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Big Surgery > Pancreatitis > Flashcards

Pancreatitis Flashcards

1
Q

What is acute pancreatitis?

A

inflammation and haemmorhaging of the pancreas usually caused by gallstones or alcohol

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2
Q

Where is the pancreas located?

A

Retroperitoneally(behind the stomach)

  • epigastrium
  • between L1-L3
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3
Q

Where does the tail of the pancreas lie?

A

-In the hilum of the spleen

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4
Q

Where does the head of the pancreas lie?

A

-In the C-loop of the duodenum

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5
Q

The pancreas has main ducts- name them and where they drain into?

A
  • There is the main pancreatic duct that goes through the whole pancreas and drains into the duodenum via the ampulla of vater
  • the accessory duct drains the head of the pancreas and drains via a different route into the duodenum
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6
Q

What two functions does the pancreas have?

A
  1. exocrine function

2. endocrine

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7
Q

What is the function of glucagon?

A

-It mobilises fatty acids, amino acids and glucose into the bloodstream

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8
Q

What is the function of insulin in the body?

A

It is anabolic and causes storing of amino acids, glucose and fatty acids

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9
Q

What is the aetiology of pancreatitis?

I GET SMASHED

A 
I-idiopathic
G-gallstones
E-ethanol
T- trauma
S-steroids
M-mumps
A-autoimmune
S-scorpion poison
H-hypercalcaemia, hypertriglyceraemia
E-ERCP
D-drugs
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10
Q

What are the clinical features of acute pancreatitis?

A
  • constant and severe epigastric pain
  • nausea and vomiting
  • radiates towards the back
  • worse after meals and when supine
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11
Q

What are the physical signs you see on patients?

A
  • abdo exam: guarding, distension, decreased bowel sounds, abdominal tenderness, may have palpable mass if pseudocyst, pancreatic phlegmon
  • general exam: signs of shock like tachycardia, hypotension, oliguria
  • skin changes- ecchymoses, grey turners and cullens sign particularly haemmorrhagic pancreatitis
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12
Q

What are the skin changes you can expect in a patient with acute pancreatitis?

A
  1. cullen’s sign- periumbilical ecchymosis and bluish discolouration
  2. Grey Turner’s sign-flank discolouration
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13
Q

How do we diagnose acute pancreatitis?

A

-clinically, tests and imaging

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14
Q

What should we expect on lab tests?

A
  1. increase in lipases x3 strongly indicate pancreatitis

2. increase in amylase which is non-specific

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15
Q

How can we test severity?

A
  1. Testing Hct

- an increase can mean third space fluid loss and fluid loss

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16
Q

What imaging do we usually do for acute pancreatitis?

A
  1. ultrasound- which is usually to help diagnose the presence of gallstones or dilation of the biliary tract
  2. CT Scan- enlargement of the pancreatic parenchyma with eodema
  3. MRCP and ERCP: if we suspect biliary tract and pancreatic duct obstruction
  4. X-ray: sentinel loop sign and colon cut off sign
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17
Q

What would be able to see on ultrasound for acute pancreatitis?

A
  • edematous swelling
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18
Q

What is the treatment for acute pancreatitis?

A
  1. make sure patient is nil per os so give food enterally and start the patient on PPI
  2. aggressive hydration with Ringers Lactate
  3. drug therapy: fentanyl(analgesia), pethidine
  4. Antibiotics: should only be used for patients with infective necrosis
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19
Q

How much fluid resuscitation do patients have to get per day?

A

-About 3-4 litres per day

20
Q

What are the localised complications that can happen?

A
  • pancreatic pseudocyst
  • pancreatic abscess
  • bacterial superinfection of necrotic tissue leading to a fever
21
Q

What are the systemic complications of acute pancreatitis?

A
  1. SIRS, DIC, sepsis
  2. pneumonia, ARDS, respiratory failure
  3. shock
  4. hypocalcaemia
22
Q

What determines the prognosis of patients with acute pancreatitis?

A
  1. abnormal haematocrit in 48 hours-either increased or decreased
  2. hypocalcaemia and hypercalcaemia
  3. increase in CRP(inflammatory marker)
23
Q

What are the two types of pathological pancreatitis?

A
  1. acute interstitial pancreatitis-mild

2. necrotising pancreatitis-severe

24
Q

How many years does it usually take for pancreatitis caused by alcohol to take place?

A

5- 10 years of heavy drinking

25
Q

When should we suspect gallstone pancreatitis or caused by carcinoma of the pancreas?

A
  • usually after a big meal

- suspect it mostly in middle or elderly patients

26
Q

What causes contraction of the gallbladder?

A

cholecystokinin

-the gallstones usually travel and block the ampulla of vater

27
Q

What is the criteria for SIRS?

