Pancreatitis Flashcards
What are the two components of pancreatic juice?
↓ vol, viscous, enzyme-rich - Acinar cells
↑ vol, watery, HCO3- rich - Duct & Centroacinar cells
Where are the enzymes synthesised and stored?
Zymogen granules
Whats the problem in acute pancreatitis?
Problem for an organ making a cocktail of digestive enzymes is autodigestion
What are the protective mechanisms?
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
How do the protective mechanisms fail?
Duodenal mucosa secretes an enzyme - Enterokinase (enteropeptidase)
converts trypsinogen → trypsin.
Trypsin then converts all other proteolytic & some lipolytic enzymes
Define acute pancreatitis
Rapid onset inflammation of the pancreas
Define chronic pancreatitis
Long-standing inflammation of the pancreas
Vicious cycle
What are the causes of acute pancreatitis?
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
How does chronic pancreatitis appear on a CT?
Rock solid depositions of pancreas
What drugs can cause acute pancreatitis?
SAND
Steroids and sulphonamides
Azothioprine
NSAIDS,
Diuretics
Describe the pathophysiology of acute pancreatitis
Stone in the ampulla causes a back pressure
Bile can back flow into pancreas and cause irritation
What are the three steps of acute pancreatitis?
↑ 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
What are symptoms of acute pancreatitis?
Epigastric pain radiating to back
often eased by sitting forward
N&V (vomiting +++)
Fevers
What does the activation of trypsin trigger?
Phospholipase A2 Elastase Complement Prothrombin Kallikrein
What does elastase do?
Eating away and disrupts blood vessels
‘Hemorrhagic pancreatitis’
Hyperglycaemia
What does prothrombin do?
Thrombin activates
Thrombosis
Ischaemia
What does Phospholipase A2 do?
Causes fat necrosis
“Saponification”
Uses up calcium looks like soap
Hypocalcaemia
What do the other substance do?
Vasodilatation
Exudate of fluid
Causes shock
What does a Phospholipase A2 and combo of FFAs do?
Interfere with surfactants of your lungs
Respiratory effects
What are the there types of acute pancreatitis?
Oedematous
Haemorrhagic
Necrotic
What are the signs of pancreatitis?
Haemodynamic instability (tachycardic, hypotensive)
Peritonism in upper abdomen/generalised
Grey-Turner’s sign (bruising in flanks)
Cullen’s sign (bruising around umbilicus)
What are the differential diagnoses?
Gallstone disease & associated complications (e.g. biliary colic & acute cholecystitis)
Peptic ulcer disease/perforation
Leaking/ruptured AAA
What would you look for in bloods for acute pancreatitis?
Amylase/lipase other causes of ↑ amylase include: Parotitis renal failure Macroamylasaemia bowel perforation lung/ovary/pancreas/colonic malignancies can produce ectopic amylase)
What investigations would you carry our in a patient you suspect to have acute pancreatitis?
X-rays Erect CXR AXR (GS, sentinal loop, AA) USS (GSs) CT abdo MRCP (suspect GSs) ERCP (last resort)
How do you assess severity of acute pancreatitis?
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
What score indicates severe pancreatitis?
Score of 3 or > within 48hrs of onset - suggests severe pancreatitis
What are the 4 principles of management acute pancreatitis?
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
What percentage of AP settle with conservative treatment?
95%
Surgery is only very rarely needed
What are the local complications associates with acute pancreatitis?
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
What are the systemic complications associates with acute pancreatitis?
Pancreatic necrosis Pancreatic abscess Pancreatic pseudocyst Haemorrhage Thrombosis Chronic pancreatitis
What are the main features of haemorrhage?
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)
What are the main features of thrombosis?
Of splenic vein, SMV, portal vein (in order of frequency)
- ascites - small bowel venous congestion/ischaemia
How do you manage infected necrosis?
Antibiotic and Surgery
What is pancreatic abscess?
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
How do you manage a pancreatic abscess?
Antibiotic and drainage
percutaneous (under CT guidance)
Surgical drainage
What is a pancreatic pseudocyst?
peri-pancreatic fluid collection
↑ [pancreatic enzymes] within a fibrous capsule
presents >6 weeks after pancreatitis
What is the management for pancreatic cyst?
95% spontaneously resolve over 6 months
Percutaneously under radiological guidance (CT)
Endoscopically - EUS puncturing posterior wall of stomach & inserting stent
Surgically via laparoscopic/open
When would you intervene for a pancreatic cyst?
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
What three questions do you ask someone with the chronic pancreatitis?
What painkillers are you taking?
What do you take for your diabetes?
How much creole are you taking?
How do you manage chronic pancreatitis?
Endoscopically
Surgical drainage
Surgical resection
