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Gwen - GI and General surgery > Hepato-biliary: Acute pancreatitis > Flashcards

Hepato-biliary: Acute pancreatitis Flashcards

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1
Q

What is acute pancreatitis?

A

Reversible inflammatory state of the pancreas

  • Mild (85%) - Mild form of interstitial edema of the gland
  • Severe (15%) - Patients with pancreatic, or peripancreatic, necrosis or acute fluid collections have severe pancreatitis
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2
Q

What are the clinical “phases” of acute pancreatits

A

Early: lasts for a week

Second: weeks to months

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3
Q

What are causes of acute pancreatitis?

A
  • Idiopathic
  • Gallstones
  • Ethanol
  • Trauma
  • Steroids
  • Mumps
  • Autoimmune
  • Scorpian venom
  • Hyperlipidaemia, hypothermia, hypercalcaemia
  • ERCP
  • Drugs
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4
Q

What is the pathophysiology of acute pancreatitis?

A

Self-perpetuating enzyme mediated autodigestion:

  • Enzymes cause leaky vessels, leading to tissue oedema and inflammation
  • Lipolytic enzymes -> fat necrosis
  • Released fatty acids bind calcium -> white precipitates in the necrotic fat
  • Proteolytic enzymes destroy aicnar tissue.
  • Destruction of blood vessels causes haemorrhage
  • Destruction of islet cells can result in hyperglycaemia
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5
Q

Why do individuals with pancreatitis get hypoglycaemia?

A

Due to destruction of islet cells

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6
Q

Why do those with pancreatitis have white patches in the necrotic fat?

A

Fatty acids produced by lipolytic enzyme breakdown of fat bind calcium, forming white deposits

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7
Q

What are symptoms of acute pancreatitis?

A
  • Gradual/sudden severe epigastric/central abdominal pain
  • Vomiting
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8
Q

What is characteristic of the pain experienced in acute pancreatitis?

A
  • Radiates to the back
  • Relieved by sitting forward
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9
Q

What are signs of acute pancreatitis?

A
  • Tachycardia
  • Pyrexia
  • Can be in profound shock
  • Jaundice - obstructive (oedema of the head of the pancreas compressing the lower end of CBD)
  • Ileus
  • Rigid abdomen +/- local/general tenderness
  • Cullen’s sign
  • Turner’s sign
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10
Q

What is Cullen’s sign?

A

Periumbilical ecchymoses (haemorrhagic discoloration)

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11
Q

What causes cullen’s sign?

A

Retroperitoneal haemorrhage - The retroperitoneum is connected to the gastro-hepatic ligament, then the falciform ligament, and finally to the round ligament (the obliterated umbilical vein), which tracks to the abdominal wall around the umbilicus. When a haemorrhage (from any cause) occurs, blood is able to move along these ligaments to the abdominal wall to produce ecchymoses

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12
Q

What is Grey Turner’s sign?

A

Ecchymoses or purple discolouration of the flanks.

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13
Q

What is the mechanism behind Grey-Turner’s sign?

A

A hole in the abdominal fascia. A defect in the transversalis fascia allows blood from the posterior pararenal space to move to the abdominal wall musculature and the subcutaneous tissue

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14
Q

What are other causes of Cullen’s sign, besides acute pancreatitis?

A
  • Retroperitoneal bleeding
  • Post surgery
  • Anticoagulation
  • Rectus sheath haematoma
  • Ectopic pregnancy
  • Ischaemic bowel
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15
Q

Why wouldnt there be rigidity on abdominal palpation

A

Because pancreas is retroperitoneal. Make sure you aren’t missing an itnra-peritoneal rigidity

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16
Q

Why might there be reduced bowel sounds?

A

Secondary to ileus in small bowel loop or transverse colon nect to pancreas

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17
Q

Differentials of acute pancreatits

A
  • Perforated PU - sudden pain then levels off compared to AP (gradual reaching max due to inflammatory process),
    • Erext CXR
  • Acute cholecystitis/biliary colic
    • AUS
  • High intestinal obstruction
    • AXR
    • CT
  • Inferior MI
    • Bloods - troponin
    • ECG
  • Ruptured AAA
    • CT
    • AUS
  • Mesenteric ischaemia
    • CT angiogram
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18
Q

What investigations would you do if you thought someone had acute pancreatitis?

A
  • Bloods - Amylase/lipase, FBC, U&Es, LFTs, Ca2+, Glucose, ABG, Lipids, Coagulation screen, CRP
  • Urinary amylase
  • Abdominal XR/Erect CXR
  • Abdominal USS
  • Contrast-enhanced spiral CT
  • MRI/MRCP
  • ERCP
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19
Q

What bloods would you do in someone with suspected acute pancreatitis?

