pancreatitis Flashcards
- What is acute pancreatitis essentially?
- Define chronic pancreatitis
Autodigestion of pancreas due to pre-activated enzymes of digestion
Leads to rapid inflammation of pancreas
Long-standing inflammation of the pancreas
- List all the causes of acute pancreatitis (GET SMASHED)
Gallstones
Ethanol
Trauma
Steroids
Mumps and other viruses (EBV, CMV)
Auto-immune (polyarteritis nodosa, SLE)
Scorpion/snake bite
Hypercalcaemia
ERCP
Drugs (SAND: steroids and sulphonamides, azothiopine, NSAIDs, diuretics [loop/thiazide])- What are the 3 ways in which gallstones can cause acute pancreatitis?
Pressure increase - Gall stone just behind the ampulla of vater causes a presure increase in the main pancreatic duct
Bile reflux - Gallstone again just behind ampulla of vater causes reflux of bile from the common bile duct into the main pancreatic duct Reflux of duodenal contents (activated enzymes) - due to passing of the gallstones leaving an incompetent ampulla of vater
- What are the 2 ways in which can alcohol lead to acute pancreatitis?
Alcohol and acetylsalicylic acid and histamine can all increase the permeabilty of the epithelial, this leads to activated enzyme diffusion into the main pancreatic duct
Alcohol precipitate proteins in the ducts can cause the formation of protein plugs which leads to an incresed upstream pressure in the main pancreatic duct
- How can pancreatic enzymes be activated intracellularly?
Disturbed golgi apparatus leads to proenzymes and lysosomal proteases incorporated into same vesicles → trypsin activated
- List the 3 different types of acute pancreatitis and briefly explain what each one is
Oedematous - swelling
Haemorrhagic - bleeding Necrotic - infected/ dying
- What are the symptoms of acute pancreatitis?
Epigastric pain - radiating to back often eased by sitting forward.
Nausea and Vomiting Fevers
- What are the signs of acute pancreatitis?
Haemodynamic instability (tachycardic, hypotensive)
Peritonism in upper abdomen OR generalised Grey-Turner's sign (bruising in flanks) Cullen's sign (bruising around umbilicus)
- What are the signs of acute pancreatitis?
Haemodynamic instability (tachycardic, hypotensive)
Peritonism in upper abdomen OR generalised Grey-Turner's sign (bruising in flanks) Cullen's sign (bruising around umbilicus)
- What differential diagnoses can be listed alongside a patient who has symptoms and signs of acute pancreatitis?
Gallstone disease and associated complications (e.g. biliary colic and acute cholecystitis)
Peptic ulcer disease/perforation Leaking/ruptured AA (aortic aneurysm)
- List all the investigations that can potentially be done to confirm a diagnosis of acute pancreatitis
Blood tests- Amylase/lipase
X-rays- Erect CXR (i.e. standing chest X-ray)- Abdominal XR (sentinel loop, gallstones) USS- Look for gallstones as a cause for pancreatitis CT abdomen - Patients not settling with conservative management and only 48-72 hours after symptom onset MRCP - If gallstones pancreatitis suspected with abdominal liver function tests (CBD stone) ERCP- Remove CBD gallstones
- List causes of increase amylase levels
Parotitis - swelling of parotid gland
Renal failure Macroamylasaemia Bowel perforation Lung/ovary/pancreas/colonic malignancies can produce ectopic amylase.
- Outline the Modified Glasgow criteria for assessing severity of acute pancreatitis and how it is used
PO2 <8kPa
Age >55 yrs
Neutrophilia- white cell count >15
Calcium <2mmol/L
Renal - urea >16mmol/L
Enzymes - aspartate aminotransferase (AST) >200iu/L, lactate dehydrogenase (LDH) >600 iu/L
Albumin <32g/L
Sugar >10mmol/L
Score of 3 or more within 48 hours suggests severe acute pancreatitis. (CRP is an independent predictor of severity >200 suggests severe pancreatitis.)
