Pancreatitis

Question 1

What are the signs and symptoms of acute pancreatitis?

Answer 1

Symptoms -
Nausea, vomiting, anorexia, sudden and sever onset of Epigastric pain (or central abdominal pain) which may radiate to the back, may be relived by sitting forward

Signs -
Increased HR
Fever
Jaundice
Shock/ Hypovolaemia
Ileus (lack of movement in small intestines)
periumbilical bruising (Cullen’s sign)
Bruising on the flanks (Grey Turner’s sign)
Indications of systemic inflammatory response (SIRS), sepsis and adult respiratory distress syndrome (ARDS)

Question 2

What are the causes of pancreatitis?

Answer 2

I GET SMASHED 
Idiopathic 
Gallstones 
Ethanol
Trauma
Steroids
Mumps
Autoimmune 
Scorpion sting 
Hyperlipidaemia/ hypercalcaemia
ERCP 
Drugs

Question 3

What are the 2 most common causes of pancreatitis?

Answer 3

Alcohol miss use and gall stones

Question 4

How do gall stones cause pancreatitis?

Answer 4

Occurs when the gall stones migrates from the gall bladder to the biliary tree and then obstructs the ampulla.

This causes biliary reflux and raised pressures are responsible for the resultant pancreatitis

Question 5

Which blood investigations are conducted to diagnose pancreatitis?

Answer 5

U and E
Calcium
CRP - >150mg/L at 36h after admission is a predictor of severe pancreatitis
LFT
Raised amylase (3x upper limit)
Septic screen (sepsis is a complication)
INR (risk of disseminated intravascular coagulopathy)

Serum lipase 3x upper limit (more sensitive and specific for pancreatitis)

ABG to monitor oxygen and acid base status especially if patient goes into adult respiratory distress syndrome

Pregnancy test- all abdominal pain

Bone profile

Serum glucose

Lipids

Question 6

Amylase level may be normal in sever pancreatitis, why?

Answer 6

This happens because the amylase level beings to fall after 24-48h

Question 7

Which conditions, if present at the time of pancreatitis can cause the amylase level to appear lower than they otherwise would in the case of this patients pancreatitis?

Answer 7

Cholecystitis, mesenteric infarction, and GI perforation

can cause lesser rises

Question 8

What is the difference between lipase and amylase in the context of pancreatitis?

Answer 8

Amylase is less specific and can appear raised in other conditions

Lipase is more sensitive and specific

Lipase rises earlier and falls later so is less likely to appear normal or low in sever pancreatitis

Question 9

Which imaging investigations are conducted to diagnose pancreatitis and what would be found in each?

Answer 9

Abdominal X ray- helps exclude causes e.g perforation

Ultrasound - used to demonstrate gallstones or a dilated common bile duct. The pancreas may be visualised.

CT- used to confirm diagnosis when uncertainty remains and to exclude complications of disease and assess severity.

MRCP- most commonly indicated in suspected gallstone pancreatitis to help evaluate for common bile duct stones.

Question 10

Which other conditions can cause a rise in amylase levels?

Answer 10

parotitis (inflammation of parotid gland), bowel obstruction, peptic ulcer or perforated ulcer, intestinal inflammation and ruptured ectopic pregnancy, cholecystitis, pancreatic CA

Question 11

Which scoring system is used in acute pancreatitis and what is it used for?

Answer 11

Glasgow score- used to assess severity of acute pancreatitis
>3 = sever disease and high mortality

P- PAO2 <8 KPA
A- Age >55 
N- Neutrophils, wcc, >15 x 10 (9)/L
C- calcium <2 mmol/L
R- Renal, urea >16 mmol/L
E- Enzymes, LDH >600 IU/L or AST >200IU/L
 A- Albumin <32 G/L
S- sugar, glucose >10mmol/L 

Completed on admission and repeated after 48h

Question 12

How is acute pancreatitis generally treated?

