Pancreatitis Flashcards
What is acute pancreatitis and how is it distinguished from chronic pancreatitis?
Inflammation of the pancreas
Distinguished form chronic pancreatitis by its limited damage to the secretory function of the gland, with no gross structural damage developing.
Repeated episodes of acute pancreatitis can eventually lead to chronic pancreatitis
What are the two most common cause of acute pancreatitis?
Gallstone disease
Alcohol
What are all the causes for acute pancreatitis?
GET SMASHED
Gallstones Ethanol Trauma Steroids Mumps Autoimmune - e.g. SLE Scorpion venom Hypercalcaemia ERCP Drugs - Azathioprine, NSAIDs or Diuretics
No evident cause is 10-20% of pts
What is the pathogenesis of acute pancreatitis?
Each cause will trigger premature and exaggerated activation of the digestive enzymes within the pancreas. Causes pancreatic inflammatory response - increases vascular permeability and subsequent fluid shift (third spacing).
Enzymes realised from pancreas into systemic system causing auto digestion of fats (fat necrosis) and blood vessels (causing haemorrhage into reteroperitoneal space). Fat necrosis can cause hypocalcaemia.
Severe end-stage pancreatitis will eventually lead to partial or complete necrosis of the pancreas.
What are the clinical feature of acute pancreatitis?
Severe epigastric pain which can radiate to the back with N/V.
Examination - epigastric tenderness with or without guarding
May be haemodynamically unstable in severe cases
What are some less common signs seen in acute pancreatitis?
Cullens sign (bruising around umbilicus) and Grey Turners sign (bruising around flanks) - represent reteroperitoneal haemorrhage
Tetany - due to hypocalcaemia from fat necrosis
Jaundice- from obstruction in gallstones
What are the differential diagnosis for acute pancreatitis?
AAA Renal calculi Chronic pancreatitis Aortic dissection Peptic ulcer disease
What initial investigations should be requested in suspected acute pancreatitis?
Routine bloods
Serum amylase - if 3x upper limit = diagnostic - not related to severity
LFTS - ALT >150U/L = strong indicator that gallstones underlying cause
Serum lipase - more accurate then serum amylase
Abdominal ultrasound - identify gallstones as underlying cause
Not routinely ordered but AXR can some ‘sentinal loop sign’ - dilated proximal bowel loop adjacent to pancreas which occurs secondary to localised inflammation.
Erect CXR to exclude perforation as cause and look for pleural effusion and signs of ARDS.
What are other causes for raised serum amylase other then acute pancreatitis?
Bowel perforation Ectopic pregnancy DKA Cholecystitis Mesenteric infarction
What investigation may be required if the initial assessment and investigation proved inconclusive in suspected acute pancreatitis?
Contrast-enhanced CT - after 48hrs often shows pancreatic oedema and swelling or pancreatic necrosis
CT used to assess severity should should only be performed 6-10 days after admission
What is the score used to assess the severity of acute pancreatitis within the first 48hrs?
Modified Glasgow criteria - any score ≥3 should be considered severe pancreatitis and referral to high-dependency care is warranted.
What is the criteria used in the modified Glasgow criteria and what is the mnemonic?
PANCREAS
PaO2 - <8kPa Age - >55yrs Neutrophils - WBC >15x10^9/L Calcium - <2mmol/L Renal function - urea >16mmol/L Enzymes - LDH >600U/L or AST >200U/L Albumin - <32g/L Sugar - blood glucose >10mmol/L
What is the management for all acute pancreatitis?
No curative management
Treat underlying cause as necessary e.g. urgent ERCP for gallstones
Supportive management mainstay of treatment with include:
- IV fluid resuscitation and O2 therapy as required
- NG tube - if vomiting profusely - encourage to eat and drink as tolerated
- Catheterisation - monitor urine output and start fluid balance chart
- opioid analgesia
What is the management for severe acute pancreatitis?
Should be managed in high dependency unit or ITU
Prophylactic broad spectrum antibiotics against infection in cases of confirmed pancreatic necrosis
Treat underlying cause once pt stabilised e.g. early laparoscopic cholecystectomy - gallstones
What are the systemic complications of acute pancreatitis?
Disseminated intravascular coagulation (DIC)
Acute respiratory distress syndrome (ARDS)
Hypocalcaemia - fat necrosis from released lipases, results in the release of free fatty acids, which react with serum calcium to form chalky deposits in fatty tissue
Hyperglycaemia - destruction of islets of Langerhans and subsequent disturbances to insulin metabolism
What are the local complications of acute pancreatitis?
Pancreatic necrosis
Pancreatic Pseudocyst
What is pancreatic necrosis?
Ongoing inflammation eventually leads to ischaemic infarction of the pancreatic tissue, should be suspected in pts with evidence of persistent systemic inflammation for more than 7-10 days after the onset of pancreatitis.
How is suspected pancreatic necrosis investigated and treated?
