Pancreatitis

Question 1

What are the problems with pancreas juice?

Answer 1

Theres lots of different types of enzymes mixed together which can lead to auto digestion -acute pancreatitis

Question 2

What are protective mechanisms of the body to prevent you getting acute pancreatitis?

Answer 2

• proteases are released as INACTIVE POR-ENZYMES which protects the acini and ducts from auto-digestion
• Only activated in the DUODENUM as this secretes enterokinase which converts trypsinogen to trypsin which activates the rest of the enzymes
• Pancreas contain TRYPSIN INHIBITOR to prevent the activation of trypsin in the pancreas

Question 3

What are the 2 types of pancreatitus?

Answer 3

ACUTE PANCREATITIS-rapid onset inflammation of pancreas

CHRONIC PANCREATITIS-long-standing inflammation of the pancreas

(the top image is acute-things are ‘muddy looking’ and less defined)

Question 4

What are the causes of pancreatitis?

Answer 4

G-gallstones

E-ethanol (alcohol)

T-trauma

S-steroids

M-mumps and other viruses

A-auto-immune(e.g. polyarteritus, nodosa, SLA)

S-scorpion/snake bite(trinidad scorpian)

H-hypercalcaemia, hypertriglyceridaemia, hyperthermia

E-ERCP

D-drugs( SAND- steroids and sulphanamides, azothioprine, NSAIDS, dieuretics)

Gallstones and alcohol are the cause of 80% of pancreatitis the others are rare

Question 5

Describe how gallstones can lead to pancreatitis?

Answer 5

1) Gallstone in the ampulla causes increased pressure as pancreatic juice can’t leave the pancreas AND can cause bile reflux into the pancreas
2) once stone passes out, all the duodenal content with activated enzymes can back flow into the pancreas(theory)

Question 6

Describe how alcohol can lead to pancreatitis?

Answer 6

3) Alcohol increase the permeability of the pancreatic duct, This means acinar cell enzymes diffuse into the periductal interstitual tissue. This leads to pancreatic juice leaking into other part of your body instead of the duodenum=eats you up
4) Alcohol causes precipitate proteins in the ducts= plugs form=increased back pressure

Question 8

What are 2 theories of how pancreatis can be caused?

Answer 8

• once gallstone passes out, all the duodenal content with activated enzymes can back flow into the pancreas
• pancreatic enzymes activated intracellularly- due to proenzymes and lysosomal poteases being incorporated into the same vesicle instead of seperately =leads to the activation of trypsin

Question 9

What pathways are activated due to pancreatitis and what problems occur as a result?

Answer 9

Extracellular/intracellular activation of trypsin can cause the activation of lots of pathways:

Phospholipase A2->hypercalcaemia and pancreatic gangrene

Elastase->hyperglycaemia, pancreatic gangrene

Cmplement->pancreatic gangrene

Prothrombin->pain, pancreatic gangrene

Kallikrein-> pain, shock

Systemic damage of lungs->hypoxia

Systemic damage of kidneys->anuria

Question 10

What are the types of acute pancreatitis?

Answer 10

Odematous pancreatitis-intistitual inflammation and oedema

Necrotic pancreatitis-severe form of acute pancreatitis where necrosis occurs in pancreas

Haemoragic pancreatitis-bleeding within or around the pancreas, can occur in patients woth necrotic pancretitis OR if pancreatic pysuedoaneurism ruptures(life threatening)

Question 11

What are symptoms of acute pancreatitis?

Answer 11

• E[pigastric pain radiating to the back(apparently sitting forward helps as pancres doesnt rest on back)
• nausa and vomiting
• fevers

Question 12

What are signs of acute pancretitis?

Answer 12

Haemodynamic instability-tachycardia, hypotensive(due to shock of fluid loss)

Peritonism-inflammation of peritoneum in upper abdomen

Grey turner sign-bruising in flanks

Cullens sign-bruising around umbilicus

(bottom 2 signs are seen in haemoragic pancreatitis)

Question 13

How is acute pancreatitis diagnosed?

Answer 13

Blood test for the detection of AMYLASE

blood amylase levels are typically elevated 3 times the normal amount

Question 14

What other things apart form pancreatitis can cause a raise in blood amylase?

Answer 14

• Gallstone disease and assosiated complications
• peptic ulcer disease(pancreatic juice leaks into body)
• leaking ruptued aortic aneurysms(pancreas goes across pancreas)
• macroamylasaemia
• renal failure
• parotitis
• bowle perforation
• lung/pancreas/colon/ovaries malignancies

Question 15

What investigations can you do to help support the diagnosis of pancreatitis?

