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AIP: Abdominal pain > Pancreatitis > Flashcards

Pancreatitis Flashcards

1
Q

Why is it important to identify acute pancreatitis?

A

it is associated with high morbidity and mortality

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2
Q

What is the mnemonic to remember causes of acute pancreatitis?

A

IGETSMASHED

  • I: idiopathic
  • G: gallstones
  • E: ethanol
  • T: trauma
  • S: steroids
  • M: mumps
  • A: autoimmune (polyarteritis nodosa/SLE)
  • S: scorpion bite
  • H: hypercalcaemia, hypertriglyceridaemia, hypothermia
  • E: ERCP
  • D: drugs
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3
Q

What are 2 examples of autoimmune disease that may cause acute pancreatitis?

A

Polyarteritis nodosa/ SLE

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4
Q

What is the mnemonic to remember causes of drug-induced pancreatitis?

A

FATSHEEP:

  • Furosemide
  • Azathioprine/ Asparaginase
  • Thiazides/ tetracycline
  • Statins/ Sulfonamides/ Sodium valproate
  • Hydrochlorothiazide
  • Estrogens
  • Ethanol
  • Prostease inhibitors and NRTIs (anti-retrovirals)
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5
Q

What are 5 examples of drugs whcih are classed as sulphonamides?

A
  1. Thiazides
  2. Furosemide
  3. Some HIV drugs (protease inhibitors and non-nucleoside reverse transcriptase inhibitors)
  4. Sulfasalazine
  5. Gliclazide
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6
Q

What are the key symptoms of acute pancreatitis?

A
  • Stabbing-like, epigastric pain which radiates to the back that is relieved by sitting forward or lying in the fetal position
  • Vomiting highly associated
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7
Q

What are 2 things that patients may report as relieving factors for the pain of acute pancreatitis?

A
  • leaning forward
  • lying in fetal position
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8
Q

What are 2 things in the history that may be highly suggestive of acute pancreatitis?

A
  1. recent alcoholic binge
  2. history of gallstones
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9
Q

What are 6 possible signs of acute pancreatitis on examination?

A
  1. May be symptoms of hypovolaemia - tachycardia, dry mucous membranes
  2. Fever - if complicated with infection
  3. Guarding in epigastric region
  4. Grey Turner’s sign - bruising along the flanks in haemorrhagic pancreatitis
  5. Cullen’s sign - bruising around peri-umbilical area
  6. Signs of third-space fluid sequestration: can lead to ARDS, pleural effusions and hypovolaemia leading to AKI
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10
Q

When will fever be present in acute pancreatitis?

A

only if it has been complicated with infection

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11
Q

What is Grey-Turner’s sign and what does it indicate?

A

bruising along the flanks, indicates retroperitoneal bleeding (highly associated with acute pancreatitis)

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12
Q

What is meant by third-space fluid sequestration?

A

when too much fluid moves from the intravascular space into the interstitial or ‘third’ space - the non-functional area between cells

can cause oedema, reduced cardiac output, hypotension

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13
Q

What are 4 things which contribute to third space fluid sequestration in acute pancreatitis?

A
  1. Inflammatory mediators
  2. Vasoactive mediators and tissue which lead to vascular injury
  3. Vasoconstriction
  4. Increased capillary permeability
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14
Q

What are 3 examples of the severe consequences of third space fluid losses in acute pancreatitis?

A
  1. ARDS (acute respiratory distress syndrome)
  2. Pleural effusions
  3. Hypovolaemia leading to AKI (acute kidney injury)
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15
Q

What are 4 blood tests which can be performed in suspected acute pancreatitis?

A
  1. FBC
  2. U+Es
  3. LFTs
  4. Amylase
  5. (Lipase - not readily available in the UK)
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16
Q

What part of the FBC can provide information about acute pancreatitis?

A

leukocytosis can indicate the presence of necrotising pancreatitis

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17
Q

When may LFTs be abnormal in acute pancreatitis?

A

if there is gallstone disease

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18
Q

When is amylase suggestive of acute pancreatitis?

