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HBP > Acute Pancreatitis > Flashcards

Acute Pancreatitis Flashcards

1
Q

(Atlanta criteria) Definition of diagnosis of acute pancreatitis

A

Two of the following
Clinical: abdominal pain consistent with pancreatitis
Biochemical: Amylase/ Lipase >2/3 upper limit
Radiological features of acute pancreatitis

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2
Q

(Atlanta criteria) Definition of types of acute pancreatitis

A

1) Interstitial oedematous pancreatitis
2) Necrotising pancreatitis

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3
Q

Atlanta classification of severity

A

Mild: no complications/organ failure
Moderate Severe: local/systemic complications + no persistent organ failure
Severe: Local/systemic complications + organ failure

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4
Q

Definition of systemic complications in (Atlanta classification)

A

exacerbation of pre-existing comorbidity, such as coronary artery disease or chronic lung disease

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5
Q

Definition of local complications (Revised Atlanta)

A

inflammatory or necrotic changes around pancreas (pericollection, pseudocyst, acute necrotic collection, walled off necrosis)

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6
Q

Pros and cons of scoring systems

A
  • Ranson: +readily measurable, - lower predictive score 60%, -initially for alcoholic pancreatitis, two time measurements can delay prediction
  • APACHE: readily measurable, can be repeated at any time, need complicated measurements more feasible in ICU,
  • Glasglow: readily available,, low predictive score, original for alcoholic pancreatitis
  • CRP: acute phase protein, peaks at 36 hours after onset (>150 indicates severity)
  • Balthazar:
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7
Q

GA LAW

A

Glucose>10mmol

Age >55

LDH >350 IU/L

AST >250 IU/L

White cell > 16

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8
Q

Acute Pancreatic Fluid Collection (APFC)

A

peripancreatic fluid associated with interstitial oedematous pancreatitis with no necrosis. Within first 4 weeks after onset

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9
Q

Pancreatic Pseudocyst

A

-encapsulated fluid collection
-well defined inflammatory wall
-minimal / no necrosis
occurs > 4 weeks after IEP

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10
Q

Acute necrotic collection

A

collection containing variable amounts of fluid + necrosis involving pancreatic parenchyma + peripancreatic tissue

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11
Q

Walled Off Necrosis

A

mature encapsulated collection
well-defined inflammatory wall
> 4 weeks after onset

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12
Q

C HOBBS

A

Calcium < 2

Hematocrit drop >10%

Oxygen (RA paAO2) < 8kPa

Base deficit > 4

BUN increase < 1.8

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13
Q

Ranson’s score

A

At 0 hours:
Age> 55
WCC > 16
Glucose >11.1 mmol/L
LDH >350 IU/L
AST >250 IU/L

At 48 hours:
Hematocrit fall >10%
BUN rise 5mg/dl
pO2 < 60mmHg
BE >4 mmol/L
Fluid sequestration >6000 mL

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14
Q

APACHE II Physiological parameters

A

GCS
Temperature
Mean arterial pressure
Heart rate
Respiratory rate

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15
Q

APACHE II Biochemical parameters

A

White cell count
Sodium
Potassium
PaO2
Creatinine
Hematocrit
pH

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16
Q

CT Severity Index (Balthazar score)
ABCDE

A

A: normal
B: enlarged pancreas
C: pancreatic inflammation/peripancreatic fat
D: single peripancreatic fluidc collection
E: 2 or more fluid collections

17
Q

Indication for intervention in necrotizing pancreatitis

A

1) documented infected NP with clinical deterioration
2) ongoing organ failure for several weeks

18
Q

Step up approach

A

Treatment of infected pancreatic necrosis with initial intervention via endoscopic/ percutaneous drainage with progression to retroperitoneal debridement with lavage

19
Q

Main causes of pancreatitis

A
  • 3 main causes
    • Gallstone
    • Alcoholic
    • Idiopathic
20
Q

Indication for intervention of pseudocyst

A

1) Symptomatic
2) Complications: infection, obstruction, haemorrhage, fistulation, pancreatic ascites
3) Growing size
4) Cystic neoplasm suspected

21
Q

Timing of cholecystectomy after resolution of pancreatitis:

1) mild
2) complications

A

1) during index admission
2) after collections subsided

22
Q

What are the indications for antibiotics in pancreatitis

A

No role for prophylactic antibiotics

1) infected necrotizing pancreatitis
2) suspected secondary infection

23
Q

Signs of infected necrotizing pancreatitis

A

Gas locules in pancreatic collection
Fever
Bacteremia
Worsening leukocytosis
Clinical deterioration

24
Q

Initial management of pancreatitis

A
  • Close monitoring +/- ICU for organ support
  • Fluid resuscitation
  • Pain control
  • Nutrition
  • ERCP for concomitant acute cholangitis
25
Q

Types of necrotizing pancreatitis

A
  • Sterile pancreatic or peripancreatic necrosis
  • Infected pancreatic necrosis
26
Q

Step up approach for surgical management of infected pancreatic necrosis

A
  • Percutaneous / endoscopic drainage
  • Endoscopic necrosectomy
  • Video assited retroperitoneal necrosectomy
  • Open retroperitoneal necrosectomy
  • Open necrosectomy (if uncontrolled sepsis)
27
Q

What types of pancreatic fluid collection are there?

A
  • Acute peripancreatic fluid collection
  • Pancreatic pseudocyst
  • Acute necrotic collection
  • Walled off necrosis
28
Q

Other causes of pancreatitis

A
  • Post ERCP
  • Trauma related
  • Metabolic: hyperlipidemia, hypercalcemia
  • Infection: mumps, TB
  • Tumor
  • Autoimmune pancreatitis
29
Q

What are the CT features of interstitial edematous pancreatitis?

A
  • Focal or diffuse pancreatic enlargement
  • Peripancreatic stranding
30
Q

CT features of AFPC

A

homogenous fluid-attenuated collection that lack a wall

always peripancreatic location

conform to retroperitoneal spaces

31
Q

CT features of acute necrotic collection

A

They are poorly organized necrotic collections, therefore often

  • multiple
  • loculated
  • presence of non-liquified debris (distinguishing factor from AFC), ex solid-appearing components of fat lobules
  • often seen in lesser sac and pararenal spaces, can track down to pelvis
32
Q

CT features of wall off necrosis

A
  • organised
  • heterogeneous
  • gas-containing collections with thick enhancing wall
33
Q

Scores for assessment of disease severity

A
  • Ranson’s score
  • APACHE
  • CRP
  • Balthazar/ CT Severity Index
34
Q

PANTER trial

A

RCT for initial treatment of acute infected necrotizing pancreatitis

Comparison: Minimally invasive step up approach vs maximal necrosectomy by laparotomy

Outcome: reduces major morbidity and mortality

35
Q

Indication for intervention in NP

A

1) documented infected NP with clinical deterioration 2) ongoing organ failure for several weeks

HBP (5 decks)

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