A
  • FBC, U&Es, LFTs
  • Amylase/lipase
  • LDH
  • Albumin
  • Ca2+
  • Glucose
  • ABG
  • Lipids
  • Coagulation screen
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20
Q

Why would you perform an erect CXR in someone with suspected acute pancreatitis?

A

To exclude a gastroduodenal perforation/pleural effusion. May also see signs of calcification

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21
Q

Why might you do an abdominal ultrasound in someone with acute pancreatitis?

A

1st line

Used to screen for possible biliary causes of pancreatitis. This is mainly used to exclude gallstones

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22
Q

Why would you consider doing a CT in someone with acute pancreatitis?

A

To assess extent/severity of pancreatic necrosis and for complications, including:

  • Abscess development
  • Fluid collection
  • Pseudocyst

Indicated in those with

  • uncertain diagnosis
  • a severe attack
  • clinical deterioration
  • suspected local complications
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23
Q

Why would you do an ERCP in someone with acute pancreatitis?

A

Used to look at pancreatic duct for inflammatory fibrosis, tumours, gallstones. Can also be used to remove stones.

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24
Q

Why might you do an abdominal X-ray in someone with suspected acute pancreatitis?

A

Look for signs of fluid collection - retroperitoneal fluid.

Also look for ielus - sentinel loop next to inflamed organ, colon cut off sign inflammed colond ue to associated pancreas.