A

if it is >3x the upper limit of normaly

but important to remember the degree of elevation is not related to the severity of the disease

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19
Q

In addition to pancreatitis, what are 5 other conditions which may also elevate amylase but to a less extent?

A
  1. Perforated duodenal ulcer/ viscus
  2. Acute cholecystitis
  3. Mesenteric infarction
  4. Pancreatic pseudocyst
  5. Diabetic ketoacidosis
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20
Q

What is the marker that is more sensitive and specific for acute pancreatitis than amylase and why isn’t it performed in the UK?

A

lipase: not readily available in UK hospitals

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21
Q

How useful are imaging tests for pancreatitis?

A

not useful for the diagnosis, but may be useful to identify causes

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22
Q

What are 4 types of imaging investigations that can be used to help identify causes of pancreatitis?

A
  1. Ultrasound abdomen: can look for gallstones
  2. MRCP: can be used to look for obstructive pancreatitis
  3. ERCP: often preferred to MRCP, and can be therapeutic
  4. Contrast-enhanced CT
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23
Q

What type of imaging can be performed at a later stage in acute pancreatitis (rather than for diagnosis) and why?

A

CT scan: if complications suspected, such as pseudocysts or necrotising pancreatitis

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24
Q

What are 3 examples of scoring systems used to identify cases of severe acute pancreatitis?

A
  1. Glasgow score
  2. Ranson score
  3. APACHE II
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25
Q

What is the value of using scoring systems to determine the severity of acute pancreatitis?

A

help identify cases which may require intensive care management

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26
Q

What is the mnemonic to remember the modified Glasgow criteria?

A

PANCREAS

  • P: PaO2 <8 kPa (60 mmHg)
  • A: Age >55 years
  • N: Neutrophils; WBC >15 x 109 /L
  • C: Calcium <2 mmol/L
  • R: Renal function- urea >16 mmol/L
  • E: Enzymes: AST/ALT > 200 iu//L or LDH > 600 iu/L
  • A: Albumin < 32 g/L
  • S: Sugar: glucose >10 mmol/L
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27
Q

When is the modified Glasgow score/Glasgow criteria performed?

A

in practice, done at admission and after 48h of admission; true score is performed after 48 hours

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28
Q

What score of the modified Glasgow criteria indicated transfer to ITU/HDU?

A

score of 3 or more positive factors

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29
Q

Why do certain factors on scoring systems indicate that certain patients with acute pancreatitis should be transferred to ITU or HDU?

A

the indications are based on the degree of potential complications arising: necrosis of surrounding tissue and therefore saponification (conversion to soap + alcohol), reduced hormone output (insulin) and ARDS

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30
Q

What is the pathophysiology of acute pancreatitis?

A

autodigestion of pancreatic tissue by the pancreatic enzymes, leading to necrosis

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31
Q

What is a rare ophthalmic feature associated with pancreatitis?

A

ischaemic (Purtscher) retinopathy - may cause temporary or permanent blindness

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32
Q

What is the specificity of raised serum amylase for pancreatitis?

A

specificity is aronud 90% (i.e. 90% of those who don’t have pancreatitis test negative for pancreatitis based on amylase)

33
Q

In addition to being more sensitive and specific than serum amylase, what is another advantage of using serum lipase instead?

A

has a longer half-life than amylase and may be useful for late presentations >24 h

34
Q

What are 3 groups into which cases of acute pancreatitis may be stratified and what is this based on?

A
  • Mild: no organ failure, no local complications
  • Moderately severe: no organ failure or transient (<48h), local complications possilbe
  • Severe: persistent organ failure (>48h), local complications possible
35
Q

What are 9 aspects of the management of acute pancreatitis?

A
  1. Aggressive fluid resuscitation with crystalloids
  2. Catheterisation
  3. Analgesia
  4. Anti-emetics
  5. Nutrition
  6. Calcium
  7. Insulin
  8. Role of antibiotics
  9. Role of surgery
36
Q

What is the recommendation for fluid resuscitation in acute pancreatitis?

