Acute Pancreatitis Flashcards
Define acute pancreatitis. What are the types of severity?
A disorder of the exocrine pancreas, and is associated with acinar cell injury with local and systemic inflammatory responses.
What is the epidemiology of acute pancreatitis?
- Common
- Annual incidence 1/1000 in UK
- Peak age 60years
- Males
- Alcohol induced more common in white females
- Principal cause is gallstones
What are the risk factors for acute pancreatitis?
- Gallstones (biggest cause in UK)
- Ethanol (2nd)
What is the aetiology of acute pancreatitis?
Insult –> activation of pancreatic protoenzymes within duct/acini –> tissue damage and inflammation
What are the symptoms of acute pancreatitis?
- Abdominal pain/epigastric (relived by sitting forward, aggrevated by movement)
- Anorexia
- Nausea
- Vomiting
What are the 2 types of pancreatitis in terms of pathophysiology?
- Oedematous
- Haemorrhagic - can produce signs such as Cullen’s sign, Grey-Turner’s sign and Fox’s sign.
What are the signs of acute pancreatitis on examination?
- Epigastric tenderness
- Fever
- Shock, tachycardia, tachypnoea
- Reduced bowel sounds (due to ileus)
- If severe and haemorrhagic, Turner’s sign and Cullen’s sign
What investigations would you do for acute pancreatitis?
Bloods:
- Amylase/lipase high (usually x3 normal but does not correlate with severity, dip after first few days but remain elevated for 14 and 5 days respectively )
- FBC (high WCC)
- U&Es
- High glucose
- High CRP
- Reduced Ca
- LFTs (deranged in gallstone pancreatitis or alcohol)
- ABG (hypoxia or metabolic acidosis)
Imaging:
- USS - gallstones/ biliary dilatation
- Erect CXR - ?pleural effusion, exclude other causes
- AXR - exclude other acute abdomen
- CT scan - Balthazar score can be calculated from this to assess grade of pancreatitis and degree of necrosis
What 2 assessments of severity are used for acute pancreatitis?
- Modified Glasgow combined with CRP (>210mg/L)
- APACHE-II score
What is the medical management of acute pancreatitis?
Medical -
- Fluid and electrolyte resuscitation (Ringer’s lactate) - MAIN THERAPY - may reduce lactic acidosis
- Analgesia - IV opioids
- Nutritional support - NG tube if vomiting. Enteral feeding has lower complication and morbidity rates so offer to pts with moderate/severe acute pancreatitis
- Oxygen
- Anti-emetic - ondansetron
- Antibiotics should NOT be routinely given
Other:
- Ca and Mg replacement - calcium gluconate and magnesium sulfate
- Insulin
Other than medical management, how is acute pancreatitis treated?
- ERCP and sphincterotomy - within 72 hours for gallstone pancreatitis, cholangitis, jaundice, dilated CBD. Definitive management of gallstones on admission/within 2 weeks.
- Catheter drainage (percutaneous or endoscopic) - if fail to respond to antibiotics in infected pancreatic necrosis
- Nephrosectomy/debridement of all necrotic tissue - for patients who do not respond to drainage
What are the local, systemic and long term complications of acute pancreatitis?
- Local - necrosis, pseudocyst (>4 weeks), abscess, ascites (if high amylase content then can cause pleural effusion), pseudoaneurysm, venous thrombosis.
- Systemic - multi-organ dysfunction, sepsis, renal failure, ARDS, DIC, hypocalcaemia, diabetes
- Long term - chronic pancreatitis (w/ diabetes and malabsorption)
What is the prognosis for acute pancreatitis?
- 80% run mild disease course (with 5% mortality)
- 20% fulminating course with high mortality (infected pancreatic necrosis has 70% mortality)
What are the levels of severity of acute pancreatitis?
Severity // Organ failure // Local complications*
Mild: No // No
Moderate: No or transient (<48 hours) // Possible
Severe: Persistent (>48 hours) // Possible
*Local and systemic complications as seen on bloods and/or CT.
What are these signs in pancreatitis?
What score is used to grade pancreatitis based on CT?
Balthazar score
The differential diagnoses include which four of the following?
- Acute cholecystitis
- Acute pancreatitis
- Perforated duodenal ulcer
- Acute appendicitis
- Alcoholic gastritis
Which 2 investigations should you arrange before the patient leaves A&E?
- Ultrasound scan abdomen
- Serum amylase and lipase
- Barium meal
- MRCP (magnetic resonance cholangio pancreatography)
- Erect chest x-ray
- Abdominal x-ray
His serum amylase comes back at 450 IU/l and lipase at 560 IU/L. The ultrasound scan reveals a normal gallbladder. In addition the intra and extra hepatic biliary system are normal. Suboptimal views of the pancreas are obtained due to body habitus and bowel gas. The patient therefore undergoes a contrast CT scan which confirms the diagnosis of acute pancreatitis. Which three of the following should be the next steps in management?