Answer 15

ERRECT CHEST X-RAY - standing up, make sure you dont have a perforation to exclude other causes

ABDOMINAL X-RAY-may see gallstoes, aortic aneurysm

ULTRASOUND-to confirm you have gallstones

CT SCANS- unnesccary unless you think something else is going on when conservative management/treatment doesn’t show improvements within 48-72 hours

MRCP-only if you think theres a gallstone

ERCP-last thing you want to do unless you have to be certain there is a gallstone

Question 16

How can you access the severity of acute pancreatitis?

Answer 16

MODIFIED GLASGOW CRITERIA(alternative is Ransons criteria)

yes for each part of the criteria would score a point

-if you get 3 or more points wothin 48hours of onset it suggests severe pancreatitis

CRP- independent predictor of severity, more than 200 -severe pancretitis( really good indicator)

Question 17

What are the 4 principles of management of CRP

Answer 17

1) FLUID RESUSITATION (via IV, cathetor)
2) ANALGESIA-pain relieving medicine
3) PANCREATIC REST-NJ feeding tube to try and avoid activiating pancreas
4) DETERMINING UNDERLYING CAUSE

Question 18

How is pancreatitis treated?

Answer 18

• 95% conservative treatment in hospital where after a few days they recover
• but if severe you can end up in ICU
• some give antibiotic if it becomes an infection rather than just inflammatory(controversial as most of the time not needed)
• surgery only rarely required

Question 21

What are the systemic complications of acute pancreatitis?

Answer 21

HYPERCALCAEMIA

HYPERGLYCAEMIA(diabetes if significant beta cell damage)

SIRS(systemmic inflammatory response system )

ARF(acute renal failure)

ARDS(adult respiratory distress syndrome)

DIC(disseminated intravascuar coagulation)

MOF(Multi-organ failure)and death

Question 22

What are local complication of acute pancreatitis?

Answer 22

PANCREATIC NECROSIS-infection(scoop out the porrige like material from pancreas in surgery)

PANCREATIC ABSCESS

PANCREATIC PSEUDOCYST

HAEMORRHAGE-due to bleeding of arroded vessels. small vessels=haemorrhagic pancreatitis, large vessels (splenic artery) = life threatening bleed unless it froms a pseudoanuerysm(need operation to stop the bleeding)

THROMBOSIS of splenic vein, SMV, Portal vein(in order of frequency). Causes build up of fluid in the abdomen(ASCITES) and SMALL BOWEL VENOUS CONGESTION/ISCHAEMIA

CHRONIC PANCREATITIS- pancreatic insufficieny

Question 23

How do you manage infected Necrotic pancreatitis?

Answer 23

Antibiotics and surgery:

• often not needed
• but high mortality rate if dead infected tissue is not debrided
• surgery involves NECROSECTOMY-removal of necrotic tissue

Question 24

What are the complications of infected necrotic pancreatitis?

Answer 24

PANCREATIC ABSCESS:

• colection of pus from pancreatic tissue necrosis
• becomes lined with granulation tissue
• presents 2-4 weeks after pancreatitis attack

PANCREATIC PYSEUDOCYST:

• peri-pancreatic FLUID collection tht can leak into abdomen
• increase in pancreatic enzymes WITHIN A FIBROUS CAPSULE
• presents more than 6 weeks after pancreatitis

Question 25

How do you manage the complications of infected acute necrotic pancreatitis?

Answer 25

PANCREATIC ABSCESS:

• Antibiotics
• surgical drainage

PANCREATIC PSEUDOCYST:

• 95% spontaneously recover over 6 months so require no intervention unless:symptomatic e.g pain, cause compression of surrounding structures(e.g CBD-obstructive jaundice, duodenum-high SBO), pyseudocyst infected-leads to abscess
• Drainage

Question 26

How can you drain a pancreatic pyseudocyst?

Answer 26

PERCUTANEOUSLY- under radiologicaln guidance

ENDOSCOPICALLY- EUS puncturing posterior wall of the stomach and inserting stent

SURGICALLY- via laproscopic/opening

Question 27

What happens in chronic pancreatitis?

Answer 27

recurrent inflammation whcih destroy endocrine and exocrine tissue= FIBROSIS of the pancreas

endocrine effect=Insuline dependent diabetes melitus

Exocrine effects-steatorrheoa

Question 28

What is the management of chronic pancreatitis?

Answer 28

Endoscopy- using this put a stent in

Surgical drainage(rare)

Surgical resection- remove part of the pancreas-tail or head depending on where it is worse(rare)