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Gastroenterology > Pancreatitis > Flashcards

Pancreatitis Flashcards

1
Q

What are the two components of pancreatic juice?

A

↓ vol, viscous, enzyme-rich - Acinar cells

↑ vol, watery, HCO3- rich - Duct & Centroacinar cells

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2
Q

Where are the enzymes synthesised and stored?

A

Zymogen granules

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3
Q

Whats the problem in acute pancreatitis?

A

Problem for an organ making a cocktail of digestive enzymes is autodigestion

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4
Q

What are the protective mechanisms?

A

Proteases are released as inactive pro-enzymes
protects acini & ducts from auto-digestion

Pancreas also contains a trypsin inhibitor to prevent trypsin activation

Enzymes only activated in duodenum

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5
Q

How do the protective mechanisms fail?

A

Duodenal mucosa secretes an enzyme - Enterokinase (enteropeptidase)
converts trypsinogen → trypsin.
Trypsin then converts all other proteolytic & some lipolytic enzymes

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6
Q

Define acute pancreatitis

A

Rapid onset inflammation of the pancreas

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7
Q

Define chronic pancreatitis

A

Long-standing inflammation of the pancreas

Vicious cycle

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8
Q

What are the causes of acute pancreatitis?

A 
G – gallstones
E – ethanol (alcohol)
T – trauma
S – steroids
M – mumps and other viruses (EBV, CMV)
A – auto-immune (Polyarteritis nodosa, SLE)
S – scorpion/snake bite (Trinidad)
H – hypercalceamia, hypertriglyceridaemia, hypothermia
E – ERCP
D – drugs
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9
Q

How does chronic pancreatitis appear on a CT?

A

Rock solid depositions of pancreas

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10
Q

What drugs can cause acute pancreatitis?

A

SAND

Steroids and sulphonamides
Azothioprine
NSAIDS,
Diuretics

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11
Q

Describe the pathophysiology of acute pancreatitis

A

Stone in the ampulla causes a back pressure

Bile can back flow into pancreas and cause irritation

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12
Q

What are the three steps of acute pancreatitis?

A

↑ permeability of pancreatic duct epithelium (Alcohol, acetylsalicylic acid, histamine)
Acinar cell enzymes diffuse into periductal interstitial tissue

Alcohol ppts proteins in ducts → ↑ upstream pressure

Pancreatic enzymes activated intracellularly
proenzymes & lysosomal proteases incorporated into same vesicles → trypsin activated

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13
Q

What are symptoms of acute pancreatitis?

A

Epigastric pain radiating to back
often eased by sitting forward

N&V (vomiting +++)

Fevers

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14
Q

What does the activation of trypsin trigger?

A 
Phospholipase A2 
Elastase
Complement
Prothrombin
Kallikrein
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15
Q

What does elastase do?

A

Eating away and disrupts blood vessels
‘Hemorrhagic pancreatitis’
Hyperglycaemia

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16
Q

What does prothrombin do?

A

Thrombin activates
Thrombosis
Ischaemia

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17
Q

What does Phospholipase A2 do?

A

Causes fat necrosis
“Saponification”
Uses up calcium looks like soap
Hypocalcaemia

18
Q

What do the other substance do?

A

Vasodilatation
Exudate of fluid
Causes shock

19
Q

What does a Phospholipase A2 and combo of FFAs do?

A

Interfere with surfactants of your lungs

Respiratory effects

20
Q

What are the there types of acute pancreatitis?

A

Oedematous
Haemorrhagic
Necrotic

21
Q

What are the signs of pancreatitis?

A

Haemodynamic instability (tachycardic, hypotensive)
Peritonism in upper abdomen/generalised
Grey-Turner’s sign (bruising in flanks)
Cullen’s sign (bruising around umbilicus)

22
Q

What are the differential diagnoses?

A

Gallstone disease & associated complications (e.g. biliary colic & acute cholecystitis)

Peptic ulcer disease/perforation

Leaking/ruptured AAA

23
Q

What would you look for in bloods for acute pancreatitis?

