Acute Pancreatitis

Question 1

Definition

Answer 1

Occurs due to inflammation of the pancreas and has a variety of different causes

Question 2

Epidemiology

Answer 2

Advanced age
Afro-Caribbean ethnicity
Sex:
- Alcohol related = MALES
- Gall stones related = FEMALES

Question 3

Aetiology (I GET SMASHED)

Answer 3

• Idiopathic
  - Gallstones (MC)
  - Ethanol abuse (Alcohol)
• Trauma (usually blunt abdominal trauma)
• Scorpion and spider bites
• Mumps virus (+ measles, coxsackie B4, mycoplasma)
• Autoimmune (SLE, Sjogren’s)
• Steroids
• Hypercalcaemia, Hyperlipidaemia
• ERCP (also other procedures e.g gastric surgery)
• Drugs (valproate, azathioprine, thiazide diuretics, tetracyclines, mesalazine, oestrogen, sitagliptin, vildagliptin)

Question 4

Pathophysiology

Answer 4

autodigestion of pancreatic tissue by the pancreatic enzymes, leading to necrosis

Question 5

Signs

Answer 5

Abdominal tenderness and guarding
Abdominal distension: common mainly due to leakage of fluid into retroperitoneum
Tachycardic +/or hypotensive
Jaundice
Pyrexic
Cullen’s sign: periumbilical bleeding secondary to intraperitoneal haemorrhage
Grey Turners sign: flank bleeding secondary to retroperitoneal haemorrhage = bruising in flank regions

Question 6

Symptoms

Answer 6

SUDDEN SEVERE EPIGASTRIC PAIN RADIATING TO BACK: RUQ, or LUQ
Nausea, vomiting and anorexia (COMMON)
Steatorrhea
Poor urinary output: due to insensible fluid loss, third-spacing and vomiting

Question 7

Diagnosis

Answer 7

• Serum amylase
  = > 3 times the upper limit of normal
• Serum lipase (more specific, less routine)
  = longer half-life than amylase and useful for late presentations > 24 hours
• Early ultrasound imaging is important to assess the aetiology as this may affect management - e.g. patients with gallstones/biliary obstruction
  = diagnosis can be made without imaging if characteristic pain + amylase/lipase

Question 8

Scoring system

Answer 8

MODIFIED GLASGOW SCORE: 3 points or more within the first 48 hours should be considered for referral to high-dependency care
P - pO2 <8kPa
A - Age > 55 years
N - Neutrophils - WCC > 15x109/L
C - Calcium <2mmol/L
R - Renal function = urea >16mmol/L
E - enzymes = AST >200U/L or LDH>600U/L
A - Albumin <32g/L
S - Sugar (Blood sugar >10mmol/L
Ranson’s criteria for pancreatitis mortality from initial and 48 hour lab values
APACHE II = assess severity within 24 hours = non specific for acute pancreatitis

Question 9

Treatment

Answer 9

ANTIBIOTICS NOT ROUTINELY RECOMMENDED
Acute emergency
FIRST LINE = IV FLUIDS
- Nil by mouth (NG feeding tube)
- Analgesia e.g. IV morphine
- Catheterise = monitor urine output
- O2 <94% supplementary oxygen required
Specific management:
- ERCP: gall stones, and cholangitis
- Cholecystectomy
- Alcohol cessation and withdrawal management
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Question 10

Complication

Answer 10

SIRS (systemically inflammatory response syndrome) = 2 + of
Tachycardia (90+ bpm)
Tachypnoea (20+ RR)
Pyrexia (38+)
WCC increased
Chronic pancreatitis
Pancreatic pseudocysts