Pancreatitis Flashcards
Causes of pancreatitis?
Gall stones Ethanol Trauma Steroids Mumps Autoimmune Scorpion toxin Hyperlipidaemia, hypothermia, hypercalcaemia ERCP, emboli Drugs:
What causes raised intraductal pressure?
Gallstones, alcohol, obstruction
What causes acinar cell injury?
alcohol, drugs, trauma, ischaemia, infection
The pathophsyiological process of pancreatitis?
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
5 pathological features of pancreatitis?
Third spacing DIC SIRS ARDS Multi organ dysfunction
How does pancreatitis present for clinical presentation of the abdomen (symptoms?)
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
How does pancreatitis present for clinical presentation of the abdomen (signs?)
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
Culen’s sign vs Grey-Turner’??
umbilicus vs flanks
ddx for pancreatitis?
Bowel obstruction Duodenal ulcer Bowel ischaemia Ectopic pregnancy AAA Myocardial infarction Biliary colic
Bedside investigations?
ECG
BM
Lab investigation?
Bloods: FBC, LFT, CRP, amylase, lipase, Uand E
Amylase vs lipase investigation?
Amylase rises quickly and falls in about 48 hours
Lipase is more sensitive and speicfic and rises in 8 hours, normalising after 14 days
Imaging??
erect CXR CT + contrast AXR Uss abdomen- galls stones? ERCP for special test: diagnostic or for radio intervention
The Glasgow score for acute pancreatitis?
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
Alternative score to Glasgow??
Ranson’s criteria, Atlanta classification
Management of mild pancreatitis?
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
Severe: management?
ITU/HDU admission
IV antibiotics if significant pancreatic necrosis
ERCP if co-existing cholangitis or biliary obstruction
Surgery
Removal of necrotic tissue
Local complications of pancreatitis?
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
Systemic complications of pancreatitis?
Haemorrhage hypovolaemic shock
Organ failure: ARDS, renal failure
Hypocalcaemia (Lipase release of free fatty acids that bind calcium)
Hyperglycaemia (endocrine pancreatic insufficiency)
Ileus
Prognosis for pancreatitis?
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
