Pancreatitis

Question 1

What is pancreatitis and what is the difference between acute and chronic?

Answer 1

Pancreatitis refers to inflammation of the pancreas.

Acute pancreatitis presents with a rapid onset of inflammation and symptoms. After an episode of acute pancreatitis, normal function usually returns.

Chronic pancreatitis involves longer-term inflammation and symptoms with a progressive and permanent deterioration in pancreatic function.

Question 2

What are the causes of pancreatitis?

Answer 2

I – Idiopathic
G – Gallstones
E – Ethanol (alcohol consumption)
T – Trauma
S – Steroids
M – Mumps
A – Autoimmune
S – Scorpion sting (the one everyone remembers)
H – Hyperlipidaemia
E – ERCP
D – Drugs (furosemide, thiazide diuretics and azathioprine)

Question 3

What is the presentation of pancreatitis ?

Answer 3

Severe epigastric pain
Radiating through to the back
Associated vomiting
Abdominal tenderness
Systemically unwell (e.g., low-grade fever and tachycardia)

Question 4

What are the investigations of pancreatitis?

Answer 4

FBC (for white cell count)
U&E (for urea)
LFT (for transaminases and albumin)
Calcium
ABG (for PaO2 and blood glucose)

Amylase is raised more than 3 times the upper limit of normal in acute pancreatitis. In chronic pancreatitis it may not rise because the pancreas has reduced function.

Lipase is also raised in acute pancreatitis. It is considered more sensitive and specific than amylase.

C-reactive protein (CRP) can be used to monitor the level of inflammation.

Ultrasound is the initial investigation of choice in assessing for gallstones.

CT abdomen can assess for complications of pancreatitis (such as necrosis, abscesses and fluid collections). It is not usually required unless complications are suspected (e.g., the patient is becoming more unwell).

Question 5

How is the Glasgow score used?

Answer 5

0 or 1 – mild pancreatitis
2 – moderate pancreatitis
3 or more – severe pancreatitis

The criteria for the Glasgow score can be remembered using the PANCREAS mnemonic (1 point for each answer):

P – Pa02 < 8 KPa
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 (Glucose >10)

Question 6

How do we manage acute pancreatitis?

Answer 6

Initial resuscitation (ABCDE approach)
IV fluids
Nil by mouth
Analgesia
Careful monitoring
Treatment of gallstones in gallstone pancreatitis (ERCP / cholecystectomy)
Antibiotics if there is evidence of a specific infection (e.g., abscess or infected necrotic area)
Treatment of complications (e.g., endoscopic or percutaneous drainage of large collections)
Most patients will improve within 3-7 days.

Question 7

What are the Complications of Acute Pancreatitis?

Answer 7

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

Question 8

What are the complications of chronic pancreatitis?

Answer 8

Chronic epigastric pain
Loss of exocrine function, resulting in a lack of pancreatic enzymes (particularly lipase) secreted into the GI tract
Loss of endocrine function, resulting in a lack of insulin, leading to diabetes
Damage and strictures to the duct system, resulting in obstruction in the excretion of pancreatic juice and bile
Formation of pseudocysts or abscesses

Question 9

How do we manage chronic pancreatitis?

Answer 9

Abstinence from alcohol and smoking is important in managing symptoms and complications.

Analgesia can be used to manage the pain, although it can be severe and difficult to manage.

Replacement pancreatic enzymes (Creon) may be required if there is a loss of pancreatic enzymes (i.e. lipase). Otherwise, a lack of enzymes leads to malabsorption of fat, greasy stools (steatorrhoea), and deficiency in fat-soluble vitamins.

Subcutaneous insulin regimes may be required to treat diabetes.

ERCP with stenting can be used to treat strictures and obstruction to the biliary system and pancreatic duct.

Surgery may be required by specialist centres to treat:

Severe chronic pain (draining the ducts and removing inflamed pancreatic tissue)
Obstruction of the biliary system and pancreatic duct
Pseudocysts
Abscesses

Question 10

Differentials for acute pancreatitis

Answer 10

Oesophageal rupture
AAA leaking
MI
Perforated gastric/ duodenal ulcer
Aortic dissection