Pancreatitis Flashcards
Define acute pancreatitis
acute inflammation of the pancreas
Where does the splenic vein lie relative to the pancreas?
splenic vein lies behind pancreas
Pancreatitis diagnosis
2/3 of:
- typical pancreatic pain
- radiographic findings of acute pancreatitis (not commonly used in first few days)
- elevations in blood chemistries (amylase/lipase >3xULN)
Typical pancreatitis pain
severe
rapid onset
better leaning forwards
radiates to back
maximal onset within 20-30mins
does not undulate
Other clues (other than pain) of acute pancreatitis
abdo pain
nausea/vomiting
tachycardia
low grade fever
abdominal guarding (involuntary contraction of abdo muscles when you push in)
loss of bowel sounds
jaundice (gallstone blocking duct causing pancreatitis)
Causes other than pancreatitis of raised amylase
renal insufficiency
salivary inflammation
macroamylasemia
hereditary
intestinal infarction/peritonitis
salpingitis/ectopic pregnancy/ovarian cysts
acidosis, ESLD
intestinal obstruction
colon, ovary, pancreatic, breast, prostate, lung, oesophageal cancer
MM, phaeo, appendicitis, gastroenteritis
burns
normal pregnancy
Gullo’s syndrome
Describe the half-lives of amylase and lipase and the clinical relevance of this
lipase has longer half life
if someone presents late, lipase will still likely be high
amylase has short half life, normal within 48 hours, amylase can be normal if a pt presents late
Acute pancreatitis causes
biliary (gallstones)
alcohol
triglycerides
post-surgical
post-ERCP
drugs (azathioprine, valproate)
tumours - head of pancreas
trauma
ischaemia/embolic
infection (mumps)
hypercalcaemia
autoimmune
hereditary
scorpions
idiopathic
What imaging should be done if gallstones are suspected?
US within first 24 hours
What imaging can be done if you are suspicious of gallstones but US is clear?
MRCP (non-contrast study)
Endoscopic ultrasound (EUS) - looking for microlithiasis
What should you consider if obstructive LFTs in pancreatitis?
acute cholangitis (needs IV abx)
bacteria builds up behind gallstone and causes infection
Drug causes of acute pancreatitis
AIDS - didanosine, pentamidine
antimicrobial - sulfonamides
diuretics - furosemide, thiazides
sodium valproate
exenatide
immunosuppressive - azathioprine
Causes of pancreatic duct obstruction
pancreatic cancers
ampullary/periampullary cancers
IPMNS
duodenal cancers/lymphoma/mets
P divisum
Ascariasis
post-acute pancreatitis with ductal stricture
What should be done for all unexplained pancreatitis within 6 weeks?
CT scan
check no malignant ductal obstruction
What infections can cause acute pancreatitis?
mumps
coxsackievirus
hep E
hep B
CMV
VZV
HIV
salmonella
mycoplasma
legionella
TB
aspergillus
cryptococcus
toxoplasma
What are the 2 pathways acute pancreatitis may go down?
acute interstitial oedematous pancreatitis (80%)
necrotising pancreatitis (20%) - higher risk of death, enzymes cause cellular death around pancreas
How do patients die with acute pancreatitis?
early within 1-2 weeks - multisystem organ failure, DIC, shock, abdo compartment syndrome, cholangitis, acidosis, haemorrhagic pancreatitis
late - acute necrotic collections, secondary biliary obstruction, hypoalbuminaemia, hospital-acquired infections, PE, gut failure
When should imaging be done in acute pancreatitis?
normally wait 5-7 days
fluid collections take time to develop
What is Cullen’s sign?
superficial oedema with bruising in the subcutaneous fatty tissue around the peri-umbilical region. This is also known as peri-umbilical ecchymosis. It is most often recognised as a result of haemorrhagic pancreatitis
What is Grey Turner’s sign?
an uncommon subcutaneous manifestation of intra-abdominal hemorrhage that manifests as ecchymosis or discoloration of the flank. This sign is classically associated with severe acute necrotizing pancreatitis, which can be associated with the Cullen sign (periumbilical ecchymosis)
Describe mild, moderate and severe acute pancreatitis?
mild = no local complication or organ failure
moderate = organ failure that lasts less than 48 hours and local complications (eg. collections)
severe = organ failure that persists for more than 48 hours
How is acute pancreatitis severity predicted?
BISAP score - done in first 24 hours - predicts mortality
How much fluid should be given in acute pancreatitis?
1L every 4 hours with a catheter
Acute pancreatitis treatment
fluids
IV morphine as analgesia
feed early - consider tube
anti-emetic
thromboprophylaxis
When should antibiotics be used in acute pancreatitis?
if used, should be broad-spectrum
use if cholangitis or infected necrosis suspected
not to be given to prevent infected necrosis
meropenem, pip/tazo
Define chronic pancreatitis
chronic, progressive pancreatic inflammation and scarring, irreversibly damaging the pancreas and resulting in loss of endocrine and exocrine function
Chronic pancreatitis diagnosis
presence of clinical symptoms
pancreatic exocrine function testing
imaging
Chronic pancreatitis symptoms
pain - chronic
epigastric
radiating to back
steatorrhoea - fat not absorbed, passed in stool –> hard to flush, floats
Risk factors for chronic pancreatitis
alcohol
smoking
high calcium
high triglycerides
obstructive (CF)
hereditary (CF)
tropical
autoimmune
chronic renal failure
CT findings in Chronic pancreatitis
dilated pancreatic duct
pancreatic atrophy
pancreatic calcifications
fluid collections
focal pancreatic enlargement
biliary duct dilatation
alterations in peripancreatic fat
normal pancreas
What is pancreatic enzyme replacement therapy (PERT)?
pancreatic enzymes given with meals to aid digestion in pts with pancreatic exocrine deficiency
eg. creon
(derived from porcine pancreases)
What surgery can be done for Chronic pancreatitis?
Peustow
slice open pancreas, stones fished out, jejunum on pancreatic ducts so drain into jejunum
