Pancreatitis Flashcards
Pathophysiology of acute pancreatitis
pancreatic enzymes released & activated in vicious circle
- oedema + fluid shift + vomiting -> hypovolaemic shock & autodigestion by enzymes and fat necrosis
- vessel autodigestion -> retroperitoneal haemorrhage
- inflammation -> pancreatic necrosis
- super-added infection (50% pts with necrosis)
epidemiology of acute pancreatitis (age, mortality rate)
4th & 5th decades
10% mortality
causes of acute pancreatitis
GET SMASHED
gallstones (45%)
ethanol (25%)
idiopathic (20%)
trauma
steroids
mumps
autoimmune
scorpion
hyperlipidaemia
ERCP (5% risk)
drugs (thiazides, azathioprine)
symptoms of acute pancreatitis
severe epigastric pain -> back (maybe relieved on sitting forward)
vomiting
signs of acute pancreatitis
shock
epigastric tenderness
jaundice
ileus
ecchymoses
Grey turners
flank bruise
Cullens
periumbilical
Severity of acute pancreatitis
1 = mild
2 = mod
3 = severe
Criteria for severity of pancreatitis
Glasgow severity score
PaO2 <8kPa
Age >55yrs
Neutrophils >15 x109/L
Ca2+ <2mM
Renal function U>16mM
Enzymes LDH>600iu/L, AST>200 iu/L
Albumin <32g/L
Sugar >10mM
blood tests for acute pancreatitis
↑amylase (>1000 / 3x ULN)
↑lipase
LFTs: cholestatic picture, ↑AST, ↑LDH
urine test for acute pancreatitis
Urine: glucose, ↑cBR, ↓urobilinogen
Imaging for acute pancreatitis
USS
CXR: ARDS
DUAXR: sentinel loop, pancreatic calcification
USS findings for acute pancreatitis
Gallstones
Dilated common bile duct (> 7mm indicates obstruction)
conservative management of acute pancreatitis
constant reassessment
fluid resus
pancreatic rest
analgesia
antibiotics
interventional management of acute pancreatitis
ERCP- if pancreatitis with dilated ducts secondary to gallstones
- ERCP + sphincterotomy → ↓ complications
indication for surgical management of acute pancreatitis
Infected pancreatic necrosis
Pseudocyst or abscess
Unsure Dx
surgical options for acute pancreatitis
Laparotomy + necrosectomy (pancreatic debridement)
Laparotomy + peritoneal lavage
Laparostomy: abdomen left open with sterile packs in ITU
early complications of acute pancreatitis
Respiratory: ARDS, pleural effusion
Shock: hypovolaemic or septic
Renal failure
DIC
Metabolic (↓ Ca2+, ↑ glucose, Metabolic acidosis)
late (>1 week) complications of acute pancreatitis
Bleeding: e.g. from splenic artery
Thrombosis → portal HTN
Fistula formation (Pancreato-cutaneous → skin breakdown)
what is a pancreatic pseudocyst?
collection of pancreatic fluid in lesser sac surrounded by granulation tissue (occurs in 20%)
presentation of pancreatic pseudocyst
4-6wks after acute attack
Persisting abdominal pain
Epigastric mass → early satiety
complications of pancreatic pseudocyst
Infection → abscess
Obstruction of duodenum or CBD
tests for pancreatic pseudocyst
Persistently ↑ amylase ± LFTs
US / CT
treatment of pancreatic pseudocyst
<6cm: spontaneous resolution
>6cm (Endoscopic cyst-gastrostomy, Percutaneous drainage under US/CT)
Complications of ERCP
Bleeding
Perforation
Pancreatitis
Cholangitis
When to use CT scan + contrast for pancreatitis
Complications of pancreatitis
CT findings for pancreatic necrosis
Non enhancing pancreas
CT findings for pancreatitis infective necrosis
Non enhancing pancreas
+ Bubbles
When to use abx for pancreatitis
Infective necrosis
Effect of Jaundice / biliary disease on clotting
Impairs clotting
Vit K fat soluble
Reduced Vit K absorption due to reduced bile following biliary obstruction
