Surg - Pancreatitis

Question 1

Atlanta classification

Answer 1

Mild acute pancreatitis
▸ No organ failure
▸ No local or systemic complications

Moderately severe acute pancreatitis
▸ Organ failure that resolves within 48 h (transient organ failure) and/or
▸ Local or systemic complications without persistent organ failure

Severe acute pancreatitis
▸ Persistent organ failure (>48 h)
–Single organ failure
–Multiple organ failure

Question 2

In the altanta classification, by how much does the amylase have to rise

Answer 2

> 3x

Question 3

Describe the amylase rise in pancreatitis

Answer 3

Rises within hours, and is normal by day 3-5

Question 4

Describe the lipase rise in pancreatitis

Answer 4

Elevated for 8-14 days

More sensitive that amylase in late presentation >48 hours

Question 5

Does the degree of enzyme rise correlate with severty

Answer 5

No

Question 6

COMMON causes of pancreatitis

Answer 6

Alcohol
Gallstone
Idiopathic (15%)
ERCP

Drugs - valproate, steroids
Viral CMV, mumps

Question 7

What Ranson score represents mild disease

Answer 7

Less than 3

Question 8

What Ranson score correlates with necrosis

Answer 8

6 or more

Question 9

Name some CT based scores

Answer 9

CT severity Index

Balthazar

Question 10

Ranson Criteria - non gallstone (gallstone)

Answer 10

Age>55       (70)
Glucose>11.1 (12.2)
WCC>16       (18)
AST>250     250
LDH>350     400
HctFall>10%  10%
Fluid sequestriation >6l (4litres)
Base def >4   (5)
BUN rise >1.8 (0.7)
Ca <2  (2)
PaO2<8 (8)

Question 11

Glascow Imrie Criteria

Answer 11

Age >55
Glucose >10
WCC >15
Serum LDH >600
Albuin <32
BUN >16.1
Ca<2
PaO2 <8

Question 12

Imaging in pancreatitis –> US

Answer 12

Used within 24 hours to assess for stones and obstruction

Question 13

Which is the gold standard imaging

Answer 13

Contrast CT

Question 14

Optimal timing for initial CT

Answer 14

> 96 hours after onset of symptoms

Question 15

When should you get an early CT

Answer 15

Diagnositc uncertaintly or other life threatening disorder

Question 16

In mild Acute Pancreatitis, when should feeding start

Answer 16

Orally and immediately

Question 17

What is the recommnded feeding in pancreatitis

Answer 17

Enteral in moderate/severe
Preserves gut muscosal function
Reduce risk of MOF and pancreatic infectious complications

Question 18

Indications for surgery

Answer 18

ERCP - gallstone panc with cholangitis OR biliary obstruction

Cholecystectomy - if mild AP, during admission. If severe, delay

Leave pseudocysts and sterile necrosis

Infected necrosis - if not responding to ABx

Question 19

How long to wait before draining necrosis and why

Answer 19

4 weeks

allow to liquify become discrete and walled off

Question 20

New atlanta classification for severity

Answer 20

Mild - absence of orga failure/local complications

Mod - Local complications and/or transient organ failure (<48 hours)

Severe (persistant organ failure >48 hours)

Question 21

Mortality of AP with necrosis

Answer 21

10% if sterile

30% is infected

Question 22

What does Cochrane say on prophylactic Abx

Answer 22

no difference in mortality

Question 23

ABx points in panc

Answer 23

Not indicated routinely
Treat co-existing extrapancreatic infection
No evidence to use to prevent infected necrosis
Consider infected necrosis if no improvement in 7-10 days

If infected - carbapenems, quinolones, metronidazole

Routine antifungals not needed

Question 24

CT severity index features

Answer 24

Graded on apperence and necrosis score

Normal
Oedema/enlarged
Inflammation
1 peri pan collection
>1 collection

0-4

Necrosis
0
<30%
30-50%
>50%

0-6

Total of 10
>7 high morbidity and mortality