Pancreatitis

Question 1

What is pancreatitis?

Answer 1

Inflammation of the pancreas due to destruction via own digestive enzymes

Question 2

What are the causes of acute pancreatitis?

Answer 2

GET SMASHED:
Gall stones —> most common
Ethanol (alcohol)
Trauma

Steroids
Mumps and viruses (epstein-barr, CMV)
Auto-immune (polyarteritis nodosa, SLE)
Scorpion/snake bite
Hypercalcaemia, hypertriglyceridaemia, hypothermia
ERCP (Endoscopic Retrograde.
CholangioPancreatography)
Drugs —> SAND - steroids and sulphonamides
- azothioprine
- NSAIDS
- diuretics

Question 3

How does a gallstone cause acute pancreatitis?

Answer 3

Gallstone —> block pancreatic juice leaving pancreatic duct —> increase pressure in duct —> distension —> issues with membrane trafficking —> zymogen granules bind with lysosomes —> digestive enzymes activated

Question 4

How does alcohol cause acute pancreatitis?

Answer 4

• inc permeability of pancreatic duct epithelium —>
  digestive enzymes into periductal interstitial tissue
• proteins form plug blocking duct —> increase
  pressure in duct —> distension —> issues with
  membrane trafficking —> zymogen granules bind
  with lysosomes —> digestive enzymes activated

Question 5

What are the consequences of acute pancreatitis?

Answer 5

Tripsin activated —> activates:
1. Phospholipase A2 —> hypocalcaemia
—> pancreatic gangrene
- hypoalbuminaemia
- fat necrosis —> Ca2+ sequestration
2. Elastase —> hyperglycaemia
- necrosis of islets —> dec insulin release
3. Complement proteins —> pancreatic gangrene
- cell toxicity —> vessel erosion —> bleeding
4. Prothrombin —> pain
—> pancreatic gangrene
- thrombosis —> ischaemia
5. Kallikrein —> pain
—> shock
- vasodilation and plasma exudation
6. Systemic damage —> hypoxia
—> anuria

Question 6

What are the symptoms and signs of acute pancreatitis?

Answer 6

• epigastric pain - radiates to back
• nausea and vomiting
• fevers
• haemodynamic instability —> tachycardic
  —> hypotensive
• peritonism (peritoneum inflammation)
• Grey-Turner’s sign —> bruising at sides (flanks)
• Cullen’s sign —> bruising around umbilicus

Question 7

How is acute pancreatitis diagnosed?

Answer 7

Blood tests —> amylase
—> lipase
X-rays - erect CXR
- AXR
USS —> look for gallstones
CT abdomen - only if still not found cause
MRCP - Magnetic Resonance
CholangioPancreatography
ERCP - Endoscopic Retrograde
CholangioPancreatography

Question 8

How is the severity of acute pancreas assessed?

Answer 8

Glasgow criteria —> PANCREAS:
- PO2 —> hypoxia
- Age > 55
- N —> leukocytosis
- Calcium —> hypocalcaemia
- Renal —> uremia
- Enzymes - AST, LDH high
- Albumin —> hyperalbuminaemia
- Sugar —> hyperglycaemia
—> over 3 within 48hrs onset —> severe

CRP > 200 —> severe

Question 9

How is acute pancreatitis treated?

Answer 9

1. Fluid resuscitation - IV, catheter, monitoring
2. Analgesia
3. Pancreatic rest - sometimes nasojejunul (NJ) feeding
   or parental nutrition (PN)
4. Determine cause

• most clear on their own (95%)
• severe —> HDU —> ICU
• antibiotics only if necrotic pancreatitis
• surgery v rare - only infected necrotic pancreatitis
  —> necrosectomy

Question 10

What are the 8 systemic complications of acute pancreatitis?

Answer 10

Systemic:
1. Hypocalcaemia
2. Saponification - fat in blood
3. Hyperglycaemia —> insulin dependent diabetes
mellitus
4. SIRS (Systemic Inflammatory Response Syndrome)
5. ARF (Acute Renal Failure)
6. ARDS (Adult Respiratory Distress Syndrome)
7. DIC (Disseminated Intravascular Coagulation)
8. MOF (Multi Organ Failure) —> death

Question 11

What are the 8 local complications of acute pancreatitis?

Answer 11

1. Pancreatic necrosis —> may be infected
2. Pancreatic abscess
3. Pancreatic pseudocyst
4. Haemorrhage - small vessels —> haemorrhagic
   pancreatitis
   - large vessels —> life-threat bleeds
5. Thrombosis - splenic vein, superior mesenteric vein,
   portal vein
   —> ascites
   —> small bowel venous congestion/
   ischaemia
6. Chronic pancreatitis development

Question 12

What is a pseudocyst?

Answer 12

Collection of peri-pancreatic fluid within fibrous capsule
- fluid high in pancreatic enzymes
- presents >6 weeks
- 95% clear after 6 months
- intervention - only if symptomatic, compresses
surrounding structures or infected
—> drainage - percutaneously (CT scan)
- endoscopically —> stent
- surgically (laproscopic)

Question 13

What are the 2 causes of chronic pancreatitis?

Answer 13

1. Alcohol abuse
2. Occlusion of main pancreatic duct

Question 14

What are the 2 complications of chronic pancreatitis?

Answer 14

1. IDDM (Insulin Dependent Diabetes Mellitus)
2. Steatorrhea

Question 15

How is chronic pancreatitis treated?

Answer 15

1. Endoscopically
2. Surgically - drainage
   - resection