Wk 2 - Pathology: Pancreatitis Flashcards
What is pancreatitis?
- Pancreatic inflammation
- Can be acute or chronic
- Represents 3% of abdominal pain presentations
Describe the aetiology (causes) of pancreatitis.
Self-perpetuating inflammation of pancreas!
- Damage to pancreas
- Premature activation of zymogen granules
- Releases proteases
- Digests pancreas and surrounding tissues
- Activation of complement, kinin, fibrinolytic and coagulation cascades
Litres of fluid may become trapped in gut, peritoneum, retroperitoneum
What are the causes of pancreatitis?
GET SMASHED
- GALLSTONES
- ETHANOL
- TRAUMA (including surgery)
- STEROIDS
- MUMPS
- AUTOIMMUNE DISEASE (Polyarteritis nodosa)
- SCORPION VENOM (Tityus Trinitatis – only in Trinidad!)
- HYPERLIPIDAEMIA (+Hypocalcaemia, Hypothermia)
- ERCP (+Emboli)
- DRUGS e.g. azathioprine
Other: idiopathic, pregnancy, petrochemicals exposure
Define acute pancreatitis.
Acute pancreatitis is an acute response to injury of the pancreas. Most commonly seen in A&E or acute surgical unit.
What is the clinical presentation of acute pancreatitis?
Clinical presentation (very sick but clinical presentation not very specific)
- Epigastric/central abdominal pain
- Radiates to back in 65%
- May be relieved by sitting forward
- Nausea and vomiting
What might you see in a patient with acute pancreatitis on examination?
- CVS
- signs of hypovolaemic shock
- RS
- hypoxia on ABG
- Abdo
- Epigastric tenderness
- Quiet/absent bowel sounds
- Jaundice
What are the classic signs of acute pancreatitis?
- Cullen’s sign: a hemorrhagic discoloration of the umbilical area due to intraperitoneal hemorrhage from any cause
- Grey Turner sign: a discoloration of the left flank associated with acute hemorrhagic pancreatitis.
Grey-Turner sign is present where there is ecchymosis in the flanks. Cullen’s sign is present when there is ecchymosis around the umbilicus. These signs can signify pancreatic necrosis leading to blood in the abdomen.
nb these are not really seen…
What is the Modified Glasgow Score?
The Glasgow Imrie score (modified Glasgow score) is a modification of the Ranson’s criteria for acute pancreatitis. Validated for acute pancreatitis secondary to gallstones of alcohol.
List the factors of the modified Glasgow score.
PANCREAS
- PaO2 < 8 kPa
- Age > 55 years
- Neutophils (WBC) > 15 x 109/L
- Calcium < 2 mmol/L (hypocalcaemic)
- Renal function: urea > 16 mmol/L
- Enzymes: LDH > 600 iu/L; AST > 200 iu/L (liver function elvation)
- Albumin < 32g/L (hypoalbuminanaemic)
- Sugar: blood glucose > 10 mmol/L
If a patient has ____ or more features of the modified Glasgow score in <48hours of onset then the patient has severe disease.
If a patient has THREE or more features of the modified Glasgow score in <48hours of onset then the patient has severe disease.
List the investigations you might do if a patient presents with pancreatitis.
Investigations
- ABG
- Serial CRP (C-reactive protein)
- Serum amylase/lipase (amylase may return to normal in 24-48 hours) - no prognostic value on its own
- Urinary amylase:creatinine ratio (if serum amylase normal)
- USS (may show gallstones/biliary obstruction) –> will not DIAGNOSE pancreatitis but may give a suggestion of cause
- Plain x-rays – exclude perforation, obstruction, respiratory complications –> loss of psoas shadow due to increased fluid
- CT 3-10 days after admission helps define viability
How are patients with acute pancreatitis usually managed?
- Usually managed on surgical wards (even tho do not usually have operations!)
- Resuscitation/Manage complications ie supportive management
- Oxygen +/- ventilatory support
- Correction of hypovolaemia
- NG (nasogastric aspiration) aspiration if paralytic ileus
- Start enteral feeding early in severe disease
- Analgesia (classically pethidine)
- VTE (venous thromboembolism) prophylaxis
- Broad-spectrum antibiotics in severe disease
- Treat underlying cause
- Cholangitis/jaundice – ERCP
- Less severe gallstone pancreatitis – MRCP following acute phase
- Pancreatic abscess or necrotising pancreatitis require surgical debridement
What is ERCP?
Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure that combines upper gastrointestinal (GI) endoscopy and x-rays to treat problems of the bile and pancreatic ducts.
What is MRCP?
Magnetic resonance cholangiopancreatography (MRCP) is a medical imaging technique. It uses magnetic resonance imaging to visualize the biliary and pancreatic ducts non-invasively. This procedure can be used to determine whether gallstones are lodged in any of the ducts surrounding the gallbladder.
List the possible complications of acute pancreatitis (early vs late).
Early
- Shock
- ARDS - Acute respiratory distress syndrome
- Renal failure
- DIC - Disseminated intravascular coagulation
- Hypocalcaemia
- Hyperglycaemia
Late
- Necrosis
- Pseudocyst –> leads to persistently elevated amylase (a pancreatic pseudocyst is a fluid-filled sac that forms in the abdomen comprised of pancreatic enzymes, blood, and necrotic tissue)
- Abscesses
- Haemorrhage (elastase erosion)
- Thrombosis
Define chronic pancreatitis.
Chronic pancreatitis can result in permanent damage to the structure and endocrine and exocrine functions of the pancreas.
Describe the aetiology of chronic pancreatitis.
- Fibrosis and exocrine pancreatic tissue destruction
- Diabetes mellitus in advanced cases
- ~80% secondary to alcohol misuse – predominantly middle-aged alcoholic men
- Other causes – malnutrition, cystic fibrosis, cassava consumption, idiopathic
How do patients with chronic pancreatitis usually present?
- Abdominal pain
- In 50%, occurs as episodes of ’acute’ pancreatitis
- May be relieved by sitting forwards/alcohol
- Weight loss
- Steatorrhoea –> excess fat in faeces. Stools may be bulky and difficult to flush, have a pale and oily appearance and can be especially foul-smelling. This is due to impaired fat absorption
- Diabetes mellitus in 30%
- ‘Erythema ab igne’ (in upper back due to hot water bottle use to relieve pain in back) – not commonly seen but textbook teaching
List the investigations you would do for a patient who presents with chronic pancreatitis.
Diagnosis
- USS
- CT – atrophy, calcification (state of the pancreas - indicates chronicity)
- AXR – calcification
- MRCP
How would you manage a patient with chronic pancreatitis?
- Alcohol avoidance – halt progression, relieve pain
- Pain relief – oral pancreatic enzyme supplements (supplements may suppress pancreatic secretion and reduce analgesic requirements in some patients)
- Surgery – abstinent patients with resistant pain
- Fat restriction – used to treat steatorrhoea
- Surgery for management of pseudocysts, ascites, CBD/duodenal stricture
What are some complications linked to chronic pancreatitis?
- Pseudocysts
- Pancreatic ascites
- CBD stricture -> extrahepatic obstructive jaundice
- Duodenal stenosis
- Portal/splenic vein thrombosis -> segmental portal hypertension, gastric varices
