Acute and chronic pancreatitis Flashcards
(40 cards)
What is the pathogenesis of gallstone pancreatitis?
Obstruction of pancreatic duct by gall stones and biliary sludge => backup of pancreatic enzymes => autodigestion of pancreas.
What is Inglefinger’s sign?
Pain worse when supine, relieved when sitting forwards
What are the clinical features of pancreatitis?
- Pain (epigastric radiating to back; non-colicky);
- N/V
- Abdo distension due to paralytic ileus
- peritoneal signs
- jaundice: compression or obstruction of bile duct
- fever (chemical; not due to infection)
- tetany: transient hypocalcemia
- ARDS
Investigation results in gallstone pancreatitis?
- High amylase (greater than EtOH pancreatitis)
- Lipase
- Leukocytosis
- Elevated AST/ALT indicates gallstone aetiology of pancreatitis
- U/S => multiple stones, oedematous pancreas
- CXR/AXR/CT (for complications)
Treatment of gallstone pancreatitis?
- NBM
- Hydration
- Analgesia
- ABx (for severe cases necrotising pancreatitis, signs of sepsis)
- Stone generally passes. Cholecystectomy recommended.
Complications of gallstone pancreatitis?
- Pseudocyst
- Abscess/infection, necrosis
- Diabetes
What are the indications for surgical management of chronic pancreatitis?
- Failure of medical treatment
- Debilitating abdominal pain
- Pseudocyst complications: persistence, haemorrhage, infection, rupture
- CBD obstruction, duodenal obstruction
- Splenic vein obstruction with variceal haemorrhage
- Rule out pancreatic Ca
- anatomical abnormality precipitating recurrence
Minimally invasive options for management of chronic pancreatitis?
- Endoscopic duct decompression
- Extracorporeal shockwave lithotripsy (if duct stones)
- Celiac plexus block
Surgical options for Mx chronic pancreatitis?
- Drainage procedures e.g. Puestow (longitudinal pancreatojejunostomy)
- Pancreatectomy
- Denervation of celiac ganglion and splanchnic nerves
When are drainage procedures the most effective surgical management of chronic pancreatitis?
Only effective if ductal system is dilated
What are the types of pancreatectomy?
- Proximal disease = Whipple (pancreatoduodenectomy)
- Distal disease = pancreatectomy +/- Roux-en-Y pancreatojejunostomy
What is the aetiology of acute pancreatitis?
I GET SMASHED Idiopathic Gallstones (45%) Ethanol (35%) Tumours Scorpion stings Microbiological Autoimmune Surgery/Trauma Hyperlipidemia/hypercalcemia/hypothermia Emobli/ischaemia Drugs/toxins
Which tumours can precipitate acute pancreatitis?
Pancreas, ampulla, choledochocele
Microbiological causes of pancreatitis?
Bacterial: mycoplasma, campylobacter, TB
Viral: mumps, rubella, varicella, viral hepatitis
AI causes of acute pancreatitis?
SLE, polyarteritis nodosa, Crohn’s
Surgical/traumatic causes of acute pancreatitis?
- Manipulation of sphincter of Oddi (e.g. ERCP)
- Post-cardiac surgery
- Blunt trauma to abdomen
- Penetrating peptic ulcer
Drugs precipitating acute pancreatitis?
Azathioprine, mercaptopurine, frusemide, oestrogens, methyldopa, H2-blockers, valproic acid, ABx, paracetamol, salicylates, methanol, organophosphates, steroids.
Pathogenesis of acute pancreatitis?
Activation of proteolytic enzymes within pancreatic cells, starting with trypsin, leading to local and systemic inflammatory response
Pathology of mild interstitial pancreatitis?
Peri-pancreatic fat necrosis and interstitial oedema.
Pathology of severe (necrotic) pancreatitis?
- Extensive peri-pancreatic and intra-pancreatic fat necrosis.
- Parenchymal necrosis and haemorrhage (infection in 60%)
Describe pancreatic enzymes in terms of sensitivity and specificity.
Increased Amylase: sensitive, not specific.
Increased Lipase: higher sensitivity and specificity, elevated for longer.
Ix in acute pancreatitis?
- Increased serum pancreatic enzymes (amylase, lipase)
- ALT >100 suggests biliary pancreatitis
- Increased WBC, glucose, low calcium
- Imaging: CT most useful
Imaging in acute pancreatitis?
- Xray: sentinel loop (dilated proximal jejunum), calcification, colon cut off sign (colonic spasm)
- U/S: best for biliary tree
- CT Contrast: contrast only seen in viable pancreatic tissue
- ERCP: if cause uncertain. Assess for duct stone, pancreatic/ampullary tumour.
Complications of severe pancreatitis?
- Shock
- Pulmonary oedema
- Multi organ dysfunction syndrome
- GI ulceration due to stress
- Death
