Acute Pancreatitis Flashcards
Aetiology of acute pancreatitis
Duct obstruction: gallstones, trauma, tumours
Metabolic/toxic: alcohol, drugs, hypercalcaemia, hyperlipidaemia
Poor blood supply : shock, hypothermia
Infection/inflammation: viruses e.g. mumps
Obstruction: Gallstone stuck distal to where the common bile duct and pancreatic ducts join → reflux of bile up the pancreatic duct → damage to acini and release of proenzymes → become activated
Alcohol → spasm/oedema of the sphincter of Oddi → formation of protein-rich pancreatic fluid → obstructs the pancreatic ducts
All other causes cause direct acinar injury
(Gallstones (50%)
Ethanol (33%)
Trauma
Steroids
Mumps
Autoimmune
Scorpion bite
Hyper-calcaemia/-lipidaemia
ERCP
Drugs (thiazides))
Risk factors for pancreatitis
Middle aged women
Young to middle-aged men
Gallstones
Alcohol
Hypertriglyceridaemia
Causative drugs e.g. azathioprine, thiazide diuretics, furosemide, sulfonamides, tetracyclines, oestrogen
ERCP
Trauma
SLE, Sjrogen’s
Hypercalcaemia
Mumps
Symptoms of acute pancreatitis
Epigastric pain
- Relived sitting forward
- Radiates to the back
- Worse on movement
Nausea and vomiting
Symptoms of pleural effusion: SOB, dry cough, pain, tightness
Anorexia
Dyspnoea
Jaundice
Signs of acute pancreatitis on examination
Obs
- Fever
- Shock - tachycardia, tachypnoea
General
- Signs of hypovolaemia
- Ischaemic (Purtscher) retinopathy (rare)
Abdo
- Epigastric tenderness
- Reduced bowel sounds on auscultation
- Cullen’s signs - umbilical bruising
- Grey Turner’s sign - bruising in the flanks (posterior), late sign
Investigations for pancreatitis
Amylase: raised 3x UL
Lipase: more sensitive and specific
- Cross match, G&S
- CRP/ESR
Severity grading:
- FBC
- U&Es
- Bone profile
- ABG
- LDH
- Albumin
- Glucose
US abdomen: visualise for inflammation + assess for gallstones
CXR: ?pleural effusion, ARDS
CTAP: diagnosis
MRCP: ?gallstones
How is pancreatitis graded
Modified Glasgow Imrie score
(PANCREAS)
PaO2 <8
Age >55
Neutrophils (WCC>15)
Calcium <2
uRea >16
Enzymes LDH >600
Albumin
Sugar >10
Management for acute pancreatitis
- fluid resus 1 hourly → 2h → 4h → 6h
- analgesia + anti-emetic
- Supportive
- sats low → oxygen
- Vomiting → NG tube (Ryles)
- nutritional support - catheter for fluid monitoring
- Thromboprophylaxis
Hypocalcaemia - replacement
Infection - IV Abs
Gallstone - ERCP, sphincterectomy
Alcohol- thiamine, vit B
Necrotising: Abx, IR drain, necrosectomy
What is used to assess organ failure in pancreatitis
Marshall score
Mild = no organ failure
Moderate = organ failre <48h
Early complications of acute pancreatitis
Early mortality caused by SIRS/multi-organ failure
Malabsorption (lipases not produced)
Multiorgan dysfunction
Sepsis
Renal failure
ARDS
DIC
Late complications of acute pancreatitis
Local:
- Peripancreatic fluid collections (most common)
- Pancreatic necrosis
- Pseudocyst (mx: observe (12w) → cystogastrostomy / aspiration)
- Abscess: due to infection of pseudocyst, (mx: trans-gastric drainage / endoscopic drainage)
- Pancreatic haemorrhage
- Ascites
- Pseudoaneurysm
- Venous thrombosis
- Chronic pancreatitis
- Enteropancreatic fistulae
Systemic:
- Diabetes mellitus (late stage as endocrine parts survive much longer than exocrine components)
- Hypocalcaemia
- Hypoglycaemia
Pleural effusions - exudative
Prognosis for acute pancreatitis
Dependent on severity
Mortality of 50% for haemorrhagic pancreatitis
Mortality 5%, rising to 35% for patients with severe disease
20% follow severe fulminating course with high mortality
80% run milder course with 5% mortality
Men with alcoholic pancreatitis much higher risk of developing chronic pancreatitis
Features of IgG4 related disease
Autoimmune pancreatitis
large numbers of IgG4 positive plasma cells
These patients respond very well to steroids
