Acute pancreatitis

Question 1

What is acute pancreatitis?

Answer 1

This is acute inflammation of the pancreas, releasing exocrine enzymes that cause autodigestion of the organ

Question 2

What is the prognosis of acute pancreatitis?

Answer 2

· Majority of patients will improve within 3-7 days of conservative management.

· Progression to chronic pancreatitis occurs only in 6%.

· Cause should be identified, and a plan to prevent recurrence initiated.

· Long-term prognosis is based on the aetiology and patient compliance to lifestyle modifications.

Question 3

What is the aetiology of acute pancreatitis?

Answer 3

I GET SMASHED:

· I - Idiopathic

· G - Gallstones
· E - Ethanol.
· T - Trauma.

· S - Steroids.
· M - Mumps.
· A - Autoimmune diseases
· S - Scorpion sting.
· H - Hypertriglyceridaemia / hypercalcaemia.
· E - ERCP (endoscopic retrograde cholangiopancreatography).
· D - Drugs.

Question 4

What risk factors are associated with acute pancreatitis?

Answer 4

· Middle-aged women - gallbladder disease.
· Young to middle aged men - high alcohol intake.
· Gallstones.
· Alcohol.
· Hypertriglyceridaemia.
· Causative drugs, such as thiazide diuretics and furosemide.
· ERCP - linked to pancreatic inflammation.
· Trauma.
· Hypercalcaemia.

Question 5

What investigations would you request if you suspected acute pancreatitis?

Answer 5

· FBC - Mild leukocytosis.
· U&E’s.
· LFT’s - AST/ALT - if >3 times the upper normal limit, predicts gallstone disease in 95%.
· CRP - if >200, associated with pancreatic necrosis.
· Haematocrit - if >44% on admission, predictor of pancreatic necrosis.
· Amylase and lipase - 3 times the upper limit of normal.

· ABG - hypoxaemia and acid-base disturbance.
· Imaging can determine possible causes:
- CXR - pleural effusion and basal atelectasis.
- AXR - isolated dilatation of the bowel, gas abruptly stopping in the mid to left transverse colon (cut-off sign).
- MRCP is indicated in patients with elevated LFT’s suggestive of bile duct obstruction.
- ERCP is not used diagnostically.
- Abdo USS is the preferred initial study is biliary aetiology is suspected.
- CT is the best initial study for staging acute pancreatitis and detecting complications.

Question 6

Suggest some differential diagnoses.

Answer 6

· Peptic ulcer disease. 
· Perforated viscus 
· Oesophageal spasm 
· Intestinal obstruction 
· AAA 
· Cholangitis 
· Gallstones. 
· Viral gastroenteritis. 
· Hepatitis.

Question 7

What treatment are all patients given?

Answer 7

·  1st line - Resuscitation - IV fluids and catheter. 
· Plus - Nutritional support - NBM. If long-term, NJ tube so as not to disturb the pancreas.
· Analgesia
·  Anti-emetic
·  Calcium replacement therapy 
· Magnesium replacement therapy 
· Insulin.
· Abx.

Question 8

How are gallstone patients treated?

Answer 8

Gallstones - surgical candidates:
- Cholecystectomy.

Gallstones - non-surgical candidates:
- ERCP with sphincterotomy.

Question 9

What other treatment options are available?

Answer 9

· Alcohol-induced:

• Benzodiazepine for withdrawal.
• Vitamin and mineral replacement - thiamine and folic acid.

· Infected pancreatic necrosis:
- Percutaneous catheter drainage.

Question 10

What complications can occur?

Answer 10

· AKI. 
· Pancreatic abscess. 
· Necrotising pancreatitis. 
· Pancreatic insufficiency. 
· Chronic pancreatitis - glucose intolerance, pancreatic insufficiency and calcifications.
· Portal vein/splenic thrombosis.
· Enteric fistula's.
· Sepsis.
· Infected pancreatic necrosis. 
· ARDS. 
· DIC. 
· Multi-organ failure.
· Pancreatic pseudocyst.