Pancreatitis

Question 1

What are the different classifications of pancreatitis?

Answer 1

• *Acute or chronic.**
• *Acute** pancreatitis is reversible.
• *Chronic** pancreatitis is irreversible.

Acute can be further classified based on severity using the Glasgow Prognostic Score.

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)

Question 2

What are the components of the Glasgow Criteria for pancreatitis?

Answer 2

Glasgow Prognostic Score.

P -PaO2 <8kPa
A -Age > 55 years
N -Neutrophils (white blood cell count) > 15 x 10⁹
C -Calcium < 2 mmol/L
R -Raised urea >16 mmol/L
E -Enzyme (lactate dehydrogenase (LDH)) > 600U/L
A -Albumin <30g/L
S -Sugar (glucose) >10mmol/L

Score of >3 should prompt Tx in ICU/HDU

Question 3

Describe the causes of pancreatitis?

Answer 3

• *G**all stones (60%)
• *E**thanol (20%)
• *T**rauma
• *S**teroids
• *M**alignancy/Mumps
• *A**utoimmune (SLE)
• *S**corpion venom
• *H**yperglycaemia/calcaemia
• *E**RCP
• *D**rugs

Question 4

Describe how gallstones and alcohol cause pancreatitis?

Answer 4

In gallstones there is a blockage of the common bile duct causing back pressure into the pancreatic duct causing irritation in the pancreas.

In alcoholic disease, the ampulla spasms, ducts are plugged by viscous secretion and alcohol is directly toxic to acinar cells.

In pancreatitis starts to secrete proteolytic enzymes which autodigest causing further damage. In severe pancreatitis there is periductal necrosis.

Question 5

Describe the complications of pancreatitis?

Answer 5

Early
Shock
ARDS
Renal failure (give lots of fluid)
DIC
Low Calcium
High Glucose

Late
Recurrent Pancreatitis
Pancreatic necrosis and pseudocysts
Bleeding / thrombosis

Question 6

Describe the classical signs and symptoms of a patient presenting with pancreatitis?

Answer 6

Symptoms:
Severe epigastric pain radiating through to the back.
May have a mild pyrexia.
May be nausea and vomiting.

In severe cases:
Gross hypotension, pyrexia, tachypnoea, acute ascites, pleural effusions, Cullen’s sign & Grey Turner’s sign

Question 7

Understand the role of the severity scoring system in management?

Answer 7

Score > 3 = severe
Principle is the high the severity the more aggressive the therapy.

Mild pancreatitis should be referred to hospital, NG tube, given crystalloids (monitering input and output), analgesia (pethidine/morphine) and NBM (when you eat the pancreas secretes digestive enzymes and damages itself further) .

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.

Question 8

Pathogenesis of pancreatitis?

Answer 8

Acute pancreatitis → release pancreatic enzymes → autodigestion of the pancreas

Leads to:

1. Oedema & fluid shift. Vomitting. Enzymes in peritoneal cavity
2. Autodigestion affects blood vessels → haemorrhage into the retroperitoneal space.
   * *GREY TURNER SIGN** & CULLEN’s SIGN
3. Disease inflammation → necrosis which may affect part of / all pancreas

Question 9

What is Cullens sign?

Answer 9

Bruising around the umbilicus

Question 10

What is Grey-turners sign?

Answer 10

Bilateral bruising of the flanks

Question 11

What investigations are need in Pancreatitis?

Answer 11

Blood tests:
FBC (WBC)
U/E’s
LFTs (gallstones)
Lipase and Amylase (should be at least 3x normal to indicate pancreatitis, lipase is more sensitive and specific)
CRP (inflammatory marker)
ABG

CXR (rule out peritonism, look for pleural effusions/ARDS)
AXR (rule out obstruction)

US (look for gall stones)
CT scan
MRI (visualise gallstones if not seen on US)

Question 12

What electrolyte abnormalities do you get in pancreatitis?

Answer 12

Hyperglycaemia: Disruption islets of Langerhans

Hypocalcaemia: Fall in ionised calcium

Reduced serum Albumin

Question 13

What is the initial management of pancreatitis

Answer 13

NG suction
Baseline ABG
Prophylactic Abx
Analgesia

DVT prophylaxis

Gallstone related → Tx of the gallstones

Question 14

Presentation Chronic Pancreatitis

Answer 14

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.

Question 15

Complications of Chronic Pancreatitis?

Answer 15

Endocrine dysfunction: diabetes
Exocrine dysfunction

Strictures which can cause obstructed jaundice and lead to liver cirrhosis.

Predisposes to pancreatic malignancy