Acute Pancreatitis Flashcards
What is it?
Acute inflammation of the pancreas
May be associated with multi-organ failure in severe cases
How does it present?
Upper abdominal pain (epigastric region sometimes radiating to back)
Nausea + vomiting
Fever (pyrexia)
How is it diagnosed?
Elevation of serum amylase (>4x upper limit of normal)
What are some causes?
ALCOHOL EXCESS GALLSTONES Post-ERCP Auto-immune Hyperlipidaemia Hypercalcaemia Hypothermia Steroids
What is the underlying pathogenesis?
Primary insult
Release of activated pancreatic enzymes
Autodigestion: proinflammatory cytokines -> oedema, fat necrosis, haemorrhage
What are some other clinical features that may be present?
Tachycardia
Hypovolaemic shock
Jaundice
Paralytic ileus
Oliguria, acute renal failure
Retroperitoneal haemorrhage: Grey Turner’s & Cullen’s signs
Hypoxia (respiratory failure in severe cases)
Hyperglycaemia (occasionally diabetic coma)
Effusions (ascitic + pleural: high amylase)
What can be done in gallstone caused acute pancreatitis?
Endoscopic ultrasound (visualises the bile duct and gallbladder given its proximity when imaging from the duodenum: in cases of suspected biliary pancreatitis it selects patients for ERCP) MRCP (non-invasive: MRI) may be used to look for the presence of stones
Endoscopic retrograde cholangiopancreatography (only do ERCP if proven pancreatitis caused by gallstones, they are the only ones that will benefit from ERCP)
What are the investigations into acute pancreatitis?
Blood tests: amylase/lipase, FBC, U&Es, LFTs, Ca2+, glucose, arterial blood gases, lipids, coagulation screen
AXR (ileus) & CXR (pleural effusion)
Abdominal ultrasound (pancreatic oedema, gallstones, pseudocyst)
CT scan (contrast enhanced): can be used to assess severity and complications
What is mild and severe acute pancreatitis?
Mild: associated with minimal organ dysfunction and uneventful recovery
Severe: associated with organ failure or local complication
What is used to assess the severity of acute pancreatitis?
Glasgow criteria (PANCREAS): score > 3 = severe pancreatitis (within 48 hrs of admission) CRP > 150mg/l also indicates severe pancreatitis Severe pancreatitis = ICU
What does the Glasgow criteria include?
White cell count >15 x 109/l Blood glucose >10 mmol/l Blood urea >16mmol/l AST >200 iu/l LDH >600 iu/l Serum albumin <32 g/l Serum calcium <2.0 mmol/l Arterial PO2 <7.5 kPa
What is the general management in acute pancreatitis?
Analgesia (pethidine, indomethacin, morphine)
Intravenous fluids
Blood transfusion (Hb <10g/dl)
Renal support = monitor urine output (catheter)
Naso-gastric tube
Respiratory support = oxygen
May need insulin
Rarely require calcium supplements
Nutrition (enteral or parenteral) in severe cases
What is the specific management in acute pancreatitis?
Antibiotics
Diagnosis of infection (CT guided FNA of pancreatic necrosis)
Nutrition (very important, despite previous theories about ‘resting the gland’, enteral feeding is superior to parenteral feeding, nasogastric feeding is tolerable in most cases, and not associated with any increase in complications)
Manipulation of the inflammatory response
Pancreatic necrosis (CT guided aspiration) -> antibiotics ± surgery
Gallstones (EUS/MRCP/ERCP/cholecystectomy)
What is the complications involved in acute pancreatitis?
Pseudocyst: fluid collection without an epithelial lining
Abscess: drainage + antibiotics
Necrosis
How does a pseudocyst present, get investigated, get managed and what are the complications that can arise?
- Symptoms can include nausea + vomiting, loss of appetite, pain and mass felt
- Diagnosed by ultrasound or CT scan
- Complications include jaundice, infection, haemorrhage, rupture
- <6cm diameter = resolve spontaneously
- Endoscopic drainage or surgery if persistent pain or complications
