Pancreatitis

Question 1

Causes ACUTE Pancreatitis

Answer 1

Idiopathic/infectious

Gallstones
Ethanol
Trauma

Steroids
Mumps/malignancy
Autoimmune
Scorpion sting
Hypercalceamia
ERCP 
Drugs

Question 2

Causes CHRONIC pancreatitis

Answer 2

Tropical
Hereditary
Alcohol
Trauma

Blockage of ducts (bile/ pancreatic)
Idiopathic
Trypsinogen defects 
Cystic Fibrosis
Hypercalceamia

Question 3

Psychopathology of Pancreatitis

Answer 3

(Impaired drainage results in pancreatic HTN releasing free ionised calcium / alcohol interferes with calcium homeostasis)

High intracellular Calcium initiates

Immune regulated inflammation
+ direct damage from premature / exaggerated activation digestive enzymes.
= Cellular necrosis

In chronic disease pancreatic parenchyma fibrosis and loses function.

Exocrine and endocrine insufficiency

self sustaining feedback loop.

Question 4

Symptoms of ACUTE pancreatitis

Answer 4

Pain: Epigastric, dull achy and “boring through” into back and shoulder. Constant with some positional relief when sitting forward and upright.
N&V with anorexia & Diarrhoea
Fever, Tachycardia

RARELY: jaundice, SOB, bruising

Question 5

O/E in pancreatitis

Answer 5

Tender abdomen with guarding
distended 
diminished bowel sounds 
Jaundiced 
Bruising in peri-umbilical region (Cullen's sign) and flank (Grey-Turner sign)

Question 6

Presentation of CHRONIC Pancreatitis

Answer 6

Very Variable, 
Middle Aged M>F 
Pain: 
Relapsing remitting (A) or constant (B)
Diarrhoea and Steattorrhoea 
Weight loss 
General Illness with malaise
Diabetes

Question 7

Investigations to confirm Pancreatitis

Answer 7

BLOODS:
Serum Amylase >3XLimit at 24hrs
Serum Lipase
CRP
Ca
BM
FBC
LFT
U&E

FAECAL ELASTASE + URINE AMYLASE!!!!!

IMAGING:
CXR
US
Contrast CT Abdo
MR(I)CP / ERCP

Question 8

Management of acute pancreatitis

Answer 8

1. ABCDE
2. Assess severity using Glasgow/APACHE scores
3. Fluids: IVI + Catheter + hourly BP
4. GI control: Nil by mouth, NG tube, NE suction, Feeding (NJ) Antiemetics
5. Analgesia PETHIDINE / MORPHINE
6. Antibiotics IMIPENIM
7. Supportive Care: observations, low threshold for ITU
8. Treat cause
9. Surgical debridement of necrosis

Question 9

Management of CHRONIC pancreatitis

Answer 9

1. LIFESTYLE: abstain from alcohol, low fat diet
2. ANALGESIA: complicated regime of paracetemol, opiates and benzos
3. ENZYME REPLACEMENT: vitamins, calcium, insulin, creon, pancrease
4. ACID: H2 blockers and PPI
5. ENDOSCOPY: duct stenting, proximal stenosis, decompression, stone removal, ECSWL (shockwave)
6. SURGERY: sphincteroplasty, drainage, resection, pancreotomy.