Pancreatitis Flashcards
Chronic Pancreatitis
Chronic pancreatitis is an inflammatory condition which can ultimately affect both the exocrine and endocrine functions of the pancreas. Around 80% of cases are due to alcohol excess with up to 20% of cases being unexplained
Features
pain is typically worse 15 to 30 minutes following a meal
steatorrhoea: symptoms of pancreatic insufficiency usually develop between 5 and 25 years after the onset of pain
diabetes mellitus develops in the majority of patients. It typically occurs more than 20 years after symptom begin
Investigation
abdominal x-ray shows pancreatic calcification in 30% of cases
CT is more sensitive at detecting pancreatic calcification. Sensitivity is 80%, specificity is 85%
functional tests: faecal elastase may be used to assess exocrine function if imaging inconclusive
Management
pancreatic enzyme supplements
analgesia
antioxidants: limited evidence base - one study suggests benefit in early disease
Chronic Pancreatitis - Example Question
A 38 year-old man, who has a job as a pastry chef is referred by his GP with pale, offensive stools and weight loss of 5 kg over the last two months. He has a past medical history of episodic acid reflux disease for which he was recently prescribed omeprazole. He drinks several glasses of wine a day and has a five year pack history.
Blood tests reveal:
Hb 9.9 g/dL Mean corpuscular volume (MCV) 115 fl Platelets 280 * 109/l WBC 7.1 * 109/l Na+ 136 mmol/l K+ 4.0 mmol/l Urea 3.2 mmol/l Creatinine 52 µmol/l Bilirubin 15 µmol/l ALP 140 u/l ALT 50 u/l γGT 210 u/l Albumin 39 g/l Vitamin B12 120 ng/l Faecal elastase 98 g/g (normal > 200)
What is the most appropriate next investigation?
> Abdominal ultrasound scan Liver biopsy Magnetic resonance cholangiopancreatography (MRCP) Colonoscopy Endoscopic retrograde cholangiopancreatography (ERCP)
Abdominal ultrasound is the most appropriate next investigation in this patient’s diagnosis. It helps rule out a mass lesion, especially as the patient has suffered from weight loss. Further, it can help detect calcification, given the most likely diagnosis is probably chronic pancreatitis, considering his alcohol history and low levels of faecal elastase. Further investigations may be CT scan or MRCP as this can image the biliary and pancreatic ducts in a non-invasive manner.
Acute Pancreatitis - Example Question
A 54-year-old woman who has recently been diagnosed with autoimmune hepatitis presents to the Emergency Department with central abdominal pain. This has been getting worse for the past 48 hours and is now 8/10 in terms of severity.
On examination she is tender in the epigastrium.
For the past 3 weeks she has been taking prednisolone 40mg od. Her long term medication includes amlodipine and lisinopril for hypertension. She is a non-smoker and drinks 10 units of alcohol/week.
A CT abdomen is requested:
SEE PASSMED CT ACUTE PANCREATITIS
What is the most likely diagnosis?
Acute cholecystitis Perforated duodenal ulcer Hepatocellular carcinoma Psoas abscess > Acute pancreatitis
The CT is consistent with acute pancreatitis. Note the diffuse parenchymal enlargement with oedema and indistinct margins.
Her recent steroid use is the likely precipitant of this episode.
Acute Pancreatitis - Causes
The vast majority of cases in the UK are caused by gallstones and alcohol
Popular mnemonic is GET SMASHED
Gallstones
Ethanol
Trauma
Steroids
Mumps (other viruses include Coxsackie B)
Autoimmune (e.g. polyarteritis nodosa), Ascaris infection
Scorpion venom
Hypertriglyceridaemia, Hyperchylomicronaemia
Hypercalcaemia
Hypothermia
ERCP
Drugs (azathioprine, mesalazine*, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate)
*pancreatitis is 7 times more common in patients taking mesalazine than sulfasalazine
Chronic Pancreatitis - Example Question
A 62-year-old woman is investigated for chronic diarrhoea. She is currently opening her bowels 5-6 times a day. This is associated with episodes of central abdominal pain. Some of these episodes are severe and do not seem correlated with the episodes of diarrhoea. Her symptoms started around 6 months ago and have slowly been getting worse.