A

Aggressive resuscitation, start with 500ml bolus of crystalloid

aim to keep urine output >30 ml/hour; fluid requirement is usually 3-5ml/kg / hour

37
Q

What form of analgesia is recommended in acute pancreatitis?

A

usually opioids IV needed

pain may be severe so this is a key priority of care

38
Q

What is the aim for urine output from a catheter in acute pancreatitis?

A

aim for >0.5 mls/kg/hr

39
Q

What are 3 aspects of the nutrition of patients with acute pancreatitis?

A
  1. Patients should not routinely be made ‘nil by mouth’ unless there is a clear reason e.g. patient is vomiting
  2. Enteral nutrition should be offered to anyone with moderatel severe or severe acute pancreatitis within 72h of presentation
  3. Parental nutrition should only be used if enteral nutrition has failed or is contraindicated
40
Q

What do NICE say about the role of antibiotics in acute pancreatitis?

A

do not offer prophylactic antimicrobials to people with acute pancreatitis, unless indication such as pancreatic necrosis

41
Q

When does necrotising pancreatitis occur?

A

complication of severe pancreatitis representing inadequate fluid resuscitation during initial management

42
Q

How can necrotising pancreatitis be diagnosed?

A

usually by CT scan

43
Q

When is calcium given in pancreatitis?

A

not routinely/prophylactically but if hypocalcaemia is present

44
Q

When is insulin given in pancreatitis?

A

in the presence of hyperglycaemia due to the damaged pancreas reducing release of the hormone

45
Q

What are 4 situations when surgery should be performed in acute pancreatitis?

A
  1. Gallstones are the cause - early cholecystectomy
  2. Obstructed biliary system due to stones - early ERCP
  3. Failure to settle with necrosis and worsening organ dysfunction - may require debridement/ fine needle aspiration
  4. Infected necrosis: radiological drainage or surgical necrosectomy
46
Q

What are 6 complications of acute pancreatitis?

A
  1. Peripancreatic fluid collections
  2. Pseudocysts
  3. Pancreatic necrosis
  4. Pacreatic abscess
  5. Haemorrhage
  6. Acute respiratory distress syndrome
47
Q

In what proportion of cases of acute pancreatitis do peripancreatic fluid collections occur?

A

25% of cases

48
Q

What is the location and structure of peripancreatic fluid collections secondary to acute pancreatitis?

A

located in or near the pancreas and lack a wall of granulation or fibrous tissue

49
Q

What is the outcome of most peripancreatic fluid collections?

A

may resolve or develop into pseudocysts or abscesses; most resolve

50
Q

What is the management of peripancreatic fluid collections?

A

as most resolve, aspiration and drainage best avoided as it may precipitate infection

51
Q

What causes pseudocysts following acute pancreatitis?

A

result from organisation of peripancreatic fluid collection. may or may not communicate with the ductal system

52
Q

What is the structure and location of most pancreatic pseudocysts?

A

collection is walled by fibrous or granulation tissue

most are retrogastric

53
Q

When do most cases of pseudocysts occur?

A

most occur 4 weeks or more after an attack of acute pancreatitis

54
Q

What abnormal blood test are pseudocysts associated with?

A

75% associated with persistent mild elevation of amylase

55
Q

What does the investigation of suspected pancreatic pseudocysts involve?

A

CT, ERCP and MRI or endoscopic USS

56
Q

What is the management of pancreatic pseudocysts?

A
  • symptomatic cases may be observed for 12 weeks as up to 50% resolve
  • treatment is either with endoscopic or surgical cystogastrostomy or aspiration
57
Q

What is cystogastrostomy?

A

surgery to create opening between a pancreatic pseudocyst and the stomach, when the cyst is in a suitable position to be drained into the stomach (conserves pancreatic juices that would otherwise be lost)

58
Q

What may pancreatic necrosis involve?

A

may involve both the pancreatic parenchyma and surrounding fat

59
Q

What are the complications of pancreatic necrosis linked to?

A

directly linked to the extent of parenchymal necrosis and extent of necrosis overall

60
Q

What are the treatment options for pancreatic necrosis?

