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
