Pancreatitis, Acute Flashcards
Describe the aetiology of acute pancreatitis.
Insult results in activation of pancreatic proenzymes within the duct/acini resulting in tissue damage and inflammation.
Most common:
•Gallstones,
•alcohol (80% cases)
Others:
•Drugs (e.g. steroids, azathioprine, thiazides, valproate),
•trauma,
•ERCP or abdominal surgery,
•infective (e.g. mumps, EBV, CMV, coxsackie B, mycoplasma),
•hyperlipidaemia,
•hyperparathyroidism,
•anatomical (e.g. pancreas divisum, annular pancreas),
•idiopathic.
Describe the epidemiology of acute pancreatitis.
•peak age
•differences in males and females
Common.
Annual UK incidence ~10/10,000.
Peak age is 60 years;
in males, alcohol-induced is more common
in females, principal cause is gallstones.
What would a patient with acute pancreatitis describe in their history?
Severe epigastric or abdominal pain (radiating to back, relieved by sitting forward, aggravated by movement).
Associated with anorexia, nausea and vomiting.
Obstructive jaundice (jaundice, dark urine, pale stools) may be present if gall stones are the cause.
There may be a history of gallstones or alcohol intake.
What would you find on examination of a patient with acute pancreatitis?
Epigastric tenderness, fever. Shock, tachycardia, tachypnoea.
⬇️ Bowel sounds (due to ileus).
If severe and haemorrhagic, Turners sign (flank bruising) or Cullens sign (periumbilical bruising).
What investigations would you perform if you suspected acute pancreatitis?
Bloods:
•⬆️ Amylase (usually >3* normal but does not correlate with severity), •FBC (⬆️ WCC), U&Es, ⬆️ glucose, ⬆️ CRP, ⬇️ Ca2+,
•LFTs (maybe deranged if gallstone pancreatitis or alcohol),
•ABG (for hypoxia or metabolic acidosis).
USS:
•For gallstones or biliary dilatation.
Erect CXR:
•There may be pleural effusion.
•Mainly for excluding other causes (eg pneumonia).
AXR:
•To exclude other causes of acute abdomen.
•Psoas shadow may be lost.
CT scan:
•If diagnostic uncertainty or if persisting organ failure, signs of sepsis or deterioration
for severe cases.
•Scoring system (Balthazar score): combination of grade of pancreatitis and degree of necrosis.
How would you manage a patient with acute pancreatitis?
Assessment of severity: The two most validated scales are:
(1) Modified Glasgow combined with CRP (>210 mg/L).
(2) APACHE-II score
Alternatively, there is the older Ransons criteria.
Medical:
•Fluid and electrolyte resuscitation,
•urinary catheter and NG tube if vomiting.
•Analgesia and blood sugar control.
•Early HDU or intensive care support.
•Meta-analysis has shown reduced infective complications and •mortality in severe pancreatitis with enteral, as opposed to parenteral, feeding.
•Prophylactic antibiotics have not been shown to reduce mortality, unless infective pancreatic necrosis develops.
ERCP and sphincterotomy:
•For gallstone pancreatitis, cholangitis, jaundice or dilated common bile duct,
•ideally within 72 h.
•All patients should undergo definitive management of gallstones during same admission or within 2 weeks.
Early detection and treatment of complications:
•e.g. if persistent symptoms and >30% pancreatic necrosis or signs of sepsis should undergo image guided fine needle aspiration for culture (BSG guidelines).
Surgical:
•Patient with necrotizing pancreatitis should be managed in a specialist unit.
•Minimal access or open necresectomy (drainage and debridement of all necrotic tissue).
Describe the modified Glasgow criteria for assessing acute pancreatitis.
More than or equal to three indicates severe disease.
(P) pO2 55
(N) WCC > 15 109/L (C) Ca2 þ 16 mmol/L
(Enz) LDH > 600
(A) Albumin > 32 g/L
(Sugar) Glucose > 10 mmol/L
How and when would you use the Ransons criteria?
Ranson’s criteria is older than the Glasgow score. It is only used for alcoholic pancreatitis.
On admission: WCC 55, AST > 250, LDH > 350, glucose > 11 mmol/L.
During first 48 h: pO2 16 mmol/L, base deficit > 4, haematocrit fall > 10%, fluid sequestration > 600 mL.
What complications are associated with acute pancreatitis?
•Local
•Systemic
•Chronic
Local: •Pancreatic necrosis, •pseudocyst (peripancreatic fluid collection persisting >4 weeks), •abscess, •ascites, •pseudoaneurysm or venous thrombosis.
Systemic: •Multiorgan dysfunction, •sepsis, •renal failure, •ARDS, •DIC, •hypocalcemia, •diabetes.
Long term:
•Chronic pancreatitis (with diabetes and malabsorption).
Wha is the prognosis for patients with acute pancreatitis?
Twenty percent follow severe fulminating course with high mortality (infected pancreatic necrosis associated with 70% mortality),
80% run milder course (but still 5% mortality).
What is the definition of acute pancreatitis?
•mild vs severe.
An acute inflammatory process of the pancreas with variable involvement of other regional tissues or remote organ systems.
Mild: Associated with minimal organ dysfunction and uneventful recovery.
Severe: Associated with organ failure and/or local complications such as necrosis, abscess or pseudocyst (1992 Atlanta classification).
