Pancreatitis Flashcards
Acute Pancreatitis
Sudden onset
Life threatening
Reversible
Causes of AP
Idiopathic (20%) Gallstones obstructing pancreatic duct (50%) Ethanol (25%) Trauma Steroids Mumps Autoimmune Scorpion bites Hyperlipideamia/hypothermia ERCP Drugs I GET SMASHED
Risk factors for gallstones
Female
Fat
Fertile
Forty
Pathogenesis of AP
Release of lytic enzymes (trypsin, lipase, phospholipidase A2) that digest pancreatic tissue and cause fat necrosis
Mild- pancreatic inflam and oedema
Severe- pancreatic necrosis and multi organ failure
Signs and symptoms of AP
Severe epigastric pain that radiates to back (as pancreas is covered by peritoneum in front but not at back) Nausea, vomiting resp distress fever haemorrhae, shock
Diagnosis of AP
Severe abdo pain
Raised serum amylase during first 24 hrs
Raised serum lipase within 73-96 hrs
Imaging; USS and CT
Prevent recurrence of AP
Remove gallstones by ERCP or cholecystectomy
reduce alcohol
consider drug causes
4 key pathological features of Chronic Pancreatitis
- Chronic, continuous inflammation
- Fibrous scarring
- Impaired pancreatic function (exo and endocrine)
- Duct strictures with formation of calculi
Causes of CP
Alcohol (60-70%)
Idiopathic (20-30%)
Pathogenesis of CP
Increased acinar protein secreted and reduction in NaHCO3 and fluids causes increased viscosity pancreatic duct (PLUGGING)
This leads to acinar atrophy and fibrosis
Alcohol may just have toxic effect on acinar cells
Lifestyle factors increasing CP risk
Tobacco smoke and alchol metabolism leads to pancreatic oxidative stress from alcohol dehydrogenase buildup.
Cytochrome P450 non-oxidative pathway and reactive oxygen species also lead to cell damage
Signs and symptoms of CP
- Prolonged chronic Intermittent severe upper abdo pain that radiates to back
- Pancreatic malabsorption leading to weight loss and steaorrhea
- Diabetes by destruction of pancreatic islet cells
Pain causes
Pressure in duct or parenchyma causing pancreatic ischaemia
Inflammation and pancreatic fibrosis
Abnormal CNS pain processing
Reduced bicarbonate secretions
Malabsorption consequences
Lipase levels fall before protease and amylase. So fat malabsorbtion leads to steatorrhea (greasy stool)
Weight loss and reduced vit A, D, E, K as fat soluble
Reduces bicarbonate - acid environment
Reduced bile acid secretion
Dignosis of CP
Faecal elastase
Endoscopic ultrasound
CT/MRI
Management of CP
Lifestyle (stop smoking and alcohol)
Pain (NSAIDs, endoscopic therapy, nerve blocks, surgery)
Treat
Identify complications
Treating CP
Replace pancreatic enzymes (pancreatin)
These are capsules taken before and during meals. Mimick normal secretion
Usuallt take these with a PPI
Complications of CP
- Pseudocysts; local fluid collection (usually in lesser sac) surrounded by granulation tissue. smaller than 6cm resolve on their own
- Bleeding; variceal (due to underlying cause or splenic vein thrombosis), pseudocyst
- Obstruction; bile duct, duodenal
- Pancreatic cancer; common, see inc pain, weihht loss, obstructive jaundice
Prognosis of CP
Age
Smoking
Liver cirrhosis
Continue alcohol
70% survival 10 yrs
45% survival 20 yrs
4% pancreatic cancer 20yrs
Pancreatin side effects
nausea, vomiting, diarrhoea
skin irritation around mouth and anus
stomach pain
What stimulates the release of enzymes in AP
- hyperstimulation of pancreas from alcohol or fat
- pancreatic duct destruction (tumours)
- defective intracellular transport and secretion of pancreatic enzymes
- reflux of infected bile or duodenal contents into pancreatic duct (gall stone obstruction)
Treatment of AP
Keep nil by mouth
Give aggressive IV water and electrolyte replacement with opiate analgesia
IF severe need to give IV nutrition
