Pancreatitis Flashcards
What are the causes of pancreatitis?
I GET SMASHED
Idiopathic Gallstones (35%) Ethanol (35%) Trauma Steroids Mumps Autoimmune e.g. SLE, Sjogren's Scorpion venom Hyperlipidaemia, hypothermia, hypercalcaemia ERCP Drugs (furosemide, oestrogens, azathioprine, thiazide diuretics, tetracyclines)
What are the most common causes of acute pancreatitis?
Gallstones and alcohol (account for 70% together)
What are the symptoms of acute pancreatitis?
Severe epigastric pain (may radiate to the back, sitting forward may relieve)
Vomiting
Anorexia
What are the signs of acute pancreatitis?
Tachycardia, fever, shock Jaundice Reduced bowel sounds (ileus) Rigid abdomen and local/general tenderness Cullen's sign (rare) Grey Turner's sign (rare) Signs of hypovolaemia
What is Cullen’s sign?
Peri-umbilical bruising
What is Grey Turner’s sign?
Flank bruising
What are the differentials of acute pancreatitis?
Perforated viscus Oesophageal spasm AAA Intestinal obstruction Ascending cholangitis Gallstones Cholecystitis Viral gastroenteritis Hepatitis Mesenteric ischaemia MI
What bloods are done in acute pancreatitis?
FBC U+E LFT Amylase Lipase CRP ABG
Amylase vs lipase?
Amylase - raised, around 3x ULN
Lipase - more sensitive and specific, rises earlier and falls later
Signs on AXR
Colon cut-off sign (gas distending the R colon stops abruptly in the mid or left transverse colon)
Calcifications
Sentinel loop of proximal jejunum from ileus
No psoas shadow
What is the standard choice of imaging in acute pancreatitis?
CT
Atlanta criteria - mild acute pancreatitis?
No organ failure or local/systemic complications, usually resolves in 1st week and doesn’t need CT, lower mortality
Atlanta criteria - moderately severe acute pancreatitis?
Transient organ failure (resolves within 48 hours), and/or local or systemic complications
Atlanta criteria - severe acute pancreatitis?
Persistent organ failure (>48 hours)
What is Ranson’s criteria used for?
Estimates mortality of patients with pancreatitis, calculated at admission and at 48 hours.
What does Ranson’s score mean?
1-2 = severe panc. unlikely
3 or more = likely, consider ITU
What are Ranson’s criteria? (11)
WBC >16K Age >55 Glucose >10mmol/l AST > 250 LDH > 350
48 hours into admission, it includes Hct, BUN, calcium, arterial p02, base deficit, and fluid needs
What does Glasgow score comprise of?
Pa02 <8kpa Age >55 Neutrophillia >15x10 to the 9/L Calcium <2 Renal function (urea) >16 Enzymes - LDH >600, AST >200 Albumin <32 Sugar >10
Why is Glasgow score better than Ransons?
Ranson you have to wait at least 48 hours before you can apply the score
When would a Glasgow score consider transfer to ITU/HDU?
If 3 or more positive factors within 48 hours
What is the pathophysiology of pancreatitis?
Inactive pro-enzymes that are released by pancreas and activated in the small intestine, are activated early (e.g. due to gallstones blocking the release of pancreatic juices)
–> autodigestion of the pancreas
–> inflammatory cytokines and neutrophils recruited
–> causes blood vessel leaks and rupture, causing swelling
Lipases destroy peripancreatic fat
Digestion and bleeding can liquefy tissue
What are the early complications of acute pancreatitis?
Shock ARDS Renal failure DIC Sepsis Hypocalcaemia Hyperglycaemia
Why do you get ARDS with acute pancreatitis?
excretion of inflammatory mediators may damage the alveolocapillary membrane, leading to destruction of pneumocytes and decrease the amount of surfactant.
Mechanism of hypocalcaemia in acute pancreatitis?
Lipases release free fatty acids, these chelate the calcium salts in the pancreas and cause soaps to form
What are the late complications of acute pancreatitis?
Pancreatic necrosis Peripancreatic fluid collections Pseudocyst Abscesses Bleeding Thrombosis Fistulae Recurrent oedematous pancreatitis
Pseudocyst presentation
Typically 4 weeks or more after an attack of acute pancreatitis
Pain, fever, palpable mass
Mild elevation of amylase
What is chronic pancreatitits?
Glucose intolerance, pancreatic insufficiency, calcifications due to chronic scarring/recurrent attacks of acute pancreatitis
How is pancreatitis managed?
NBM + NJ feeding IV fluids Analgesia + anti-emetic Antibiotics (if needed) Surgery (if needed)
Indication for abx in pancreatitis?
If nectrotising to prevent becoming infected
If signs/symptoms/lab tests indicate infection
If associated cholangitis or acute infections
Role of surgery?
If gallstones –> early cholecystectomy
Obstructed biliary system due to stones –> early ERCP
Fail to settle with necrosis and are worsening –> debridement or fine needle aspiration
Infective necrosis –> radiological drainage or surgical necrosectomy
