Pancreatitis Flashcards
What does the pancreas do?
Endocrine: production of hormones involved in regulation of sugar in the body and metabolism
Exocrine: secretion of enzymes involved in digestion
What does the endocrine portion of the pancreas produce?
Insulin: lowers blood sugar
Glucagon: raises blood sugar
What does the exocrine portion of the pancreas produce?
Digestive enzymes: amylase, lipase, proteases
These help digestion in the small intestine
What is the difference between acute and chronic pancreatitis?
Acute: when a normal pancreas becomes damaged but it returns to its normal self afterwards.
Isolated or recurrent attacks
Chronic: continuing inflammation with irreversible structural changes
Sometimes there is overlap!
What causes acute pancreatitis?
GET SMASHED
Gall stones
Ethanol
Trauma
Steroids Mumps Autoimmune Scorpion stings Hyperlipidaemia ERCP Drugs
What is ERCP?
Endoscopic retrograde cholangiopancreatography
A procedure where a camera is fed into the pancreatic ducts via the duodenum
What’s the general pathogenesis of acute pancreatitis?
The causes (GET SMASHED) all cause a rise in intracellular calcium levels
This leads to excessive release of pancreatic enzymes
These damage the acinar cells, necrosis occurs
Inflammatory cells migrate to the area,
They release pro-inflammatory cytokines leading to an immune response
Can become systemic leading to multiple organ failure
Clinical features of acute pancreatitis?
Epigastric or upper abdominal pain radiating to back
Nausea + vomiting
Epigastric or general abdominal tenderness, guarding and rigidity
Pyrexia
Tachycardia
Jaundice
Septic shock
Grey Turner’s sign or Cullen’s sign
Can initially present with coma, multi-organ failure
What is Grey Turner’s sign?
Left flank ecchymosis (bruising)
Area between ribs and hips
What is Cullen’s sign?
Periumbilical ecchymosis
What is ecchymosis?
Discoloration of skin due to bleeding underneath
What 3 classes of acute pancreatitis are there?
Oedematous: associated with phlegmon formation
Severe/necrotising: associated with pseudocyst formation
Haemorrhagic: bleeding
What is phlegmon?
Diffuse inflammatory process where pus abscesses are formed
What is a pseudocyst?
Persistent pancreatic fluid collection which can become infected
Investigations for acute pancreatitis?
Bloods:
- raised serum amylase or lipase
- raised CRP
- U+E, FBC, ABG to measure severity
Radiology
- X-ray
- USS: look for gallstones
- Contrast CT + MRI
- ERCP
What can you see on a CT of a patient with acute pancreatitis?
Loss of fat planes
Pancreatic oedema
Swelling
Fluid build up
What is the Glasgow Scoring System of acute pancreatitis used for?
PANCREAS
It determines the severity of the pancreatitis
A score of more than 3 = ITU admission
What is the Glasgow Scoring System?
Measures severity of acute pancreatitis:
PANCREAS
PaO2 less than 8kPa Aged above 55 Neutrophils raised Calcium low Raised urea Elevated enzymes (LDH test) Albumin low Sugar high
What is the LDH blood test?
Lactate dehydrogenase levels in the blood
High levels = severe tissue damage
What are some other scoring systems for acute pancreatitis?
Ranson Criteria: measures severity and risk or mortality
Balthazar score: looks at CT scan
Necrosis score: % of necrosis of pancreas
Management of acute pancreatitis?
Assessment of severity
ABCDE resuscitation
Analgesia
Bowel rest: nil by mouth
Drainage of fluid build-up
Antibiotics: chosen from result of fluid drainage
Nutrition: IV, Nasogastric
Admit to ITU if risk of organ failrue
What are 2 complications of acute pancreatitis?
SIRS - Systemic Inflammatory Response Syndrome
MODS - Multiple Organ Dysfunction Syndrome
What is SIRS?
Systemic Inflammatory Response Syndrome
A state of inflammation in the body where there is no documented infection
Tachypnoea
Tachycardia
Pryexia
Raised WBC
What is MODS?
Multiple Organ Dysfunction Syndrome
A complication of SIRS leading to loss of homeostasis mechanisms in the body
SIRS is a complication of MODS.
True or false?
False
MODS occurs as a complication of SIRS
What are the 2 key causes of acute pancreatitis?
Gall stones
Alcohol
How do gall stones cause acute pancreatitis?
They block the bile duct
Blocking pancreatic enzymes from getting to duodenum
Enzymes are forced back to the pancreas
Where they irritate the pancreas
Leading to pancreatitis
What is the general pathophysiology of chronic pancreatitis?
Mechanism is pretty unclear
Thought to be due to obstruction/reduction of bicarbonate excretion
Which leads to the activation of pancreatic enzymes
Also, protein precipitation in pancreas blocks ducts, leading to ductal hypertension
This causes damage
Both these lead to inflammation, necrosis and fibrosis of pancreatic tissue
What are the causes of chronic pancreatitis?
Alcohol
Familial Autoimmune Cystic fibrosis Pancreatic duct obstruction Haemochromatosis
What is haemochromatosis?
The build of iron in the body
It is deposited in organs, especially the liver and skin
How does alcohol cause chronic pancreatitis?
Alcohol causes proteins to precipitate (become solid) in the ducts of the pancreas
This leads to local pancreatic dilation and fibrosis
Also, alcohol has direct toxic effect on pancreas
This results in pancreatic fibrosis and calcification
Only heavy drinkers get chronic pancreatitis.
True or false?
False
Even people who drink alcohol reasonably are at risk
Why does the pancreas become fibrotic in chronic pancreatitis?
Because of long term inflammation that results in irreversible damage
Is the damage reversible in:
- acute pancreatitis
- chronic pancreatitis?
Acute = yes Chronic = no
Is chronic pancreatitis progressive or does it go in phases?
Both
Patients relapse and get worse
But relapses are intermittent
What are the clinical features of chronic pancreatitis?
Epigastric pain that bores through to the back
Weight loss + anorexia
Nausea and vomiting
Diabetes develops due to lack of insulin production
Steatorrhoea develops due to lack of lipase production
Malabsorption due to lack of digestive enzymes
What can help relieve the epigastric pain experience in pancreatitis?
Leaning forward
Heat
What should you rule out before diagnosing chronic pancreatitis?
Pancreatic carcinoma
Investigations of chronic pancreatitis?
USS + CT: shows up calcification and fibrosis
ERCP: check out state of pancreas
AXR: pancreas appears speckled due to calcification
Bloods:
- raised ESR + CRP
- autoantibodies in autoimmune pancreatitis
- raised blood glucose
What blood results would you see in autoimmune chronic pancreatitis?
Elevated levels of serum gammaglobulins and immunoglobulins
Auto-antibodies
Treatment of chronic pancreatitis?
Analgesia
Give lipase + fat soluble vitamins
Give insulin to treat diabetes
Autoimmune pancreatitis responds well to steroids
Modify diet: low fat, no alcohol
Surgery if necessary: pancreatectomy
