa
A - Age > 55
N - Neutrophils (WBC > 15)
C - Calcium < 2
R - uRea > 16
E - Enzymes (LDH > 600 or AST/ALT > 200)
A - Albumin < 32
S - Sugar > 10

Question 10

Acute pancreatitis management

Answer 10

Admission for supportive management and monitoring
Moderate of severe should be considered for HDU or ITU

Initial resuscitation (ABCDE)
IV fluids
NBM
Analgesia
Treat cause e.g. gallstones - ERCP or cholecystectomy
ABX if signs of infection e.g. abscess or infected necrotic area
Most will improve within 3-7 days

Question 11

Acute pancreatitis complications

Answer 11

Necrosis of pancreas
Infection in necrotic area
Abscess formation 
Acute peripancreatic fluid collections
Pseudocysts (collections of pancreatic juices) - can develop 4 weeks after acute pancreatitis 
Chronic pancreatitis

Question 12

Most common cause of chronic pancreatitis

Answer 12

Alcohol consumption

Question 13

Chronic pancreatitis presentation

Answer 13

Similar symptoms to acute but less intense and longer lasting

Question 14

Chronic pancreatitis complications

Answer 14

Chronic epigastric pain
Loss of exocrine function = lack of pancreatic enzymes (lipase) secreted into GI tract
Loss of endocrine function = lack of insulin, leading to diabetes
Damage and strictures to the duct system - can cause obstruction
Formation of pseudocysts or abscesses

Question 15

Chronic pancreatitis management

Answer 15

Abstinence from alcohol and smoking
Analgesia to manage pain
Replacement pancreatic enzymes (Creon) if loss of pancreatic enzymes (e.g. lipase). Lack of enzymes may lead to malabsorption of fat, greasy stools (steatorrhoea) and deficiency of fat soluble vitamins
Subcutaneous insulin regimes if diabetes
ERCP with stenting to treat strictures and obstruction to the biliary system and pancreatic duct
Specialist surgery