Pancreatitis Flashcards
Where is the pancreas?
Head and tail
Retroperitoneal
Head of pancreas lies at the same level as the duodenum at L1
Tail points towards hilum of the spleen
What is the function of the pancreas?
Exocrine - secrete digestion enzymes e.g. lipase
Endocrine
1. alpha = glycogen and beta = insulin for overall blood control
Secretes bicarbonate to increase the pH of the duodenal chyme = acid base balance of blood
What causes pancreatitis?
Mnemonic
Most common: acute vs chronic
Pathology
[I GET SMASHED]
Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune pancreatitis
Scorpion sting
Hyperlipidaemia, hypothermia, hyperparathyroidism
ERCP (Endoscopic Retrograde Cholangio-pancreatography)
Drugs e.g. Valproate, azathioprine, oestrogens, thiazides diuretics, tetracycline, sulfasalazine
Alcohol is the most common cause of chronic pancreatitis
Gallstones is the most common cause of acute
Pathology: acinar cell injury causes premature activation of enzymes
Clinical Features
Epigastric pain radiating to the back
(Can be relieved by moving forward)
Abdominal distension
Nausea and vomiting
Loss of appetite
Diarrhoea
Need to ask if history of recurrent gall stones, weight loss for malignancy?
Pancreatitis
Differential diagnoses
Peptic Ulcer Disease
Abdominal Aortic Aneurysm
GORD
Myocardial infarction
Examination findings
Epigastric tenderness
Peritonism: guarding, percussion tenderness, rebound tenderness
Grey-turner’s sign [2 words and you have 2 flanks]: Flank bruising (as blood from a haemorrhagic pancreatitis tracks around)
Cullen’s sign [1 word and 1 umbilicus / Edward Cullen being nasty and sucking your belly buttone]: bruising around the umbilicus
Tachycardia
Hypocalcaemia
Pancreatitis
Investigations to do
Bedside:
- ECG
- Urine dip (for other causes of abdominal pain e.g. UTI)
Bloods:
- FBC: raised White cell count
- U+Es: dehydration causing AKI
- LFTs: could see obstruction if cause is pancreatitis
- Lipids
- LDH
- CRP: inflammation - still above 150 after 48 hours it is severe
- Bone profile
- Amylase / lipase (raised in acute)
- ABG: to look at pH, and used in grading systems
- Glucose (can go up in pancreas)
- Urine dip: to keep acute abdomen ddx wide
- Pregnancy Test
Imaging:
- Ultrasound to look for gallstones
- CT scan with contrast to confirm diagnosis
- Chest X ray to look for air under diaphragm/ Abdominal X ray to look for ddx or complications
- ERCP
Acute vs Chronic
Acute: acute inflammatory process, acute pain and raised pancreatic enzymes
Chronic: continuing inflammatory process, irreversible morphological change, pain +/- loss of function
Complications of Pancreatitis
Necrosis
Abscess formation
Pseudo cyst - fluid collection around the pancreas is normal and tends to resolve spontaneously. However in pancreatic pseudocyst, this pancreatic enzyme rich fluid persists
Sepsis
Differentials for pancreatitis
Cholecystitis
?Generalised peritonitis
Bowel Obstruction
Myocardial Infarction
Why is severe pancreatitis an emergency?
Because severe pancreatitis can result in a systemic inflammatory response syndrome and so impair function of other organs
The Glasgow Score
What does it measure?
What are the parameters? What counts as severe?
Estimates the severity of an episode of acute pancreatitis
PaO2 <8 Age >55 Neutrophils = WCC >15 Calcium <2 Renal, Urea >16 Enzymes = LDH >600, AST >200 Albumin <32 Sugar, Glucose >10
1 point each
3 or more counts as severe so think ITU
Acute Pancreatitis Management
Analgesia
Fluid resuscitation - IV fluids, fluid chart , catheterisation (careful fluid balance)
Nill by mouth
Low fat diet and enteral feeding and TPN if lieu’s
Surgery cholecystectomy: in gallstone pancreatitis or complications e.g. necrosis, pseudocyst
Antibiotics only really for pancreatitic necrosis
Chronic pancreatitis causes
Gallstones
Ethanol
Recurrent episodes of acute pancreatitis
Chronic pancreatitis
Features
Epigastric pain radiating to back (especially 15 minutes after eating)
Malabsorption and weight loss
Steatorrhoea
