Pancreatitis Flashcards
What are the different classifications of pancreatitis?
Acute or chronic.
Acute pancreatitis is reversible.
Chronic pancreatitis is irreversible.
Acute can be further classified based on severity using the Glasgow Prognostic Score. However NEWS score is now more frequently used.
P -PaO2 A -Age N -Neutrophils (white blood cell count) C -Calcium R -Raised urea E -Enzyme (lactate dehydrogenase (LDH)) A -Albumin S -Sugar (glucose)
Describe the causes of pancreatitis?
Gall stones
Ethanol
Trauma
Steroids Malignancy/Mumps (+EBV,CMV) Autoimmune (SLE, polyarthritis nodosa) Scorpion venom Hyperglycaemia/calcaemia/ hypothermia ERCP Drugs
Describe how gallstones and alcohol cause pancreatitis?
In gallstones there is a blockage of the common bile duct causing back pressure into the pancreatic duct. This can cause gastric contents to enter the pancreatic duct, activating pro-enzymes (usually activated in guy by proteases), and causing inflammation.
In alcoholic disease, the ampulla spasms, ducts are plugged by viscous secretion and alcohol is directly toxic to acinar cells.
Describe the complications of pancreatitis?
EARLY
- Pancreatic necrosis (becomes infected in 30-70% of cases)
- Infected necrosis (trebles mortality)
- Acute Fluid Collections (pulmonary oedema/pleural effusion)
- ARDS
- Hypovolaemic shock (fluid leakage into third space)
- DIC
- Renal failure
- Secondary diabetes
- Malabsorbtion
LATE
- Pancreatic abscess (requires surgery, bacteria from duodenum travels up duct into pancreas)
- Pancreatic pseudo-cyst (contains pancreatic juice in a wall of fibrous or granulation tissue)
- Haemhorrage (may eat into the splenic aa causing massive bleeding)
- Ruptured pseudo-cyst causing pancreatic ascites.
- Increased chance of pancreatic cancer
- Fistulae
Describe the classical signs and symptoms of a patient presenting with acute pancreatitis?
Symptoms: Severe epigastric (upper abdominal) pain radiating through to the back. Better leaning forward. May have a mild pyrexia. May be nausea and vomiting. Tachycardia Jaundice in 30%
In severe cases: Hypotensive shock. Pyrexia. Rigid abdomen Acute ascites/pleural effusions. Bruising around the umbilicus (Cullen's sign) or flanks (Grey Turner's sign) - late signs, poor prognosis. May have ileus
Outline how you would investigate a patient presenting with signs and symptoms of pancreatitis?
History and Examination
Bloods: FBC (WBC) U/E's LFTs (gallstones) Lipase and Amylase (amylase should be at least 3x normal to indicate pancreatitis or >1000U/ml, lipase is more sensitive and specific) CRP (inflammatory marker) ABG (monitor acid base and watch for respiratory failure) Glucose Calcium
CXR (rule out perforation, look for pleural effusions/ARDS)
AXR (rule out other causes of acute abdo pain, look for ileus)
USS (look for gall stones)
CT scan (dont need to do immediately unless clinical doubt, shows abscess, collections, necrosis, pseudocysts)
MRCP (visualise gallstones if not seen on US)
Generally patients get AXR/CT on admission, then CT or MRCP after 2-3 days to assess severity of necrosis
Understand the role of the severity scoring system in management?
Mild: patient is stable
Mod-severe: patient has some degree of organ failure which resolves within 48hrs (AKI, respiratory compromise etc)
Severe: organ failure persisting greater than 48hrs
Mild pancreatitis should be referred to hospital, given fluids, and analgesia. Eating should be as tolerated often it can exacerbate the pain.
Severe pancreatitis needs HDU referral, monitoring hypovolaemic shock is necessary, maintaining fluids and urine output.
Removal of gall stones and debridement of necrotic tissue is required, if possible, within 48 hours of admission.
Describe the presentation on chronic pancreatitis?
Often acute episodes with intervening remission which become chronic.
- Abdominal pain: severe, radiating to the back, better on leaning forward.
- Nausea and vomiting
- Anorexia
- Exocrine dysfunction: weight loss, steatorrhoea and bloating
- Endocrine dysfunction: diabetes
Describe how chronic pancreatitis is diagnosed?
It is diagnosed by the visualisation of pancreatic calcification on AXR or CT scan.
Biopsy could also be used however it is high risk so is very rarely used.
Describe some of the complications of chronic pancreatitis?
Endocrine dysfunction: diabetes
Exocrine dysfunction
Strictures which can cause obstructed jaundice and lead to liver cirrhosis.
Predisposes to pancreatic malignancy.
Describe the treatment options for pancreatic strictures?
Stenting of strictures with ERCP. However, issues with stenting include blockage and predisposition to infection.
Long term treatment is surgical with billiary bypass.
Which drugs can cause pancreatitis?
Steroids, NSAIDs, sulphonamides, thiazides, ACE inhibitors, AZT
Describe what happens to the pancreas in pancreatitis?
In pancreatitis when the pancreas becomes damaged it
starts to secrete proteolytic enzymes which autodigest causing further damage. In severe pancreatitis there is periductal necrosis.
Inflammation > Vessels leak and rupture > Enzymes released and destroy fats > liquification, necrosis, haemhorrage
Which cause of pancreatitis results in these injuries:
- Periductal - necrosis of cells adjacent to ducts
- Panlobular - necrosis of the whole lobule
- Perilobular - necrosis of the peripheries of the lobules
- Ductal obstruction e.g. stones
- Toxins, drugs, viruses, metabolic insults
- Hypothermia/ shock
Describe the management of a patient with pancreatitis, both acute a long term.
ACUTE
- A-E
- IV fluid, catheterise, consider CVP monitoring
- Hourly Obs
- Analgesia (pethidine)
- NBM
- Consider ITU
- Maintain nutritional support (NG feeding or oral)
GENERAL
- Anticoagulation
- PPI to prevent stress ulcer
- LOOK FOR CAUSE
- Gallstones > urgent ERCP
- Ileus > NG tube
- Abscess or necrosis on CT > may need surgical debridement
- May need Abx
- May need insulin sliding scale