A
  • necrosectomy: early necrosectomy should be avoided unless compelling indications for surgery exist
  • sterile necrosis should be managed conservatively (at least initially)
  • some centres will perform fine-needle aspiration sampling of necrotic tissue if infection suspected
61
Q

What are 2 reasons why fine needle aspiration of pancreatic necrosis to detect infection may not be a good idea?

A
  1. False negatives may occur
  2. Extent of sepsis and organ dysfunction may be a better guide to surgery
62
Q

What is a pancreatic abscess?

A

intraabdominal collection of pus associated with pancreas but in the absence of necrosis

63
Q

What usually causes pancreatic abscess?

A

typically due to infected pseudocyst

64
Q

What are 2 options for treatment of pancreatic abscess?

A
  1. Transgastric drainage
  2. Endoscopic drainage
65
Q

What can cause haemorrhage as a complication of acute pancreatitis?

A

Infected necrosis may involve vascular structures with resultant haemorrhage - may occur de novo or due to surgical necrosectomy

66
Q

What sign may be present when retroperitoneal haemorrhage occurs?

A

Grey-Turner’s sign

67
Q

What is the mortality rate of acute respiratory distress syndrome if it occurs with acute pancreatitis?

A

associated with high-mortality rate of around 20%

68
Q

What causes chronic pancreatitis?

A

chronic inflammation and fibrosis of both the exocrine and endocrine components of the pancreas

69
Q

What causes the majority of cases of chronic pancreatitis?

A

80% caused by alcohol excess (20% of cases unexplained)

70
Q

What are 3 types of causes of chronic pancreatitis in addition to alcohol excess?

A
  1. Genetic: cystic fibrosis, haemochromatosis
  2. Ductal obstruction: tumours, stones, structural abnormalities including pancreas divisum and annular pancreas
  3. Metabolic: raised triglycerides
71
Q

What are 4 key clinical features of chronic pancreatitis?

A
  1. Epigastric pain, worse 15-30 minutes following a meal, relieved by sitting forward
  2. Sympoms of pancreatic insufficiency e.g. steatorrhoea
  3. Diabetes mellitus symptoms: thirst, polyuria, tiredness
  4. Epigastric tenderness on examination
72
Q

What are the features of the epigastric pain of chronic pancreatitis?

A

worse after eating fatty food (15-30 min afterwards)

relieved by sitting forward

73
Q

What 2 groups can the investigations for chronic pancreatitis be split into?

A

structural and functional

74
Q

What are 2 types of investigations to demonstrate the structural effects of chronic pancreatitis?

A
  1. Abdominal x-ray: to show pancreatic calcification
  2. CT scan: to show calcifcation
75
Q

What are 2 functional investigations in chronic pancreatitis?

A
  1. Faecal elastase (decreased) - demonstrate exocrine dysfunction
  2. Fasting glucose/ OGTT - endocrine dysfunction
76
Q

What is a key way that the investigations for chronic and acute pancreatitis differ?

A

serum amylase and lipase not typically raised in chronic pancreatitis, unlike acute

77
Q

How do abdominal x-ray and CT compare for demonstrating calcification in chronic pancreatitis?

A

abdominal x-ray shows it in 30% of cases, CT more sensitive at detecting it (sensitivity 80%, specificity 85%)

78
Q

What are 6 aspects of the management of chronic pancreatitis?

A
  1. Conservative measures: ethanol abstinence, good diet
  2. Analgesia
  3. Insulin to manage endocrine dysfunction
  4. Pancreatic enzyme replacement to manage exocrine dysfunction
  5. Antioxidants: limited evidence base
  6. Invasive measures if all else fails: coeliac plexus block, pancreatectomy
79
Q

What are 4 examples of complications of chronic pancreatitis?

A
  1. Pseudocyst
  2. Pancreatic cancer
  3. Endocrine dysfunction - diabetes mellitus
  4. Exocrine dysfunciton - malabsorption and steatorrhoea

AIP: Abdominal pain (20 decks)

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