- Start oral feeding
- Intravenous antbiotics
- Intravenous fluids
- Analgesia
- ERCP
- Blood gas analysis
- Blood cultures
he improves steadily and is discharged a few days later with normal liver function tests, serum amylase and lipase. He is strongly cautioned against further alcohol use. 2 weeks after his discharge he is readmitted with upper abdominal pain. He denies any further alcohol use. On examination his abdomen is distended. In addition he is very tender in the epigastric region. His WCC is 22 x109/L, amylase is 210 IU/L, lipase 97 IU/L. An initial ultrasound abdomen again shows suboptimal views of the pancreas. A CT scan abdomen shows a cystic lesion in the tail of the pancreas.What is the most likely diagnosis?
- Intraductal pancreatic mutinous neoplasm (IPMN)
- Pancreatic pseudocyst
- Pancreatic cancer
- Reactive lymph node
- Pancreatic abscess
- Pancreatic hemorrhage
Pancreatic pseudocysts can often be dealt with conservatively. However, if they were to be cause complications such as infection / obstruction they can be drained. Which two of the following techniques would be the first line methods for draining a pseudocyst?
- Laparotomy
- Endoscopic ultrasound (EUS)
- Gastroscopy
- CT guided Aspiration of the pseudocyst
- Laparoscopy
The patient is unfortunately lost to follow up and re-presents 10 year later, again with severe abdominal pain, weight loss and loose stools. He had a relapse of his alcohol about 5 years ago and is currently drinking about 4-5 units/day. On examination he is cachet. Initial lab work reveals: Blood glucose 12 mmol/l Amylase 45 IU/L Bilirubin 21 mmol/L Alkaline phosphatase 150 IU/L There are no stigmata of chronic liver disease. An abdominal x-ray shows calcification in the upper abdomen. The most likely cause of the elevated blood glucose and loose stools is what?:
- Dietary indiscretion
- Alcohol excess
- Coeliac disease
- Pancreatic insufficiency
- Recurrence of pseudocyst
How can you establish the diagnosis of pancreatic exocrine insufficiency?
- faecal calprotectin
- Faecal elastase
- Pancreatic CT scan
- ERCP
- SeHCAT scan
- MRCP
What is the treatment for pancreatic exocrine insufficiency:
- Loperamide
- Low dose oral steroid
- Cholestyramine
- Oral pancreatic enzyme replacement e.g. Creon
- Low fat diet
The differential diagnoses include which four of the following?
- Acute cholecystitis
- Acute pancreatitis
- Perforated duodenal ulcer
- Acute appendicitis
- Alcoholic gastritis
Which 2 investigations should you arrange before the patient leaves A&E?
- Ultrasound scan abdomen - seldom used in acute setting. CT scan is better for acute abdomen.
- Serum amylase and lipase - can confirm pancreatitis if above 1000. Serum lipase is not widely used.
- MRCP - may be useful later
- Erect chest x-ray - rules out perforated viscus
His serum amylase comes back at 450 IU/l and lipase at 560 IU/L. The ultrasound scan reveals a normal gallbladder. In addition the intra and extra hepatic biliary system are normal. Suboptimal views of the pancreas are obtained due to body habitus and bowel gas. The patient therefore undergoes a contrast CT scan which confirms the diagnosis of acute pancreatitis. Which three of the following should be the next steps in management?
- Intravenous fluids - . Large amounts of fluid may be lost in third spaces, and patients often require over 5 litres in 2-3 hours, however titrate fluids carefully to fluid status.
- Analgesia - pain in pancreatitis is considerable, causing splinting of the diaphragm and possible respiratory compromise
- Blood gas analysis - fundamental to pancreatitis scoring, which in turn guides management.
- Blood cultures, IV antibiotics not indicated as no signs of sepsis.
- ERCP not needed as gallstone pancreatitis not suspected
- Oral feeding in first 24hrs ameliorates course of pancreatitis. NG tube may help if vomiting.
he improves steadily and is discharged a few days later with normal liver function tests, serum amylase and lipase. He is strongly cautioned against further alcohol use. 2 weeks after his discharge he is readmitted with upper abdominal pain. He denies any further alcohol use. On examination his abdomen is distended. In addition he is very tender in the epigastric region. His WCC is 22 x109/L, amylase is 210 IU/L, lipase 97 IU/L. An initial ultrasound abdomen again shows suboptimal views of the pancreas. A CT scan abdomen shows a cystic lesion in the tail of the pancreas.What is the most likely diagnosis?
- Pancreatic pseudocyst - no pain or features of sepsis. May cause ascites if high amylase in ascitic fluid. Pancreatic haemorrhage would present with shock and FBC would show. IPMN is a benign tumour of the pancreatic ducts although it does have malignant potential. Again, it is unlikely to have developed in the interval since the previous scan.