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25
Why might you perform a glucose in someone with suspected pancreatitis?
Look for signs of hypo/hyperglycaemia
26
Why might you look at LFTs in someone with suspected acute pancreatitis?
**Obstructive jaundice pattern** Look for signs of liver dysfunction caused by blockage of biliary system - e.g. gallstones which could cause pancreatitis
27
Why might you perform a coagulation screen in someone presenting with features of acute pancreatitis?
Look for causes of cullen's/Grey-turner's sign - clotting disorders
28
Why would you do an ABG in someone with acute pancreatitis?
Look for signs of acid/base disturbance and monitor oxygenation (to assess severity - Modified glasgow criteria)
29
How is amylase excreted?
Renally - renal failure will lead to accumulation
30
What are causes of raised serum amylase?
* **Upper GI perforation** * **Biliary peritonitis** * **Intestinal infarction** * **Macroamylasaemia**
31
Why is a serum calcium measured in acute pancreatitis?
Look for hypocalcaemia & to assess severity - Modified glasgow criteria Due to deposition of calcium in fat necrosis Appears 3-8 days after acute attack
32
Why would you assess U+E's in someone with suspected acute pancreatitis?
Assess severity - Modified glasgow criteria Concernad about 3rd space fluid loss - ARF
33
How would you manage gallstones as a cause of acute pancreatitis?
ERCP - can remove gallstones if progressive jaundice If mild AP then during same admission If severe then should be delayed until inflammatory process settled If local complications - done when these have resolved or dealt with seperately
34
Why might you do a CRP in someone with suspected acute pancreatitis?
Assess disease severity and prognosis
35
What level would you expect amylase to reach?
400 units is suggestive \>1000 is diagnostic
36
How long does it take amylase to intially rise?
Within 6 hours NON SPECIFIC AND NON PROGNOSTIC
37
How long does it take amylase levels to fall back to normal after initial presentation of acute pancreatitis?
3-5 days - Late presentation may give false negative result
38
Other causes of raised amylase
Acute cholecystitis, CBD stone, perofrated PI, mesenteric ischaemia, pancreatic cancer
39
More specific test other than amylase that isn't readily availble but would be ideal
Lipase
40
Diagnostic criteria for acute pancreatitis
1. Abdominal pain consistent with acute pancreatitis 2. Serum lipase (or amylase) levels at least 3x greater than the upper limit 3. Characteristic findings on contrast, CT or less commonly MRI/AUS
41
Difference between mild/moderate/secere AP
Mild - no organ failure, no local or systemic complications Moderate - transient organ failure (resolves\<48 hours) Severe - persistant organ failure (\>48 hours)
42
How would you assess the severity of pancreatitis in someone with acute pancreatitis?
Modified glasgow severity score * **P**aO2 \< 8kPa * **A**ge \> 55 * **N**eutrophilia \> 15x109 * **C**alcium \< 2mmol/L * **R**enal function - Urea \> 16 mmol/L * **E**nzymes - LDH \> 600iu/L; AST \> 200iu/L * **A**lbumin \< 32g/L * **S**ugar - \>10 mmol/L
43
In the glasgow criteria for severity of pancreatitis, what threshold is used for PaO2?
\<8kPa
44
In the glasgow criteria for severity of pancreatitis, what threshold is used for WBC?
\>15x109
45
In the glasgow criteria for severity of pancreatitis, what threshold is used for Age?
55 yrs
46
In the glasgow criteria for severity of pancreatitis, what threshold is used for Calcium?
\<2 mmol/L
47
In the glasgow criteria for severity of pancreatitis, what threshold is used for Urea?
\>16 mmol/L
48
In the glasgow criteria for severity of pancreatitis, what threshold is used for LDH?
\>600 iu/L
49
In the glasgow criteria for severity of pancreatitis, what threshold is used for AST?
\> 200iu/L
50
In the glasgow criteria for severity of pancreatitis, what threshold is used for serum Albumin?
\<32g/L
51
In the glasgow criteria for severity of pancreatitis, what threshold is used for blood glucose?
\>10 mmol/L
52
Whats merits "severe pancreatitis" using the glasgow criteria for severity?
\>3 positive factors within 48 hours of onset
53
How would you initially manage severe acute pancreatitis?
HDU/ITU * **Oxygen** * **Nil by mouth** - Consider NG/NJ or TPN * **IV fluids** * **Invasive monitoring with hourly obs -** vital signs, urine output (catheter), central venous pressure & blood gases * **Analgesia** * **Consider Prophylactic ABx** - may decrease local/systemic complications in severe AP (pancreatic necrosis) * **Daily bloods -** FBC, U+E's, LFTs, clotting, serum calcium & blood glucose, amylase, consider ABG * NJ tube if inflammation around pancreas/duodenum is too large
54
What analgesia would you use in someone with acute pancreatitis?
* **Tramadol** * **Pethidine** * **Indomethacin**
55
Why would you give IV fluids in someone with acute pancreatitis?
To counter third-space sequestration -\> give until vital signs are satisfactory and urine flow \> 30ml/h
56
If someone was having problems with controlling their blood sugars, what might you consider giving them?
Insulin
57
What daily boods would you perform in someone with acute pancreatitis?
FBC, U+E's, LFTs, Ca2+, clotting screen, glucose, amylase, ABG
58
What are early complications of acute pancreatitis?
* **Shock** * **ARDS** * **Renal Failure** * **DIC** * **Sepsis** * **Hypocalcaemia/****Hyperglycaemia** * **Ileus** * **Confusion/encephalopathy**
59
What are late complications of pancreatitis?
\>1 week * **Acute fluid collection/Pancreatic ascites** - foramen of winslow connects lesser and greater sac so fluid can move into greater sac leading to 3rd space loss * **Pancreatic necrosis (sterile or infective)** - * **Pancreatic Pseudocyst** * **​Acute** collection of pancreatic juice enclosed in a wall of fribrous/granulation tissue that arises following an attack of acute pancreatitis * **Chronic** if the cyst persists for \>6 weeks * **Pancreatic Abscess** - circumscribed intra-abdominal colelction of pus, usually in close priximity to the pancreas * **Bleeding** - from elastase eroding vessels * **Portal/splenic vein thrombosis** * **Fistulae** * **Pleural effusion**