Answer 12

Main treatment is supportive treatment -
1- Nil by mouth- consider NJ feeing. Aim is to decrease pancreatic stimulation)

2- Give colloid fluids until vital signs are satisfactory and urine flow stays at >30mL/h. Give O2 is partial pressures are low

3. Insert urinary catheter and consider CVP (Central venous pressure) monitoring to guide haemodynamic therapy
4. Give analgesia e.g. pethidine IM or morphine (may cause sphincter of oddi to contract but it is a better analgesia and not contraindicated)
5. Assess vital signs hourly (pulse, BP, urine output)
6. Assess FBC, U and E, Calsium, Glucose, Amylase and ABG daily.
7. ERCP + gallstone removal may be needed if there is progressive jaundice.
8. Repeat imaging (usually CT) is performed in order to monitor progress.

Question 13

How is nutrition handled in those with acute pancreatitis?

Answer 13

Mild cases- Low fat diet may be introduced once the patient can tolerate it e.g. pain has settled + appetite has returned

Moderate/ Sever - Enteral feeding (through GI) is preferred to total parenteral ( through veins) nutrition. Nasojejunal feeding is commonly used.

Total parenteral nutrition is used in patients with ileus or where nutritional requirements are not being met.

Question 14

Why is enteral feeing preferred to parenteral feeding?

Answer 14

It is thought enteral feeding helps maintain the mucosa and prevent translocation of bacteria which can cause bacteraemia

Question 15

Antibiotics are not usually used in acute pancreatitis, why? When can they be used in the treatment of a patient?

Answer 15

Antibiotics should be commenced in patients with suspected/confirmed infected pancreatic necrosis, cholangitis or other infective source

Question 16

How is gall stone pancreatitis diagnosed?

Answer 16

After an acute pancreatitis diagnosis and ultrasound should be conducted

If ultrasound is inconclusive or there are signs or blood tests indicative of an obstructed biliary system MRCP should be conducted to assess common bile duct stones

Question 17

How should those with gall stone pancreatitis be treated?

Answer 17

Same as with acute pancreatitis

In patients with gallstone pancreatitis, CBD stones and cholangitis urgent decompression is required ( T tube is used to drain bile out of the duct)

ERCP should also be promptly organised for those with stones obstructing the CBD to remove the stones

Cholecystectomy is recommended following recovery from gallstone pancreatitis. Ideally, in cases that are relatively mild, this can be completed during the index admission.

Question 18

What are the early complications of pancreatitis?

Answer 18

Shock 
Adult respiratory distress syndrome 
Renal failure (give lots of fluids)
Sepsis
Disseminated intravascular coagulation (venous thrombosis)
Low calcium 
High glucose

Question 19

What are the late complications of pancreatitis?

Answer 19

Pancreatic necrosis

Pseudocyst

Abscesses

Bleeding from elastase eroding a major ves-
sel (eg splenic artery) - need embolization

Thrombosis may occur in
the splenic/gastroduodenal arteries, or colic branches of the SMA causing bowel
necrosis

Fistulae normally close spontaneously

Recurrent oedematous pancreatitis so often
that near-total pancreatectomy is contemplated

Question 20

Which aspects if the blood tests would indicate biliary pancreatitis?

Answer 20

High Bilirubin
Cholestasis Picture in LFT’s
A less than 10-fold increase in ALT and a more than 3-fold increase in ALP
If ALP is raised markedly compared to ALT,
Raised GGT

Question 21

Many patients with acute pancreatitis develop systemic inflammatory response syndrome. How would you determine if a patient has developed this condition?

Answer 21

Must have 2 of these:
®	fever >38.0°C
®	hypothermia <36.0°C
®	Tachycardia >90
®	Tachypnea >20 breaths/minute
®	leucocytosis >12*109/l
®	leucopoenia <4*109/l

Question 22

What is the purpose of a CT scan in the management of acute pancreatitis?

Answer 22

If patients do not clinically improve after 48-72 hours it is used to assess for pancreatic necrosis or other complications.

The necrosis can only be seen on a CT scan with IV contrast after 48-72 hours.

Question 23

What are the requirements for a pancreatitis diagnosis?

Answer 23

In diagnosing pancreatitis only 2 out of the following 3 need to be present-

® Abdominal pain plus a history suggestive of acute pancreatitis
® Serum amylase/lipase of over three times the upper limit of normal
® Imaging findings characteristic of acute pancreatitis