Pancreatitis (acute)

Question 1

Definition

Answer 1

• An acute inflammatory process of the pancreas with variable involvement of other regional tissues or remote organ systems.

Question 2

Classification

Answer 2

o Mild: minimal organ dysfunction and uneventful recovery

o Severe: organ failure and/or local complications such as necrosis, abscesses and
pseudocysts

Question 3

Aetiology

Answer 3

An insult will result in the activation of pancreatic proenzymes within the pancreatic duct/acini leading to tissue damage and inflammation

Question 4

Causes

Answer 4

GET SMASHED

o Gallstones
o Ethanol
o Trauma
o Steroids
o Mumps/HIV/Coxsackie
o Autoimmune
o Scorpion Venom
o Hypercalcaemia/hypertriglyceramia/hypothermia
o ERCP
o Drugs (e.g. sodium valproate, steroids, thiazides and azathioprine)

Question 5

Epidemiology

Answer 5

COMMON

• UK Annual Incidence: 10/10,000
• Peak age: 60 yrs

• Most common cause in:
o Males = alcohol
o Females = gallstones

Question 6

Presenting symptoms

Answer 6

• Severe epigastric pain
• Radiating to the back
• Relieved by sitting forward
• Aggravated by movement
• Associated with anorexia, nausea and vomiting

• IMPORTANT: check whether the patient has a history of high alcohol intake or gallstone

Question 7

Signs on physical examination

Answer 7

• Epigastric tenderness
• Fever
• Shock (includes tachycardia and tachypnoea)
• Decreased bowel sounds (due to ileus)

• In severe pancreatitis:
o Cullen’s sign (periumbilical bruising)
o Grey-Turner sign (flank bruising)

Question 8

Investigations (bloods)

Answer 8

o VERY HIGH SERUM AMYLASE (this does not correlate with severity)

o High WCC
o U&Es (to check for dehydration)
o High glucose
o High CRP
o Low Calcium (saponification - calcium binds to digested lipids from the pancreas
to form soap)
o LFTs (may be deranged if gallstone pancreatitis or alcohol)
o ABG (for hypoxia or metabolic acidosis)

Question 9

Investigations (other)

Answer 9

• USS: check for evidence of gallstones in biliary tree
• Erect CXR: may be pleural effusion. Also to check for bowel perforation
• AXR: exclude other causes of acute abdomen
• CT Scan: if diagnosis is uncertain or if persisting organ failure

Question 10

Management plan (assessing severity)

Answer 10

Assessment of severity has TWO main scales:

o Modified Glasgow Score (combined with CRP (> 210 mg/L)
o APACHE-II Score

o NOTE: In the USA, the Ranson score is often used (this is specific for alcoholic
pancreatitis)

Question 11

Management plan (medical)

Answer 11

o Fluid and electrolyte resuscitation
o Urinary catheter and NG tube if vomiting
o Analgesia
o Blood sugar control
o HDU and ITU care
o Prophylactic antibiotics may be useful in reducing mortality

Question 12

Management plan (ERCP and sphincterotomy)

Answer 12

o Used for gallstone pancreatitis, cholangitis, jaundice or dilated common bile duct
o Ideally performed within 72 hours
o All patients presenting with gallstone pancreatitis should undergo definitive
management of gallstones during the same admission or within 2 weeks

Question 13

Management plan (early detection/treatment of complications)

Answer 13

o For example if there are persistent symptoms or > 30% pancreatic necrosis or
signs of sepsis –> image guided fine needle aspiration for culture

Question 14

Management plan (surgical)

Answer 14

o Necrotising pancreatitis should be managed by specialists
o Necresectomy (drainage and debridement of necrotic tissue) may be necessary

Question 15

Possible complications (local)

Answer 15

o Pancreatic necrosis
o Pseudocyst (peripancreatic fluid collection lasting > 4 weeks) 
o Abscess
o Ascites
o Pseudoaneurysm
o Venous thrombosis

Question 16

Possible complications (systemic)

Answer 16

o Multiorgan dysfunction
o Sepsis
o Renal failure
o ARDS
o DIC
o Hypocalcaemia
o Diabetes

Question 17

Possible complications (long term)

Answer 17

could result in chronic pancreatitis

Question 18

Prognosis

Answer 18

• 20% follow severe fulminating course with high mortality
• Infected pancreatic necrosis has a 70% mortality
• 80% follow a milder course (but this still has 5% mortality)