Clinical examination is unremarkable.
She is a non-smoker and drinks around 6 units of alcohol per week. Her past medical history includes depression and asthma.
SEE Passmed CT Chronic Pancreatitis
What is the most likely diagnosis?
Crohn's disease Pancreatic cancer > Chronic pancreatitis Ulcerative colitis Multiple endocrine neoplasia
The CT shows classic changes consistent with chronic pancreatits. Note the irregular shaped pancreas with the typical calcifications.
Whilst a history of alcohol excess is a common cause of chronic pancreatitis it only accounts for around 60% of cases
Chronic Pancreatitis - Example Question
A 30-year-old woman presents to the Emergency Department with abdominal pain. She is currently being investigated by her GP for recurrent episodes of abdominal and back pain that have been ongoing for the past year or so. There is no pattern to when the pain comes on but it is often severe and usually lasts several hours. Her past medical history includes psoriasis for which she uses topical calcipotriol on a daily basis. She is a non-smoker and used to drink excess amounts of alcohol but stopped 6 months ago as it was exacerbating her psoriasis. Her bowels have been looser than normal for the past few months. She has lost around 3kg in the past year but thinks this is due to careful eating.
On examination her abdomen is soft and not distended. There is mild tenderness in the epigastrium but no guarding. Blood pressure, pulse and temperature are normal.
An abdominal x-ray is requested:
SEE PASSMED AXR CHRONIC PANCREATITIS
What is the most likely underlying diagnosis?
Pancreatic cancer Bony metastates > Chronic pancreatitis Crohn's disease Colorectal cancer
Multiple small calcific foci can be seen in the pancreas consistent with a background of chronic pancreatitis. The history of alcohol excess with recurrent abdominal pain is also in keeping with this diagnosis.
Acute Pancreatitis - Gallstones: Example Question
She has no significant past medical history apart from a laparoscopic appendicectomy for appendicitis when she was 20 years old, and a normal vaginal delivery 5 years ago. She does not smoke but has 1 glass of wine approximately 3 times per week.
She looks unwell and examination of her abdomen reveals epigastric tenderness.
Hb 135 g/l Platelets 402 * 109/l WBC 14 * 109/l Neutrophils 13.5 * 109/l Lipase 1200 U/l
Lipase 1200 U/l
Total cholesterol 5.4 mmol/L
HDL 1.2 mmol/L
LDL 4 mmol/L
Triglyceride 2 mmol/L
What is the most likely underlying cause of her symptoms?
Coxsackie virus Hypertriglyceridaemia Hepatitis B virus Alcohol abuse > Gallstones
This patient has acute pancreatitis. While there are multiple causes of acute pancreatitis, the most common causes include gallstones and alcohol intake. Less common causes include recent endoscopic retrograde cholangiopancreatography (ERCP), infections such as mumps and Coxsackie virus, hypertriglyceridaemia, hypercalcaemia, medications and sphincter of Oddi dysfunction.
In a significant proportion of cases of pancreatitis, no specific cause is found (idiopathic).
Drug-Induced Pancreatitis - Example Question
A 68-year-old gentleman presents with severe abdominal pain. He has a past medical history of depression and type 2 diabetes. His medications include; levemir, sitagliptin and gliclazide. He denies smoking, alcohol or illicit drug use. He also claims he has been taking all his diabetic medications.
On examination he is overweight. He has dry mucus membranes. He has generalised abdominal pain with no rebound or guarding. His bowel sounds are present and normal. His blood pressure is 101/76 mmHg, his pulse rate is 113 beats per minute and his temperature is 37.8ºC.