Pancreatic pseudocysts can often be dealt with conservatively. However, if they were to be cause complications such as infection / obstruction they can be drained. Which two of the following techniques would be the first line methods for draining a pseudocyst?
- Endoscopic ultrasound (EUS)
- CT guided Aspiration of the pseudocyst
Re-presents 10 year later, again with severe abdominal pain, weight loss and loose stools. He had a relapse of his alcohol about 5 years ago and is currently drinking about 4-5 units/day. Blood glucose 12 mmol/l Amylase 45 IU/L Bilirubin 21 mmol/L Alkaline phosphatase 150 IU/L . The most likely cause of the elevated blood glucose and loose stools is what?:
- Pancreatic insufficiency- due to on-going alcohol use.This is supported by the pancreatic calcification on the abdominal film. Serum amylase may be normal in chronic pancreatitis. DM and malabsorption are common sequelae.
How can you establish the diagnosis of pancreatic exocrine insufficiency?
- faecal calprotectin - measure of gastrointestinal inflammation (think of it like CRP for the bowel)
- Faecal elastase - measures pancreatic exocrine function
- SeHCAT scan- measures bile salt reabsorption and is not relevant here.
What is the treatment for pancreatic exocrine insufficiency:
- Oral pancreatic enzyme replacement e.g. Creon
What differential diagnoses would you consider?
- Gallstone ileus
- Acute cholecystitis
- Acute pancreatitis
- Chronic pancreatitis
- Perforated duodenal ulcer
- Intestinal ischaemia
What initial investigations would be helpful in making a diagnosis?
- Magnetic resonance cholangiopancreatography (MRCP)
- Serum amylase
- Chest x-ray
- Ultrasound of the upper abdomen
- Supine abdominal x-ray
- Endoscope retrograde pancreatography (ERCP)
- Mesenteric angiogram
1.
- Acute cholecystitis
- Acute pancreatitis
- Perforated duodenal ulcer
Gallstone ileus is more common in the elderly and presents with evidence of small bowel obstruction. This patient clinically has an ileus and the severe upper abdominal pain could relate to acute pancreatitis or cholecystitis, a perforated duodenal ulcer or possibly a myocardial infarction. . The history is not typical of ischaemia which is not relieved by sitting and is often associated with rectal bleeding.
2.
- Serum amylase
- Chest x-ray
- Ultrasound of the upper abdomen
- Supine abdominal x-ray
In practice, most patients presenting with peritonitis like this would have CT as their first imaging.
The initial chest radiograph (Figure 1) and abdominal radiograph (Figure 2) are included below. Which one of the following statements correctly describes the findings?
- There is free intraperitoneal air beneath the right hemidiaphragm with evidence of dilated small bowel also noted.
- Normal appearances of chest and abdomen.
- There is air beneath the right hemidiaphragm suspicious of a subphrenic abscess with mild small bowel dilatation also noted.
- The chest radiograph is normal. Air in normal large bowel is identified beneath the right hemidiaphragm and dilated small bowel loops are present, in keeping with an ileus.
- There is a right lower lobe pneumonia with cavitation present and the bowel gas pattern is within normal limits.
The serum amylase measurement is 800U/ml. This result:
- Excludes acute pancreatitis
- May occur with cholecystitis
- Is diagnostic of duodenal perforation
- May be associated with acute pancreatitis
- Is indicative of chronic pancreatitis
The chest and abdominal radiographs have shown no evidence of free intraperitoneal air and ultrasound of the upper abdomen has demonstrated a normal gall bladder and biliary tree. Acute pancreatitis is felt to be the most likely diagnosis clinically, although the pancreas has not been well visualised at ultrasound due to overlying bowel gas. The patient has ongoing pain. Which investigation would you request to confirm your diagnosis?
- MRCP
- Repeat ultrasound examination following prolonged fasting
- ERCP
- CT of the abdomen
- None required at this stage
- Normal large bowel can be seen interposed between liver and right hemidiaphragm. This is a normal variant and is known as Chilaiditis syndrome, do not confuse this appearance with free intraperitoneal air. Dilated small bowel loops are present on the abdominal radiograph – in keeping with ileus. (4)
- In acute pancreatitis the amylase level may be very high (>1000 U/ml). If the pancreatitis has been going on for a few days the level may drop however and moderate elevation is also seen in other conditions e.g. duodenal perforation, mesenteric infraction, acute cholecystitis
- May occur with cholecystitis
- May be associated with acute pancreatitis
3. CT abdo - no definitive diagnosis although several excluded. The history and course suggest of acute pancreatitis and CT would be helpful to see the inflamed gland, and grade the level of inflammation and associated fluid formation. MRCP/ERCP are not indicated and ERCP may precipitate pancreatitis.