60
61
What is a acute pancreatic pseudocyst?
Collection of pancreatic juice enclosed in a wall of fibrous or granulation tissue that arises following an attack of acute pancreatitis
62
What are features of someone with a pancreatic pseudocyst?
Persistent hyperamylasaemia and/or pain
63
How would you investigate someone for a pancreatic pseudocyst?
* **CT** * **Amylase**
64
Indications for manageming pancreatic psuedocyst
Cyst\> 6cm and \>12 weeks in duration are unlikely to resolve Offered only for symptomatic cysts or onset of complications
65
How would you manage someone with a pancreatic pseudocyst?
Consider any of: * **Percutaneous US/CT guided drainage** * **Endoscopic/Laproscopic/open cystogastrostomy**
66
What are complications associated with pancreatic pseudocyst formation?
* **Jaundice** * **Infection** * **Haemorrhage** * **Rupture** * **Pressure effect**
67
How would you treat someone with a pancreatic abscess?
Antibiotics and analgesia
68
Why can individuals with pancreatitis get bowel necrosis?
Thrombosis can occur in the splenic/gastroduodenal arteries, or colic branches of SMA
69
What score do individuals need to get on glasgow severity scale for pancreatitis to be determined to have severe acute pancreatitis?
Score \>3
70
What is the definition of mild pancreatitis?
* **No organ failure** * **No local or systemic complications**
71
What is classed as moderate acute pancreatitis?
Organ failure that resolves within 48 hrs +/- local/systemic complications without persistent organ failure
72
What is classed as severe acute pancreatitis?
Persistent organ failure \> 48 hrs (single or multiple)
73
When is a psuedocyst classed as chronic?
When it persists \>6 weeks
74
75
What is a pancreatic abscess?
Circumscribed intra-abdominal collection of pus, usually in a proximity to the pancreas, containing little or no pancreatic necrosis, which arises as a consequence of acute pancreatitis
76
What is pancreatic necrosis?
Diffuse or focal area(s) of non-viable pancreatic parenchyma * **Sterile necrosis** * **Infected necrosis**
77
Management of pancreatic necrosis
Sterile necorisis - treated conservatively Infected necrosis - necrosectomy guided by CT findings
78
What is meant by walled off necrosis?
A mature, encapsulated collection of pancreatic and/or peripancreatic necrosis that has developed a well-defined inflammatory wall Usually occurs after 4 weeks
79
What is an acute necrotic collection?
A collection containing variable amounts of both fluid and necrosis associated with necrotizing pancreatitis Usually occurs \< 4 weeks
80
Why can those with acute pancreatitis present with profound shock?
Caused by hypovolaemia & circulating cytokines
81
How long after initial insult does it take for amylase to start to rise in acute pancreatitis?
Within 6 hours
82
Wich stays elevated for longer in acute pancreatitis; serum amylase or serum lipase?
Serum Lipase
83
Why can someone get hypocalcaemia in acute pancreatitis?
Due to deposition of calcium in fat necrosis - appears 3-8 days after attack
84
When is CT indicated for in acute pancreatitis?
* **All patients with severe attacks** - 3-10 days after admission * **Diagnosis uncertain** - within 24 hours * **Clinical deterioration** * **Patients with organ failure/signs of sepsis** * **Suspected local complications**
85
What criteria need to be met to make the diagnosis of acute pancreatitis?
Diagnosis requires two of the following three features: 1. **Abdominal pain consistent with acute pancreatitis** 2. **Serum lipase/amylase activity at least 3x greater than upper normal limits** 3. **Characteristic findings on contrast-enhanced CT or less commonly MRI /abdominal US**
86
What would your differential diagnosis be for someone with symptoms of acute pancreatitis?
* **Perforated peptic ulcer** * **Acute cholecystitis / Biliary colic** * **High intestinal obstruction** * **Myocardial infarction** * **Rupture abdominal aortic aneurysm** * **Mesenteric ischemia**
87
Name the different scoring systems which are used to assess pancreatitis severity?
* **Ranson’s criteria** * **Glasgow Scoring System** * **APACHE II score** * **Modified Marshall scoring system**
88
When would you consider CT scanning someone with severe acute pancreatitis?
Between days 3-10 - look for evidence of local complications
89
How would you manage mild pancreatitis?
* **Ward management with basic observations** * **​**Oxygen * IV fluids * Analgesia * Blood transfusion * Diet - nutrition, NG tube * Monitor urine output - risk of renal failure * Blood sugar control * **Analgesia** * **Fluids**
90
91
When would you consider an early ERCP in someone with severe acute pancreatitis?
* **Severe gallstone pancreatitis** * **Signs of cholangitis**
92
How would you manage infected pancreatic necrosis?
Necrosectomy guided by CT findings
93
How would you manage non-infected pancreatic necrosis?
Treat conservatively
94
What complications can occur with a pancreatic pseudocyst?
* **Infection** * **Rupture** * **Pressure effect** * **Erosion into a blood vessel**
95
When is treatment for a pancreatic pseudocyst offered?
Only if symptomatic or onset of complications
96
How would you manage acute fluid collections
50% resolve spontaneously Percutaneous aspiration may introduce infection Aspiration only if infection suspected or symptomatic
97
Prognosis of acute pancreatitis
Most will recover with general supportitive care 25% develop severe acute pancreatits with multi-organ faulure
98
Local complications acute pancreatitis
Acute fluid colelction Pseudocyst Abscess Pancreatic necorisis -sterile, infected Pancreatic ascites Pleural effusion Portal/splenic vein thrombosis - splenic vein is just above pancreas Pseudoaneurysm - can weaken splenic artery wall Chronic pancreatitis
99
Systemic complications of acute pancreatitis
Shock - cause of most deaths ARDS Renal failure DIC Hypocalcaemia/Hyperglycaemia Ileus Confusion/encephalopathy
100
When do you re-evaluate those with acute pancreatits
24hr 48hr 7 days

Gwen - GI and General surgery (44 decks)

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