A 
Amylase/lipase 
other causes of ↑ amylase include:
Parotitis
renal failure
Macroamylasaemia
bowel perforation
lung/ovary/pancreas/colonic malignancies can produce ectopic amylase)
24
Q

What investigations would you carry our in a patient you suspect to have acute pancreatitis?

A 
X-rays
Erect CXR
AXR (GS, sentinal loop, AA)
USS (GSs)
CT abdo 
MRCP (suspect GSs)
ERCP (last resort)
25
Q

How do you assess severity of acute pancreatitis?

A 
Modified Glasgow criteria (alternative is Ranson’s criteria):
P – PO2 <8KPa
A – age >55yrs
N – WCC >15
C – calcium <2mmol/L
R – renal: urea >16mmol/L
E – enzymes: AST >200iu/L, LDH >600iu/L
A – Albumin <32g/L
S – sugar >10mmol/L

CRP is an independent predictor of severity
>200 suggests severe pancreatitis

26
Q

What score indicates severe pancreatitis?

A

Score of 3 or > within 48hrs of onset - suggests severe pancreatitis

27
Q

What are the 4 principles of management acute pancreatitis?

A

Fluid resuscitation (IV fluids, urinary catheter, strict fluid balance monitoring)
Analgesia
Pancreatic rest (+/- nutritional support if prolonged recovery [NJ feeding or TPN])
Determining underlying cause

28
Q

What percentage of AP settle with conservative treatment?

A

95%

Surgery is only very rarely needed

29
Q

What are the local complications associates with acute pancreatitis?

A

Hypocalcaemia
Hyperglycaemia
SIRS (Systemic Inflammatory Response Syndrome)
ARF (Acute Renal Failure)
ARDS (Adult Respiratory Distress Syndrome)
DIC (Disseminated Intravascular Coagulation)
MOF (Multi Organ Failure) & death

30
Q

What are the systemic complications associates with acute pancreatitis?

A 
Pancreatic necrosis 
Pancreatic abscess
Pancreatic pseudocyst
Haemorrhage
Thrombosis  
Chronic pancreatitis
31
Q

What are the main features of haemorrhage?

A

Due to bleeding from arroded vessels
Small vessels  haemorrhagic pancreatitis (Cullen’s/Grey Turner’s sign)
Large vessels (e.g. Splenic artery)
 life threatening bleed (unless forms pseudoaneurysm)

32
Q

What are the main features of thrombosis?

A

Of splenic vein, SMV, portal vein (in order of frequency)

 - ascites
 - small bowel venous congestion/ischaemia
33
Q

How do you manage infected necrosis?

A

Antibiotic and Surgery

34
Q

What is pancreatic abscess?

A

Complication of infected necrosis
collection of pus from pancreatic tissue necrosis & infection
becomes lined by granulation tissue
presents 2-4 weeks after attack of pancreatitis

35
Q

How do you manage a pancreatic abscess?

A

Antibiotic and drainage
percutaneous (under CT guidance)
Surgical drainage

36
Q

What is a pancreatic pseudocyst?

A

peri-pancreatic fluid collection
↑ [pancreatic enzymes] within a fibrous capsule
presents >6 weeks after pancreatitis

37
Q

What is the management for pancreatic cyst?

A

95% spontaneously resolve over 6 months
Percutaneously under radiological guidance (CT)
Endoscopically - EUS puncturing posterior wall of stomach & inserting stent
Surgically via laparoscopic/open

38
Q

When would you intervene for a pancreatic cyst?

A 
Pseudocyst symptomatic (pain)
Pseudocyst causing compression of surrounding structures e.g. CBD (obstructive jaundice), duodenum (high SBO)
Pseudocyst infected (abscess)
These 3x situations pseudocyst → drained
39
Q

What three questions do you ask someone with the chronic pancreatitis?

A

What painkillers are you taking?
What do you take for your diabetes?
How much creole are you taking?

40
Q

How do you manage chronic pancreatitis?

A

Endoscopically
Surgical drainage
Surgical resection

Gastroenterology (12 decks)

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