Confirm by CT imaging
Treatment often is pancreatic necrosectomy - intervention should be delayed until walled-off necrosis has developed, typically 3-5 week after onset of symptoms
What is a complication of pancreatic necrosis?
Prone to infection - suspected in clinical deterioration associated with raised infection markers
Definitive diagnosis can be confirmed via fine needle aspiration of the necrosis
What is a pancreatic pseudocyst?
Collection of fluid containing enzymes, blood and necrotic tissue. Typically weeks after initial pancreatic episode. Lack epithelial lining and instead have vascular and fibrotic wall surrounding the collection.
Where do pancreatic pseudocyst occur?
Can occur anywhere adjacent to pancreas but usually occur in the lesser sac obstructing the gastro-epiploic foramen by inflammatory adhesions.
What are the symptoms of pancreatic pseudocyst?
Incidental finding or can present wit symptom of mass effect such as biliary obstruction or gastric outlet obstruction
What are the complications of pancreatic pseudocyst?
Haemorrhage/rupture
Infected
What are the management options of pancreatic pseudocyst?
50% spontaneously resolve so conservative management.
If present for longer then 6 week unlikely to resolve spontaneously so treatment option are:
- surgical debridement
- endoscopic drainage
What is chronic pancreatitis?
Chronic fibro-inflammatory disease of the pancreas resulting in progressive and irreversible damage to the pancreatic parenchyma.
Affects males in a 4:1 ratio compared to females.
What are the main causes of chronic pancreatitis?
Chronic alcohol abuse
Idiopathic
What are some less common causes of chronic pancreatitis?
Metabolic - hyperlipidaemia, hypercalcaemia
Infection - viral (HIV, mumps) and bacterial (Echinococcus)
Hereditary - cystic fibrosis
Autoimmune - SLE or autoimmune pancreatitis (AIP)
Anatomical - malignancy or stricture formation
Congenital - pancreas divisum or annular pancreas
What is the major symptom in chronic pancreatitis?
Chronic epigastric pain and back
May be complicated by recurring attacks of acute pancreatitis (acute-on-chronic pancreatitis)
What secondary symptoms may pts present with in chronic pancreatitis?
Endocrine insufficiency - damage to islets of Langerhans which results in failure of insulin production and impaired glucose regulation or eventual DM (type 3c (pancreatogenic) diabetes).
Exocrine insufficiency - damage of acinar cells which results in failure to produce digestive enzymes causing malabsorption, presenting with weight loss, diarrhoea or steatorrhoea.
Mass effects of pseudocysts from previous acute pancreatitis - biliary obstruction or gastric outlet obstruction.
What will be found on examination of chronic pancreatitis?
Abdomen soft and tender in epigastrium.
Evidence of significant cachexia.
What is the differential diagnosis for persistent central abdominal pain other then chronic pancreatitis?
Peptic ulcer disease Reflux disease AAA Biliary colic Chronic mesenteric ischaemia
What investigations, other then imaging, should be requested in suspected chronic pancreatitis?
- Urine dip and routine bloods including FBC, LFTS (concurrent jaundice) and CRP - standard for abdominal pain
- Amylase and lipase levels - not raised in established disease
- Blood glucose
- faecal elastase level - low in most cases of chronic pancreatitis
What imaging should be requested in suspected chronic pancreatitis?
Ultrasound imaging
CT imaging
MRI imaging (MRCP)
Normal appearance of pancreas on imaging does not exclude chronic pancreatitis
What additional specialist test could be done in diagnostic uncertainty after initial investigations of chronic pancreatitis?
Secretin stimulation test
Endoscopic ultrasound (EUS)
What is the definitive management of chronic pancreatitis?
Treating reversible underlying cause e.g. alcohol cessation or statin therapy for hyperlipidaemia
What is the mainstay management of chronic pancreatitis?
Analgesia - neuropathic analgesia such as pregabalin most effective + WHO analgesic ladder for acute flares of pain.
What are some non-pharmacological approaches for chronic pancreatitis?
Endosonography-guided celiac plexus blockade
Thoracoscopic splanchnicectomy
Provide short-term pain relief but have disappointing long-term effects
What is the management for the secondary symptoms in chronic pancreatitis?
Enzyme replacement (including lipases) such as Creon - taken with meals Vitamin supplements as risk of deficiency in fat soluble vitamins (A,D,E and K)
Insulin regimes in pancreatogenic diabetes with annul surveillance with HBA1c.
Steroids reduce symptoms in chronic pancreatitis with autoimmune aetiology only.
What is a complication of chronic pancreatitis?
Pancreatic malignancy - had disease for 20 or more years
What are the endoscopic management options in chronic pancreatitis pts who have a targeted underlying disease?
Endoscopic retrograde cholangiopancreatography (ERCP)
Extracorporeal shock wave lithotripsy (ESWL)
What are the surgical management for chronic pancreatitis?
Freys procedure
Lateral pancreaticojejunostomy
Whipples procedure - pancreaticoduodenoectomy - suspicion of pancreatic head malignancy
