Pancreatitis

Question 1

Causes of pancreatitis?

Answer 1

Gall stones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion toxin
Hyperlipidaemia, hypothermia, hypercalcaemia
ERCP, emboli
Drugs:

Question 2

What causes raised intraductal pressure?

Answer 2

Gallstones, alcohol, obstruction

Question 3

What causes acinar cell injury?

Answer 3

alcohol, drugs, trauma, ischaemia, infection

Question 4

The pathophsyiological process of pancreatitis?

Answer 4

Raised intraductal pressure and/or damaged acinar cells leads to trypsinogen activation, where trypsin activates proteases that are released systemically to introduce inflammaiton. this obviously exacerbates the trypsinogen activation, cycling the process more and more

Question 5

5 pathological features of pancreatitis?

Answer 5

Third spacing
DIC
SIRS
ARDS
Multi organ dysfunction

Question 6

How does pancreatitis present for clinical presentation of the abdomen (symptoms?)

Answer 6

S: epigastric region
O: minutes to hours
C: knawing boring
R: to the back
A: nausea, vomiting, anorexia
T: constant, progressively worse
E: worse after food, better leaning forward 
S: very severe

Previous episodes likely

Question 7

How does pancreatitis present for clinical presentation of the abdomen (signs?)

Answer 7

Mild pyrexia
Tachycardia
?jaundice
Rigid abdomen with epigastric or generalised tenderness
?bowel sounds – paralytic ileus sign of severe pancreatitis
Signs of retroperitoneal haemorrhage = severe
Umbilicus = Cullen’s sign
Flanks = Grey-Turner’s sign

Question 8

Culen’s sign vs Grey-Turner’??

Answer 8

umbilicus vs flanks

Question 9

ddx for pancreatitis?

Answer 9

Bowel obstruction
Duodenal ulcer
Bowel ischaemia
Ectopic pregnancy
AAA
Myocardial infarction
Biliary colic

Question 10

Bedside investigations?

Answer 10

ECG

BM

Question 11

Lab investigation?

Answer 11

Bloods: FBC, LFT, CRP, amylase, lipase, Uand E

Question 12

Amylase vs lipase investigation?

Answer 12

Amylase rises quickly and falls in about 48 hours

Lipase is more sensitive and speicfic and rises in 8 hours, normalising after 14 days

Question 13

Imaging??

Answer 13

erect CXR
CT + contrast
AXR
Uss abdomen- galls stones?
ERCP for special test: diagnostic or for radio intervention

Question 14

The Glasgow score for acute pancreatitis?

Answer 14

PaO2 below 8
Age above 55 years
Neutrophil: 15 x10^9 per litre
Calcium below 2mmolL-1
Renal : Urea above 16mmolL-1
Enzyme: LDH > 600, AST> 2000
Albumin <32gL-1
Sugar:  >10mmol

Score above 3 = severe

Question 15

Alternative score to Glasgow??

Answer 15

Ranson’s criteria, Atlanta classification

Question 16

Management of mild pancreatitis?

Answer 16

Analgesia
IV fluids – to maintain adequate urine output
NBM
Anti-emetic
NG tube if vomiting
May need insulin
If gallstones causative, once recovered consider cholecystectomy

Question 17

Severe: management?

Answer 17

ITU/HDU admission
IV antibiotics if significant pancreatic necrosis
ERCP if co-existing cholangitis or biliary obstruction
Surgery
Removal of necrotic tissue

Question 18

Local complications of pancreatitis?

Answer 18

Pancreatic abscess
Develops months after acute pancreatitis 
Needs surgery 
Cholecystitis
10% patients with severe pancreatitis 
Pancreatic necrosis
3 x mortality 
Rising CRP, confirm on CT
Infection occurs in up to 70% cases, requires abx and surgical debridement 

Pseudocyst 
Approx. 4 weeks after pancreatitis
Needs surgery – can rupture or haemorrhage 
Acute fluid collections
Spontaneously resolve usually

Question 19

Systemic complications of pancreatitis?

Answer 19

Haemorrhage  hypovolaemic shock
Organ failure: ARDS, renal failure
Hypocalcaemia (Lipase release of free fatty acids that bind calcium)
Hyperglycaemia (endocrine pancreatic insufficiency)
Ileus

Question 20

Prognosis for pancreatitis?

Answer 20

22% patients have recurrent episodes
Progression to chronic pancreatitis in approx. 6%
More likely if have recurrent episodes, alcoholism, smoking
Mild cases: 5% mortality
Severe cases: 30% mortality
May need enzyme replacement if ongoing steatorrhoea and weight loss