A
  • systemic inflammatory response syndrome
  • HR: >90 bpm
  • Resp rate: >20 or >32mmHG
  • WWC: <4000 AND >12000
  • Temperature: <36 and >38 degrees
28
Q

What are the 3 degrees of severity of pancreatitis?

A
  1. mild acute pancreatitis-this is with at least 80% of patients
    -No organ failure, no local complications
  2. moderately severe acute pancreatitis
    -transient organ failure for less than 48 hours
  3. severe acute pancreatitis
    persistent organ failure for more than 48 hours
29
Q

What is the management of mild pancreatitis?

A

supportie measures like:

  • bed rest
  • nil per mouth
  • intravenous fluids
  • analgesics
30
Q

What is the treatment of pancreatitis that is is caused by gallstones?
-Gallstone pancreatitis?

A
  • gallstone pancreatitis is treated with conservative treatment initially
  • usually settles after the stones passes into the bowel
  • usually we do an elective cholecystectomy(1-4 weeks later) to prevent a second attack
31
Q

What is the treatment of severe acute pancreatitis?

A
  • ICU management
  • volume replacement to treat the hypovolaemia
  • management of respiratory failure
  • treat the hypocalcaemia, hyperglycaemia and the renal failure
32
Q

What are the 3 ways to drain pancreatic pseudocyst collections?

A
  • endoscopically
  • percutaneously which is not preferred
  • surgically
33
Q

What are the 2 congenital abnormalities of the pancreas that can causes acute pancreatitis?

A
  1. Annular pancreas- is when the 2nd part of the duodenum is surrounded by the pancreas
  2. Divisum pancreas
34
Q

What are the local complications of acute pancreatitis?

A
  1. Psuedocyst-persistent fluid collection walled off by fibrosis which can occur after 4 weeks and causes infection, gastric outlet obstruction and peritonitis
  2. Acute fluid collection
  3. Abscess
  4. Infected necrosis
  5. Pancreatic necrosis
35
Q

What are the systemic complications of acute pancreatitis?

A
  1. Hypovolaemia
  2. Renal failure, cardiac failure, SIRS
  3. Hypocalcaemia, hyperglycaemia
  4. Shock
  5. Multiple organ failure
36
Q

What are the symptoms that patients with acute pancreatitis present with?

A
  1. Epic Astrid pain that radiates to the back
  2. Nausea and vomiting and anorexia
  3. They feel better when leaning forward and hunched
37
Q

What is Ranson’s criteria?

A

It is a criteria used to determine the prognosis of the patient with acute pancreatitis
High ransons criteria means the patient is very unwell and needs ICU

38
Q

What other bloods would you do in the patient other than lipase and amylase?

A
  1. FBC
  2. LFT
  3. Urea and electrolytes
  4. clotting profiles
  5. serum calcium
39
Q

What are the scoring systems we can use to score the severity of pancreatitis?

A
  1. Glasgow
  2. Apache II
  3. Ransons criteria
  4. BISAP
  5. SOFA
    Which indicate that a Hct>44% for 48 hrs, CRP >150 for 48 hours and SIRS> 48 h is severe pancreatitis
40
Q

What is the surgical interventions for the complications?

A
  1. pseudocyst if larger than 6 cm and lasting more than 6 weeks, drain the pseudocyst
  2. infected pancreatic necrosis
  3. sterile necrosis by doing a necrosectomy
41
Q

What is chronic pancreatitis?

A
  1. Chronic inflammatory disorder With or without calcification and that causes exocrine and endocrine loss
42
Q

What are the causes of chronic pancreatitis?

A

T-toxins like alcohol and calcium
I- idiopathic
G-genetic like cystic fibrosis and alpha1 anti-trypsin
A-autoimmune
R-repeated bouts of acute pancreatitis
O-obstruction of the ampulla of vater, or cancer of the pancreatic head

43
Q

What is the clinical presentation of patients with chronic pancreatitis?

A
  1. Long-standing epigastric pain that radiates to the back
  2. Present for most of the day and most analgesia does not work
  3. Late symptoms are steattorrhea and diabetes mellitus
44
Q

What are the complications of chronic pancreatitis?

A
  1. Pseudo tats
  2. DM
  3. Obstructive jaundice
  4. Hepatic and splenic vein thrombosis
  5. Pancreatic ascites
  6. Exocrine dysfunction
45
Q

What are the special investigations you would get for chronic pancreatitis?

A
  1. Blood glucose to check for DM
  2. ERCP and MRCP to help plan the surgery
  3. CT abdomen for the pseudocyst
  4. Ultrasound for the bile duct obstruction
  5. Steatocrit to assess steatorrhea
  6. LFT liver function
46
Q

What is the management of chronic pancreatitis?

A 
1. Medical:
Start the patient on supplements to combat the loss of pancreatic enzymes 
-treat DM
-stop alcohol and smoking
-analgesia

2.Surgery: Frey’s procedure

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