- What are the 4 principles of management when it comes to acute pancreatitis?
Fluid resuscitation (IV fluids, urinary catheter, strict fluid balance monitoring)
Analgesia Pancreatic rest (+/- nutritional support if prolonged recover → nasojejunal (NJ) tube feeding or total parenteral nutrition (TPN) feeding) Determining underlying cause
- How do you manage patient who has a score, according to the Modified Glasgow criteria, indicative of severe acute pancreatitis?
- Should you use antibiotics in the management of patients with acute pancreatitis?
- Is surgery ever required in the treatment of acute pancreatitis?
Place them on high dependency unit (HDU)
No, unless they have necrotic pancreatitis/infected necrosis (Antibiotics not given routinely) Yes, but rarely
- How does hypocalcaemia occur as a result of pancreatitis?
- How does hyperglycaemia occur as a result of pancreatitis?
Phospholipases and lipases elevate serum FFAs → chelation of Ca2+ salts → serum Ca2+ decrease (saponification)
Phospholipase A2 activity hydrolyses serum albumin → decreased albumin → decreased Ca2+ transport
Pancreatic islet necrosis reduces insulin secretion through pancreatic beta-cell → increased glucose (hyperglycaemia)
- How is pancreatic gangrene a symptom of pancreatitis?
Phospholipase A2 activity increased → Fat necrosis → Pancreatic gangrene
Elastase activity increased → Vessel arrosion → Bleeding → Pancreatic gangrene Prothrombin activity increased → Thrombin → Thrombosis → Ischaemia → Pancreatic gangrene
- How is shock a symptom of acute pancreatitis?
- Systemic damage to which organs causes hypoxia and anuria in acute pancreatitis?
Kalikrein activated → Bradykinin kalidin → Vasodilation and plasma exudation → Shock
Damage to the lungs → hypoxia Damage to the kidneys → anuria
- List all the systemic complications of acute pancreatitis
Hypocalcaemia
Hyperglycaemia Systemic Inflammatory Response Syndrome (SIRS) Acute Renal Failure (ARF) Adult Respiratory Distress Syndrome (ARDS) Disseminated Intravascular Coagulation (DIC) Multi Organ Failure (MOF) and death
- List all the local complications of acute pancreatitis
Pancreatic necrosis +/- infection (infected necrosis)
Pancreatic abscess
Pancreatic pseudocyst
Haemorrhage → bleeding from eroded vessels
Small vessels → haemorrhagic pancreatitis (Cullen’s/Grey Turner’s sign)
Large vessels (e.g. splenic artery) → life threatening bleed (unless forms pseudo-aneurysm)
Thrombosis of splenic vein, superior mesenteric vein, portal vein → vasculature to liver compromised → ascites → small bowel venous congestion/ ischaemia
Chronic pancreatitis/pancreatic insufficiency (if recurrent attacks)
- Outline the management of acute pancreatitis caused by an infected necrosis
Antibiotics + Percutaneous drainage
Infected pancreatic necrosis is the only indication for surgical intervention in the context of acute pancreatitis. (High mortality if dead infected tissue isn't removed). Surgery involves necrosectomy (excision of necrotic tissue).
- What is meant by a pseudocyst?
- Where do the exocrine secretion of the pancreas (pancreatic juice) enter into the duodenum via?
Peri-pancreatic fluid colection due to a pancreatic leak : formation of a fibrous capsule encapsulating pancreatic enzymes
MPD/sphincter of Oddi/ampulla
- What 2 main things can chronic pancreatitis lead to the development of?
Insulin dependent diabetes mellitus (IDDM)
Steatorrhoea
- Outline the management/treatment for chronic pancreatitis
Pancreatic stone causing upstream back pressure within the pancreatic duct. endoscopist can insert stent to remove the stone through the AoV.
Surgical drainage - Removal of pus and necrotic tissue. Surgical resection - Head/tail or entire pancreas removed → Phantom pain may arise.