Investigations;
Erect Chest X Ray Clear
Ultrasound scan of the abdomen Biliary duct 3mm
Normal appearance of gallbladder
Diffuse increase echogenicity of liver, normal size
Pancreas no visible abnormality
Hb 134 g/dL
WCC 13.1 *10^9/l
Platelets 234 *10^9/l
MCV 89 fL
Sodium 148 mmol/L Potassium 5.6 mmol/L Creatinine 165 µmol/L Urea 10.4 mmol/L Alkaline Phosphatase 76 IU/L Alanine Transaminase 42 IU/L Gamma-glutamyl transpeptidase 60 IU/L Amylase 1378 IU/L Glucose 38 mmol/l Urinalysis WCC + RBC ve Ketones +
What is the likely underlying diagnosis?
Diabetic ketoacidosis Perforated small bowel > Drug induced pancreatitis Acute hepatitis Alcohol induced pancreatitis
Answer: Sitagliptiin induced pancreatitis.
Patients with perforated small bowel or DKA can present with a raised amylase. The level suggests the cause is most likely pancreatitis. A perforated small bowel would more likely show free gas on a Chest X ray, diminished bowel sounds and guarding. Diabetic ketoacidosis would show more ketones on urinalysis and is rare, although still possible, in type 2 diabetics.
The gentleman has no evidence of gallstones or biliary obstruction. This combined with a normal liver function tests makes gallstone unlikely. The patient denies alcohol intake and non-alcoholic fatty liver can produce the appearances on ultrasound scan.
Both dipeptidyl peptidase 4 inhibitors (sitagliptin) and glucagon like peptide-1 agonists have been linked to pancreatitis. They are still both under investigation but is to be discontinued in the event of an episode of pancreatitis.
Primary Hypertriglyceridaemia and Acute Pancreatitis - Example Question
A 41-year-old woman is admitted to hospital with acute epigastric abdominal pain that radiates to her back. She has nausea but has not vomited. A diagnosis of acute pancreatitis is suspected and she is commenced on intravenous fluids. Her observations include a blood pressure of 129/72 mmHg, pulse of 88 bpm, and oxygen sats of 97%.
Blood tests are performed and reveal:
Hb 13.9 g/l Platelets 194 * 109/l WBC 8.6 * 109/l Na+ 139 mmol/l K+ 4.2 mmol/l Urea 4.1 mmol/l Creatinine 92 µmol/l Bilirubin 10 µmol/l ALP 39 u/l ALT 34 u/l γGT 44 u/l Albumin 48 g/l Triglycerides 12.1 mmol/l HDL cholesterol 1.1 mmol/l LDL cholesterol 3.5 mmol/l
What is the most appropriate treatment for this patients condition?
Atorvastatin > Fenofibrate Lovastatin Ezetimibe Alirocumab
The diagnosis is hypertriglyceridaemia, which has caused this patients acute pancreatitis. Fibrates are the treatment for hypertriglyceridaemia at high enough levels to cause acute pancreatitis.
Hyperchylomicronaemia
= Caused by hereditary lipoprotein lipase deficiency and apolipoprotein CII deficiency
Predisposes to recurrent attacks of PANCREATITIS
What percentage of Chronic Pancreatitis in the UK is due to ETOH?
80%!
Hypertriglyceridaemia and Acute epigastric pain?
If hypertriglyceridaemia i.e. levels > 10mmol/L
= RF FOR ACUTE PANCREATITIS
Always do Amylase
Drug induced Pancreatitis
Azathioprine Mesalazine* Didanosine (NRTI) Bendroflumethiazide Furosemide Pentamidine Steroids Sodium valproate
Both dipeptidyl peptidase 4 inhibitors (sitagliptin) and glucagon like peptide-1 agonists have been linked to pancreatitis. They are still both under investigation but is to be discontinued in the event of an episode of pancreatitis.
*pancreatitis is 7 times more common in patients taking mesalazine than sulfasalazine
