Pancreatitis (Acute and Chronic) Flashcards
Define AP
Acute inflammatory process of the pancreas
- Self-perpetuating pancreatic inflammation by enzyme-mediated auto-digestion
- Oedema and fluid shifts → hypovolaemia
- (Extracellular fluid trapped in gut, peritoneum, retroperitoneum)
Mild: (80%) minimal organ dysfunction and uneventful recovery Severe: (20%) associated with organ failure or local complication such as necrosis, abscess or pseudocyst → life threatening
Progression may be rapid from mild oedema to necrotizing
Causes AP
insult results in activation of pancreatic proenzymes within the duct/acini resulting in tissue damage and inflammation
Most common cause:
- 80% alcohol
- Gallstones
- Other: drugs (steroid, azathioprine, thiazides, valproate) Trauma, infection, abdo surgery, ↑lipids, hyperparathyroidism, anatomical, idiopathic
Conventional Causes of Pancreatitis: GET SMASHED
- Gallstones
- Ethanol
- Trauma
- Steroids
- Mumps/HIV/Coxsackie
- Autoimmune
- Scorpion Venom
- Hypercalcaemia/hypercalcaemia/hypothermia
- ERCP
- Drugs (e.g. sodium valproate, steroids, thiazides and azathioprine)
Epidemiology AP
COMMON
UK Annual Incidence: 10/10,000
Peak age: 60 yrs
Most common cause in:
- Males = alcohol
- Females = gallstones
Symptoms AP
- 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 gallstones
Signs AP
- Epigastric tenderness
- Fever
- Shock (includes tachycardia and tachypnoea)
- Decreased bowel sounds (due to ileus)
- In severe pancreatitis:
- Cullen’s sign (periumbilical bruising)
- Grey-Turner sign (flank bruising)
Investigations AP
Blood:
- VERY HIGH SERUM AMYLASE (this does not correlate with severity)
- High WCC
- U&Es (to check for dehydration)
- High glucose
- High CRP
- Low Calcium (saponification - calcium binds to digested lipids from the pancreas to form soap)
- LFTs (may be deranged if gallstone pancreatitis or alcohol)
- ABG (for hypoxia or metabolic acidosis)
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
Management AP
Assessment of severity has TWO main scales:
- Modified Glasgow Score (combined with CRP (> 210 mg/L)
- APACHE-II Score
Medical Management:
- Fluid and electrolyte resuscitation
- Urinary catheter and NG tube if vomiting
- Analgesia
- Blood sugar control
- HDU and ITU care
- Prophylactic antibiotics may be useful in reducing mortality
ERCP and Sphincterotomy:
- Used for gallstone pancreatitis, cholangitis, jaundice or dilated common bile duct
- Ideally performed within 72 hours
- All patients presenting with gallstone pancreatitis should undergo definitive management of gallstones during the same admission or within 2 weeks
- Early detection and treatment of complications:
- For example if there are persistent symptoms or > 30% pancreatic necrosis or signs of sepsis –> image guided fine needle aspiration for culture
Surgical:
- Necrotising pancreatitis should be managed by specialists
- Necresectomy (drainage and debridement of necrotic tissue) may be necessary
Complications AP
Local:
- Pancreatic necrosis
- Pseudocyst (peripancreatic fluid collection lasting > 4 weeks)
- Abscess
- Ascites
- Pseudoaneurysm
- Venous thrombosis
Systemic:
- Multiorgan dysfunction
- Sepsis
- Renal failure
- ARDS
- DIC
- Hypocalcaemia
- Diabetes
Long-Term: could result in chronic pancreatitis
Prognosis AP
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)
Define CP
Chronic inflammatory disease of the pancreas characterised by irreversible parenchymal atrophy and fibrosis leading to impaired endocrine and exocrine function and recurrent abdominal pain.
Causes CP
- ALCOHOL - 70%
- Idiopathic - 20%
- RARE: recurrent acute pancreatitis, ductal obstruction, pancreas divisum, hereditary pancreatitis, tropical pancreatitis, autoimmune pancreatitis, hyperparathyroidism
EXTRA information about pathology/pathogenesis:
Chronic pancreatitis is caused by disruption of normal pancreatic glandular architecture due to chronic inflammation and fibrosis, calcification, parenchymal atrophy, ductal dilation and cyst and stone formation
Pain is associated with raised intraductal pressures
Epidemiology CP
Annual UK incidence: 1/100,000
Prevalence: 3/100,000
Mean age: 40-50 yrs (in alcohol-associated disease)
Symptoms CP
- Recurrent severe epigastric pain
- Pain radiates to the back
- Pain relieved by sitting forward
- Pain can be aggravated by eating or drinking alcohol
- Over many years –> weight loss, bloating and steatorrhoea
Signs CP
- Epigastric tenderness
- Signs of complications e.g. weight loss, malnutrition
Investigations CP
Bloods:
- High glucose (endocrine dysfunction) - glucose tolerance test may be performed
- Amylase and lipase usually normal
- High Ig (especially IgG4 in autoimmune pancreatitis)
Ultrasound
ERCP or MRCP:
- Early changes that can be seen include main duct dilatation and stumping of branches
- Late manifestations include duct strictures with alternating dilatation
Abdominal X-Ray:
- May show pancreatic calcification
CT Scan:
- May show pancreatic calcification and pancreatic cysts
Tests of pancreatic exocrine function:
- Faecal elastase (reflects pancreatic exocrine function)
