Acute pancreatitis

Question 1

What is acute pancreatitis?

Answer 1

Acute pancreatitis refers to acute inflammation of the pancreas

Question 2

What is the epidemiology?

Answer 2

In the United Kingdom, the prevalence of pancreatitis is around 56 cases per 100,000 annually.2

Though it is mild in most people (mortality <1%), patients can deteriorate quickly. There is a high mortality rate (~15%) in patients with severe pancreatitis.

Question 3

True or false: pancreatic function typically returns to normal after acute pancreatitis

Answer 3

true

Question 4

What are the three main causes of acute pancreatitis?

Answer 4

1) gallstones
2) alcohol
3) post-endoscopic retrograde cholangiopancreatography

Question 5

What does ERCP stand for?

Answer 5

endoscopic retrograde cholangiopancreatography

Question 6

Describe how gallstones can cause acute pancreatitis: (2)

Answer 6

1) gallstones get trapped at the ampulla of Vater, blocking the flow of bile and pancreatic juice into the duodenum

2) reflux of bile into the pancreatic duct and prevention of pancreatic juice containing enzymes from being excreted results in inflammation of the pancreas

Question 7

In what two patient demographics is gallstone pancreatitis more common?

Answer 7

1. women
2. elderly

Question 8

What mnemonic can be used to recite the causes of acute pancreatitis?

Answer 8

I GET SMASHED

Question 9

Using the mnemonic I GET SMASHED, give the causes of acute pancreatits:

Answer 9

1) Idiopathic
2) Gallstones
3) Ethanol
4) Trauma
5) Steroids
6) Mumps
7) Autoimmune
8) Scorpion sting
9) Hyperlipidaemia
10) ERCP
11) drugs

Question 10

Name 3 drugs that can cause acute pancreatitis:

Answer 10

1) furosemide
2) thiazide
3) azathioprine

Question 11

What digestive enzyme causes most of the damage in acute pancreatitis?

Answer 11

trypsin

Question 12

Give 4 clinical symptoms seen in acute pancreatitis:

Answer 12

1. Severe epigastric pain that radiates through to the back
2. associated vomiting
3. abdominal tenderness
4. systemically unwell (low grade fever, tachycardia)

Question 13

What is cullen’s sign?

Answer 13

Bruising at the umbilicus due to retroperitoneal bleed seen in severe necrotising pancreatitis

Question 14

What is grey turner’s sign?

Answer 14

Bruising at the flank due to retroperitoneal bleed seen in severe necrotising pancreatitis.

Question 15

Give two examination findings associated with acute pancreatitis:

Answer 15

1) abdominal tenderness and guarding
2) reduced or absent bowel sounds

Question 16

What serum test is extremely sensitive to acute pancreatitis?

Answer 16

serum amylase

Question 17

After how many days does serum amylase return back to normal levels following acute pancreatitis?

Answer 17

3-5 days (late presentations can therefore be missed)

Question 18

Name 3 specific blood tests used to monitor inflammation of the pancreas:

Answer 18

1) serum amylase
2) serum lipase
3) CRP

Question 19

Which is elevated for longer in acute pancreatitis, serum amylase or serum lipase?

Answer 19

serum lipase

Question 20

Name 6 baseline investigations used to manage abdominal pain which should be repeated every 24 hours:

Answer 20

1) FBC
2) U&Es
3) serum creatinine
4) LFTs
5) blood glucose
6) ABG

Question 21

What imaging method is used to identify gallstones?

Answer 21

abdominal ultrasound

Question 22

What imaging method is used to assess pancreatic necrosis?

Answer 22

CT abdomen

Question 23

After how many hours after an acute pancreatic episode should CT abdomen be used to assess the extent of pancreatic necrosis?

Answer 23

72 hours

Question 24

Why is an erect CXR offered to all those with a suspected acute pancreatitis?

Answer 24

to exclude gastroduodenal perforation (which can also raise serum amylase)

Question 25

What is systemic inflammatory response syndrome?

Answer 25

2 or more of the following in the context of inflammation:
1) fever/hypothermia
2) tachycardia
3) tachypnoea
4) leukocytosis/leukopenia

Question 26

What is the Glasgow score used for?

