Pancreatitis Flashcards
Causes of pancreatitis
I - idiopathic
G - gallstones
E - ethanol
T - trauma
S - steroids
M - mumps
A - autoimmune
S - scorpion sting (Trinidad)
H - hypercalcaemia & hyperlipidaemia
E - ERCP
D - drugs (sulphonamides, azathioprine, NSAIDs, diuretics)
Typical pain distribution of pancreatitis?
Central abdo pain (epigastric) that radiates to the back
What are the signs o/e for pancreatic haemorrhage?
Cullen’s & Grey-Turner’s
What is the Glasgow-Emery score? (PANCREAS)
Prognostic indicators for pancreatitis:
P -
A -
N -
C -
R -
E -
A -
S -
What are the key factors on presentation with pancreatitis that indicate potential necrotic processes?
Haemorrhagic
ARDS
What are the key functions of the pancreas?
Endocrine
- alpha cells
- beta cells - insulin
Exocrine - digestive enzymes released as zymogens stored as zymogen granules (protease vs protease inhibitors)
Why do pancreatic enzymes only work once they reach the duodenum?
Enteropeptidases in the duodenum convert trypsinogen to trypsin which is then able to convert all the zymogens to their active forms.
What are the most common causes of acute pancreatitis?
- GSD
- Alcohol
How does alcohol cause pancreatitis?
Alcohol
- increases zymogen secretion from acinar cells
- decreases fluid & bicarb in ducts = viscous pancreatic juices;
Plugs form, block ducts = increased ductal pressure & distension - zymogen granules fuse with lysosomes (release trypsin = autodigestion)
- stimulates cytokine release (neutrophils release superoxides & proteases)
- oxidative metabolism of alcohol = ROS
How do gallstones cause acute pancreatitis?
Block sphincter of Oddi - bile backs up pancreatic duct = inflammation
How does pancreatitis progress to Liquefactive Haemorrhagic Necrosis?
Proteases & inflammatory response = tissue destruction & blood vessel leaks/rupture
Lipases-destroy prepancreatic fat
= liquefies tissue
What is a pancreatic pseudocyst and how does it present?
Fibrous tissue surrounding liquefactive necrotic tissue
- abdo pain
- loss of appetite
- palpable mass
(Raised amylase, lipase & bilirubin)
Abdo CT
What is the main complication of pancreatic pseudocysts?
Pancreatic abscess = high fever, WCC
What are the complications of acute pancreatitis?
- chronic pancreatitis
- pancreatic pseudocysts
- pancreatic abscesses
- hypovolaemic shock
- DIC
- ARDS (most lethal; inflammation, leaky vessels, difficulty breathing)
What are the signs/symptoms of acute pancreatitis?
- epigastric pain radiates to back
- N+V
- hypocalcaemia (fat necrosis)
- Cullen’s sign
- Grey Turner’s sign
What blood results are characteristic of acute pancreatitis?
- low calcium
- raised amylase, lipase
What findings would be on imaging for acute pancreatitis?
CT
- inflammation
- necrosis
- pseudocysts
USS
- gallstones
How is acute pancreatitis treated?
- treat ULC
- pain management
- hydration
- electrolytes
Rest bowels - NBM, IV/NG tube
Treat complications
- O2Tx
- Abx
What characterises chronic pancreatitis?
Irreversible structural changes
- fibrosis
- atrophy
- calcification
Causes of acute pancreatitis that often lead to chronic disease:
- alcohol
- trauma
- tumours
- CF
How does CF cause pancreatitis?
CFTR gene mutation disrupts ion transport = viscous & sticky
- main cause in children
What is the pathophysiology of chronic pancreatitis?
- structural changes to ducts
- fibrosis
- calcium deposits
How does repeated bouts of acute pancreatitis lead to chronic disease?
Repeated bouts of acute pancreatitis =
- ductal dilation,
- stellate cells lay down fibrotic tissue = narrowed ducts & stenosis
How does alcohol cause chronic pancreatitis?
Alcohol
- calcium deposits on protein plugs
Why is amylase not a good indicator of chronic pancreatitis?
Insufficient healthy tissue
How to diagnose chronic pancreatitis
Calcifications
- AXR
- CT abdo (dense, fluid-filled mass, darker)
Ducts
- ERCP/MRCP = chain-of-lakes pancreas (dilation & stenosis)
What are the complications of chronic pancreatitis?
Pancreatic insufficiency - impaired acinar cells = malabsorption
- WL
- Vit ADEK deficiencies
- steatorrhoea (undigested fat)
DM - alpha & beta damage
Pseudocysts - ductal obstruction = pressure, fluid accumulation
Pancreatic cancer - rare
What is the treatment of chronic pancreatitis?
- analgesia
- risk factor control (alcohol, meat, obesity)
- pancreatic insufficiency (exogenous enzyme replacement, nutritional supplements)
- DM (insulin replacement Tx)
How does pancreatitis cause SIRS?
Hypovolaemic shock = SOB, hypoxaemia, hypotension, fever
Name 5 classic pancreatitis presentations
- hepatomegaly (alcoholic)
- xanthomas (hyperlipidaemia)
- swollen parotids (mumps)
- Cullen’s sign (necrosis)
- Grey-Turner’s sign (necrosis)
What blood results would be expected in an acute pancreatitis picture?
- lipase & amylase 3x limit
- FBC (leukocytosis, raised Hct)
dehydration, acute haemorrhage - CRP & LDH raised
- Cr
dehydration - low calcium (fat necrosis)
- hyper/hypoglycaemia
What results on an abdo USS show pancreatitis?
- pancreas enlarged & hypoechoic
- gallstones
What results on an A/CXR show pancreatitis?
- sentinel loop (ileus inflammation)
- pleural effusion
How is an abdo CT used to stage pancreatitis?
Balthazar score
- necrosis
- inflammation
- fluid collection around pancreas
What are the two methods of staging pancreatitis?
Atlanta & Ranson’s criteria
What comprises the Atlanta classification?
Mild - no organ failure or complications
Moderate - transient organ failure (resolves in 48h) +/- complications
Severe - organ failure >48h
What are Ranson’s criteria?
Admission
- 55
- high WCC, LDH, AST
- hyperglycaemia
48h after admission
- low Hct, Ca, pO2
- high urea, base defecit
- fluid sequestration
1-3 = mild
> 3 = severe
How to treat mild pancreatitis
- fluid resus (saline 5-10 ml/kg/h for 12-24h)
Risk: persistent hypo (ischaemia & necrosis) - oral nutrition in 24h
How to treat severe pancreatitis
- fluid resus (20 ml/kg/h for 30 mins then 3ml)
- IV opioids (morphine, fentanyl)
- parental/enteral feeding
What potential complications can arise from pancreatitis?
- ARDS
- pleural effusions (pancreaticopleural fistula)
- ascites
- saponification of fatty tissue (enzymes)
- acute peripancreatic fluid collection becomes acute necrotic collection
- pancreatic pseudocyst
- necrotic abscess
How to treat ARDS
Intubation
How to treat a necrotic abscess
Broad spectrum abx (meropenem, amoxicillin)
- no improvement in 4w = necrosectomy/debridement
