Pancreatitis (acute and chronic) Flashcards
What is pancreatitis?
Acute pancreatitis = inflammation of the exocrine pancreas, associated with acinar cell injury
Chronic pancreatitis = continuing, chronic, inflammatory process of the pancreas, characterized by irreversible morphologic changes
What is the aetiology of ACUTE Pancreatitis?
Causes = I GET SMASHED – Gallstones and ethanol make up 80-90%
I = Idiopathic
G = Gallstones (40%) (temporarily lodged at the SoO)
The risk is inversely proportional to its size
E = Ethanol (at least 35%)
Leads to IC accumulation of digestive enzymes
Increases permeability of ductules, allowing
enzymes to reach parenchyma
Increases protein content of pancreatic juice,
causing formation of protein plugs
T = Trauma
S = Steroids
M = Mumps/malignancy
A = Autoimmune
SLE, Sjogren’s
S = Scorpion venom
H = Hyperlipidaemia, hypercalcaemia, hypothermia
E = ERCP (2-3%)
D = Drugs
What are the risk factors of ACUTE pancreatitis?
Middle aged Gallstones Alcohol Hypertriglyceridemia Medications - Azathioprine, thiazide diuretics and furosemide HIV/AIDs ERCP Trauma SLE Sjogrens Hypercalcaemia Mumps
What is the aetiology for CHRONIC pancreatitis?
80% caused by alcohol
Chronic pancreatitis 50x more likely in alcoholics (>150g/day)
Smoking inhibits the exocrine pancreatic secretion of bicarbonate and fluid
What are the risk factors for CHRONIC pancreatitis?
Alcohol (70-80%) - Co-factors required – as only 3% of alcoholics get pancreatitis
Smoking
Family history
Coeliac disease
High-fat, high-protein diet
Tropical geography
What is the epidemiology of pancreatitis?
Acute pancreatitis
• Alcoholic pancreatitis more frequent in men
• Highest incidence in US (40 cases per 100,000)
• Gallstone pancreatitis more common in Europe
• Hospitalisation 3x higher for black people
Chronic pancreatitis • Similar frequencies across the globe • Hospitalisation rates higher for black people • Males more commonly affected • Prevalence of around 0.04%
What are the symptoms of ACUTE pancreatitis?
Nausea and vomiting
Anorexia
Abdominal pain - Dull and steady, Sudden in onset, Gradually intensifies until reaching a constant ache, Often upper abdominal, epigastric pain, Radiates to back (50% patients), Improves by foetal position
Diarrhoea
What are the symptoms of CHRONIC pancreatitis?
Nausea and vomiting
Abdominal pain - Intermittent attacks of severe pain, Umbilical or LUQ, Radiates in bandlike fashion, Tends to last at least several hours, Relieved by sitting forward
Steatorrhoea
Painful joints
What are the signs of ACUTE pancreatitis?
Fever Tachycardia Muscular guarding Jaundice Hypotension Abdominal distension
Haemorrhagic pancreatitis
Grey-Turner’s sign - Bilateral flank blue discolouration
Cullen’s sign - Peri umbilical blue discolouration
Fox’s sign - Ecchymosis over the inguinal ligament area
Hypocalcaemia cause
Chvostek’s sign - Facial muscle spasm when facial nerve is tapped
Trousseau’s sign - Carpopedal spasm when blood pressure cuff applied
What are the signs of CHRONIC pancreatitis?
Jaundice
Weight loss and malnutrition
Bloating
Skin nodules
What are the appropriate investigations for ACUTE pancreatitis?
Bloods
Raised serum amylase - >3x upper limit of normal (will return to normal after 3-5 days from onset)
Raised serum lipase
Serum lipase:amylase ratio >5
AST/ALT - >3x upper limit of normal predicts gallstones as aetiology in 95%
Haematocrit
CRP >200
ABG - Hypoxemia
Ultrasound - Pancreatic inflammation, Peri-pancreatic stranding, Calcifications, Free fluid
CXR - Atelectasis (complete/partial collapse of a lung – when alveoli become deflated), Pleural effusion
Other investigations
Abdo CT – most specific + sensitive - Peripancreatic fat obliteration, Necrosis, Irregular contours, Pseudocysts
MRCP - If renal insufficiency, hence can’t CT
ERCP - Identify and retrieval of stones
AXR - Sentinel loop (isolated dilatation and ileus) adjacent to pancreas, Cut-off sign with gas distending the right colon
What are the appropriate investigations for CHRONIC pancreatitis?
Bloods – amylase NOT elevated
Blood glucose - May be elevated
CT scan - Pancreatic calcifications, Enlargement of the pancreas, Ductal dilation
Ultrasound - Anatomical changes, Contour irregularity
AXR - Pancreatic calcifications
Other investigations
ERCP - Characteristic beading of the main pancreatic duct
Faecal elastase - Low
Direct pancreatic function tests - Decreased function
Genetic screening
Biopsy
What is management of ACUTE pancreatitis?
All o Initial resuscitation - IV hydration, Monitor urinary output o Nutritional support - Initially should be NBM, May need trans-pyloric nasojejunostomy o Analgesia - Morphine + fentanyl o Anti-emetic - Ondanestron o Calcium/magnesium replacement
Gallstones
o Surgical candidates = cholecystectomy
o Non-surgical candidates = ERCP
Alcohol induced
o Benzodiazepine
o Vitamin and mineral replacement (inc magnesium, B12, folate)
Hypocalcaemia
o Calcium replacement
Infected pancreatic necrosis
o Antibiotic - Imipenem or ciprofloxacin or metronidazole
o Necrosectomy
What is management of CHRONIC pancreatitis?
Lifestyle modifications o Alcohol cessation o Smoking cessation o Low fat diet o Enteral feeding
Analgesia
Pancreatic enzymes plus PPI – insulin, glucagon
Octreotide – mimic somatostatin, inhibit glucagon, insulin + growth hormone
Antioxidants
Pseudocyst decompression
What are possible complications of ACUTE pancreatitis?
• Acute RF
• Necrotising pancreatitis
• Pancreatic abscess, ascites and effusion
• Pancreatic insufficiency
• Chronic pancreatitis
• Acute lung injury
• Multi-organ failure
• Sepsis
• DIC
• Pseudocyst
o Collections of fluids with high concentrations of enzymes
o Not a real cyst – walls are the peritoneum, mesentery and serosa
o Presents often as pain, with a palpable mass
o Diagnosed by CT and treated with excision and drainage
• GI bleeding
• Obstruction
