GI: Acute Pancreatitis

Question 1

Describe the 2 most common aetiologies of acute pancreatitis.

Answer 1

1. Gallstones: block CBD causing backpressure in main pancreatic duct… outflow obstruction and activation of proteases… pancreatic autodigestion and inflammation +/- peritubular necrosis
2. Alcohol: altered balance between proteases and protease inhibitors… pancreatic autodigestion and inflammation +/- peritubular necrosis

Question 2

List the causes of acute pancreatitis.

Answer 2

Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps (and other viruses, e.g. hepatitis, Coxsackie B) and Malignancy
Autoimmune
Scorpion venom
Hyperlipidaemia, hypercalcaemia, hyperparathyroidism
ERCP
Drugs, e.g. metformin, sodium valproate

Question 3

What are the symptoms of acute pancreatitis?

Answer 3

• severe LUQ/epigastric pain, may radiate to back (tends to decrease over 72hrs), may be relieved by sitting forward
• nausea and vomiting

Question 4

What are the signs of acute pancreatitis?

Answer 4

• epigastric/generalised abdominal tenderness, often with rigidity
• probable tachycardia
• mild pyrexia
• +/- jaundice
• rare signs of haemorrhage: Cullen’s and Grey-Turner’s

Question 5

Which blood results are indicative of pancreatitis?

Answer 5

• increased amylase >3x (>1000 i.u/ml)

- increased lipase

Question 6

What is the role of imaging in acute pancreatitis?

Answer 6

Imaging may be normal in mild cases but can be used to clarify diagnosis if equivocal, to assess severity, detect complications and determine possible causes.

Contrast CT provides most comprehensive initial assessment but USS is useful for follow-up of specific abnormalities, e.g. fluid collections and pseudocysts.

Question 7

Describe your initial management of someone presenting with mild acute pancreatitis. And with severe pancreatitis.

Answer 7

Mild:

1. fluid resuscitation
2. analgesia, e.g. pethidine or buprenorphine +/- IV benzodiazepines
3. NG tube if profuse vomiting; encourage oral intake if pt able to eat

Severe: above +
4. O2
5. enteral nasogastric or nasojejunal feeding
6. urgent ERCP and sphincterotomy, esp. in Pts with ascending cholangitis, jaundice or dilated CBD (<72hrs pain onset)
If infected necrotic tissue or infected peripancreatic fluid collections:
7. surgical debridement +/- continuous peritoneal irrigation

Question 8

Why is morphine relatively contra-indicated in acute pancreatitis?

Answer 8

due to spastic effect on sphincter or Oddi

Question 9

Name 4 complications off acute pancreatitis.

Answer 9

1. death (2-5%): ARDS and pulmonary failure or multi-organ failure
2. pancreatic necrosis and infection
3. pancreatic pseudocysts or abscesses
4. diabetes mellitus and intestinal malabsorption due to loss of pancreatic secretions in severe attacks that havve caused substantial pancreatic necrosis

Question 10

How would you assess severity of acute pancreatitis? How does this affect prognosis?

Answer 10

Glasgow-Imrie criteria (traditionally scored with values at 48hrs post-admission):

• PaO2 <7.9kPa
• Age >55yrs
• Neutrophils - WCC >15x10^9/L
• Calcium <2mmol/L
• Renal function: Urea >16mmol/L
• Enzymes: LDH >600iu/L
• Albumin <32g/L
• Sugar: Glucose >10mmol/L

Score:
- 0-2 = 2% mortality
>3 is severe
- 3-4 = 15% mortality
- 5-6 = 40% mortality 
- 7-8 = 100% mortality