Answer 26

to assess the severity of pancreatitis

Question 27

Give the 8 features of the Glasgow score:

Answer 27

1 point for each of the following:
1) PaO2 <8kPa
2) Age >55
3) Neutrophils WBC >15
4) Calcium <2
5) urea >16
6) enzymes (LDH >600 or AST/ALT >200)
7) albumin <32
8) sugar (glucose >10)

Question 28

Describe the Atlanta criteria:

Answer 28

classes acute pancreatitis as mild, moderate or severe using the absence or presence of organ failure

Question 29

Describe the Marshall scoring system:

Answer 29

gives points from 0-4 based on blood pressure, serum creatinine and PO2

Question 30

Describe the Ranson scoring system:

Answer 30

similar to the Glasgow criteria but looks at some additional biochemistry such as aminotransferase, haematocrit fall and base deficit

Question 31

Name 4 pancreatic severity/ prognosis scoring systems:

Answer 31

1) Glasgow score
2) Marshall scoring system
3) Atlanta criteria
4) Ranson scoring system

Question 32

True or false: moderate or severe cases of acute pancreatitis should be admitted to the intensive care unit

Answer 32

True

Question 33

Give 8 points of management for acute pancreatitis:

Answer 33

1) initial resuscitation (ABCDE)
2) IV fluids
3) nil by mouth (NG)
4) Analgesia
5) careful monitoring using scoring systems
6) treatment of gallstones
7) antibiotics (if evidence of infected necrotic area or abscess)
8) treatment of complications e.g. drain abscess

Question 34

Give 2 ways in which you can remove gallstones?

Answer 34

1) cholecystectomy
2) ERCP

Question 35

What is the preferred analgesic for acute pancreatitis?

Answer 35

tramadol

Question 36

Give 2 systemic complications of acute pancreatitis:

Answer 36

1) systemic inflammatory response syndrome
2) multiorgan dysfunction

Question 37

Give 4 pancreatic complications of acute pancreatitis:

Answer 37

1) pancreatic fluid collections
2) necrosis
3) pancreatic abscess
4) pancreatic pseudocyst (forms 4-6 weeks after)

Question 38

Give 3 lung complications of acute pancreatitis:

Answer 38

1) pleural effusion
2) acute respiratory distress syndrome
3) pneumonia

Question 39

Give a kidney-related complication of acute pancreatitis:

Answer 39

AKI

Question 40

Give 2 GI-related complications of acute pancreatitis:

Answer 40

1) GI bleed for gastric or duodenal erosions
2) paralytic ileus

Question 41

Give 3 hepatobiliary complications of acute pancreatitis:

Answer 41

1) jaundice
2) common bile duct obstruction
3) portal vein thrombosis

Question 42

Give 3 metabolic complications of acute pancreatitis:

Answer 42

1) hypoglycaemia
2) hyperglycaemia
3) hypocalcaemia

Question 43

Give a haematological complication of acute pancreatitis:

Answer 43

disseminated intravascular coagulation (DIC)

Question 44

What is the most common cause of chronic pancreatitis?

Answer 44

Alcohol

Question 45

Describe how alcohol can cause pancreatitis: (2)

Answer 45

1) ethanol increases intracellular calcium which promotes trypsinogen activation to trypsin
2) this increases intrapancreatic enzyme activity, causing calcification and ductal obstruction

Question 46

Give 3 genetic mutations associated with chronic pancreatitis:

Answer 46

1) SPINK-1
2) CASR
3) CFTR

Question 47

Give 4 complications associated with chronic pancreatitis:

Answer 47

1) loss of endocrine function (lack of insulin)
2) loss of exocrine function (lack of enzymes)
3) chronic epigastric pain
4) damage and strictures to the duct system resulting in obstruction

Question 48

Give 5 treatment methods for chronic pancreatitis:

Answer 48

1) abstinence from alcohol and smoking
2) analgesia
3) enzyme replacement (Creon)
4) insulin
5) ERCP with stenting to treat strictures and obstruction