Acute pancreatitis

Question 1

what is pancreatitis and what can cause it?

Answer 1

inflammation of the pancreas

Pneumonic: ‘I GET SMASHED’

• idiopathic
• gall stone pathology
• ethanol (alcohol)
• trauma
• scorpion sting
• mumps
• steroid
• autoimmune conditions e.g. SLE
• hypercalcaemia
• ERCP
• drugs

Drugs pneumonic ‘SAND’

• sulphonamides
• azathioprine
• NSAIDs
• Diuretics

other causes:
ampullary or pancreatic cancer, congenital abnormalities, hypertriglyceridemia

Question 2

explain the pathophysiology of pancreatitis

Answer 2

activation of zymogens (trypsin) –> pancreatic inflammatory response –> interstitial oedematous pancreatitis
increasing severity –> extensive local damage and active cytokines and complement –> SIRS and organ failure
as it gets more severe
ischemia and reperfusion –> necrosis (end-stage pancreatitis) at this stage the peritoneal cavity is full of dark, blood-stained inflammatory exudate

also, hypocalcemia develops:
lipase digests fat (fat necrosis) –> free fatty acids –> react with calcium (saponification) –> form chalky deposit in fat tissue

Question 3

what are the clinical features of acute pancreatitis?

Answer 3

symptoms:
- severe epigastric pain radiating to the back
- nausea & vomiting
- restless (trying to find a comfortable position) –> relieved by leaning forward - pancreatic position
- tetany (hypocalcemia)

signs:
- tender epigastric region
(guarding and rigid abdomen in severe)
- Grey Turner’s + Cullen’s –> retroperitoneal hemorrhage

Question 4

what investigation would you do for suspected pancreatitis and what would the findings be?
(split into lab test and imaging)

Answer 4

lab tests
serum amylase: diagnostic if 3x normal upper limit
LFTs: raised ALT in gallstone obstruction
serum lipase: more accurate than amylase - remains elevated for longer

imaging
USS - identify possible gall stone
CXR - pleural effusion or signs of ARDS(ground glass appearance)
contrast CT - if blood test and USS are inconclusive (typically only picks up severe pancreatitis 4+ days after onset)
ERCP: done in patients for whom we didn’t identify an underlying cause –> after recovery

look at ct and x-ray online

Question 5

what are the two categories of acute pancreatitis and what scoring system is used to differentiate between the two?

Answer 5

Mild and Severe acute pancreatitis 
the scoring system is known as the Glasgow scoring system: 
pneumonic = 'PANCREAS'
PaO2 : < 8kpa or 60mmHg 
Age: > 55
Neutrophil count: > 15 x 10^9 /L
Ca: < 2 mmol
Raised plasma urea: > 16mmol 
Enzyme (plama LDH) > 600 
Albumin < 32 g/l
Sugar(plasma glucose): > 10mmol

three or more = severe

Question 6

what is the management of pancreatitis?

Answer 6

Mild:

• IV fluid resuscitation (recommend crystalloid (preferably Hartmanns) at 250-500ml/hr
• analgesia: opioids
• later management to deal with cause e.g ERCP for gallstones/ cholecystectomy

severe:

• same as above
• NG tube if vomiting
• TPN if paralytic ileus develops
• catheterization: accurately monitor urine output
• admission to ICU

if gall stone pathology is identified, sphincterotomy of the sphincter of Oddi should be performed within 72 hours

Question 7

what are the complications of acute pancreatitis??

Answer 7

systemic :

• disseminated intravascular coagulation (DIC)
• acute respiratory distress syndrome (ARDS)
• hypocalcaemia
• hyperglycaemia
• hypovolemic shock and multiorgan faiulure

local:
- pancreatic necrosis and infection
- pancreatic pseudocyst
- pancreatic abscess
- bowel ischemia
- intestinal malabsorption - pancreatic insufficiency

Question 8

explain how pancreatic necrosis and infection develop with pancreatitis.
also, how is it identified?
how is it treated?

Answer 8

seen on ct as the necrotic pancreas doesn’t opacify due to lack of blood supply.
persistent inflammation for more thane 7-10 days
often this gets infected within two weeks by GI bacteria

identified by aspiration under ct guidance

operative drainage, debridement, and irrigation are often necessary

Question 9

explain what a pancreatic pseudocyst is
what are the symptoms?
how is it identified?
how is it managed?

Answer 9

collection of pancreatic enzymes, inflammatory fluid, and necrotic debris –> usually int he lesser sac
can occur even after a mild attack and can be the size of a football–> palpable as a mass

may present with jaundice or biliary obstruction due to mass effect
prone to hemorrhage or rupture
CT scanning is the imaging of choice

50% will resolve spontaneously however over 6 weeks = less likely
surgical debridement or endoscopic drainage

Question 10

why might amylase not be raised in acute pancreatitis?

Answer 10

rarely the inflammation destroys the gland, therefore, no amylase production. also, amylase tends to shoot up on onset and then drop back down to normal therefore if pt present late the amylase level may have dropped.