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Pancreatitis Flashcards

(33 cards)

1
Q

What is acute pancreatitis and what would you see in a CT scan for acute pancreatitis

A

Rapid onset inflammation of the pancreas

CT scan- pancreas becomes muddy *as seen on diagram *. Normally pancreas is smooth

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2
Q

What is the definition of chronic pancreatitis and what are the signs you’d see on a CT scan for chronic pancreatitis

A

Long stands inflammation of the pancreas

CT scan- would see calcium (white spots) deposit on head of pancreas

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3
Q

Mention all the aetiology of the acute pancreatitis.

Which 3 are most common and which is least common

A

Acronym: GETSMASHED

3 most common are: gallstones, ethanol and trauma

Least common: Trinidad scorpion bite

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4
Q

Describe the pathogenesis of acute pancreatitis WHEN GALLSTONES is the aetiology

A

Gallstones causes reflux of bile from CBD into Main pancreatic duct.

This increases pressure in MPD. Hence increased permeability of pancreatic duct epithelium

Acinar cells enzymes (already in MPD) diffuse into periductal interstitial tissues

Pancreatic enzymes activated extracellularly and cause damage- trypsin activated

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5
Q

Describe the pathogenesis of acute pancreatitis when alcohol is the aetiological agent

A

Alcohol precipitates proteins in duct which can lead to increase in upstream pressure.

Hence acinar cells diffuse into periductal interstitial tissue and cause damage

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6
Q

How can pancreatic enzymes be activated intracellularly - another form of pathogenesis

A

Proenzymes and lysosomal proteases incorporated into the same vesicle

This activates trypsin

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7
Q

What are the potential downstream effects of extracellular or intracellular trypsin activation

DRAW DIAGRAM

A
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8
Q

What are the 3 common named type of acute pancreatitis? What can cause them? Why isn’t it ideal to call them these names?

A

Oedematous pancreatitis

Hameorrhagic pancreatitis - caused by arroding of blood vessels

Necrotic pancreatitis - caused by infection which can lead to infective necrosis. Bacteria produce gas in pancreas.

not ideal: very hard to distinguish on scans which is which

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9
Q

What are the symptoms of Avute pancreatitis

A
  • Epigastric pain radiating to the back. This is often eased by sitting forward
  • N&V - vomiting
  • fevers
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10
Q

What are the signs of acute pancreatitis

A
  • Haemodynamic instability - tachycardia and hypotensive
  • Peritonism in upper abdomen / or any part of abdomen
  • Grey- Tuner’s sign - bruising in flanks
  • Cullen’s sign- bruising around umbilicus
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11
Q

What 2 signs of acute pancreatitis are definitely seen in haemorrghic pancreatitis

A

Grey turner sign

Cullen’s sign

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12
Q

What are the potential differential diagnoses for the causes of acute pancreatitis

A

Gallstone disease and associated complications like biliary colic and acute cholecyctitis

Peptic ulcer disease/perforation

leaking/ruptured abdominal aortic aneurysm

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13
Q

What are the investigations you’d perform to hone down differential diagnoses. What will you look for for each investigation?

A
  • Blood test- look for elevated amylase or lipase
  • Erect chest x-ray
  • Abdominal x ray- look for sentinel loop or gallstones
  • USS (Ultrasound)- look for GSs as cause of pancreatitis
  • CT abdomen- do this only if pt isn’t settling with conservative management and 48-72 hrs after symptoms onset
  • MRCP- only if GS pancreatitis is suspected with abnormal liver function tests (CBD stone)
  • ERCP - you HAVE TO BE SURE IT’S CBD Gallstones
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14
Q

What is the criterial for measuring severity of acute pancreatitis ? List it out and what result suggest severe pancreatitis

A

Modified Glasgow criteria

a score of 3 or above within 48hrs of onset suggest severe pancreatis

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15
Q

What molecule in the blood can be used as an independent predictor of severity of acute pancreatitis

A

CRP

above 200 CRP suggest severe pancreatitis

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16
Q

What are the systemic complications of Acute pancreatitis

A
  • Hypocalcaemia; as a result of saponification
  • Hyperglycaemia (diabetes if beta cells damage is significant)
  • SIRS- Systemic inflammatory Response Syndrome
  • ARF- Acute Renal Failure
  • ARDS- Adult Respiratory Distress Syndrome
  • DIC- Disseminated Intravascular Coagulation
  • Multi Organ failure and death
17
Q

What are the local complications of acute pancreatitis

A
  • Pancreatic necrosis with or without infection
  • Pancreatic abscess
  • Pancreatic pseudo cyst
  • Haemorrhage- due to bleeding from arroded vessels
  • Thrombosis of: Splenic vein (lowest frequency), SMV, portal vein(highest frequency)
  • Chronic pancreatitis
18
Q

A local complication of acute pancreatitis is haemorrhage

describe the outcome for haemorrhaging of small and large vessels

A

Small vessels- causes haemorrhaging pancreatitis, hence Cullen’s or grey-Turner’s signs seen

Large vessels- (like splenic artery) can be life threaintie unless it forms a pseudoaneurysm

19
Q

Thrombosis is one of the local complications of acute pancreatitis. Describe what the outcome could be?

A

Formation of ascites

small bowel venous congestion/ischaemia

20
Q

Outline the process of saponification

A

Lipases converts lipids to FFAs

FFAs chelate Calcium salts

this decreases Ca2+ serum levels

21
Q

What complication of acute pancreatic gives the only indication for surgical intervention? Also what does surgical intervention entail

A

Infected pancreatic necrosis- high mortality rate if dead infected tissue isn’t debrided

Surgery involves necrosectomy

22
Q

What is a complication of infected pancreatic necrosis . Describe what it is and when it presents

A

Formation of pancreatic abscess

  • this is a collection of pus form pancreatic tissue necrosis and infection
  • becomes lined by granulation tissue
  • presents 2-4 weeks after attack of pancreatitis
23
Q

How do you manage pancreatic abscess?

A

Antibiotics and drainage

drainage could entail

  • percutanoeus - CT guidance .
  • Surgical drainage - VERY HIGH MORTALITY RATE

*diagram shows percutanoues CT drainage*

24
Q

What is pancreatic pseudocyts and when does it present

A

Peri-pancreatic fluid collection

increased pancreatic enzymes within a fibrous capsule. NO EPTIHELIAL LINING

it presents more than 6 weeks after pancreatitis

25
When does pancreatic psueodcyts require intervention
It normally doesnt; 95% of cases spontaneously resolve over 6 months Requires intervention when: * pseudo cyst is symptomatic- pain * Pseudocyst is infected (abscess) * Pseudocyst causes compression of surrounding structures. E.g. CBD in obstructive jaundice and duodenum (high SBO) theses 3 situations will require drainage of pseudocyts
26
What are the different ways of draining Pseudocyst
Percutaneously - under CT guidance Endoscopically- using EUS- puncturing posteiror wall of stomach and inserting stent Surgically- either open or laparoscopic . This entail: * pseudocystgastrostomy- cyst opened into stomach * pseudocystjejunostomy- onto jejunum
27
Describe the pathophysiology of chronic pancreatitis DRAW
Destroys endocrine and exocrine tissue; this leads to fibrosis of pancreas this could lead to steatorrhea or insulin dependent diabetes mellitus
28
What are the 3 mamangement options for chronic pancreatitis
Endoscopic management Surgical drainage; Pseudocyst can form Surgical resection
29
What questions do you NEED to ask those pt with chronic pancreatitis to give better efficient care
What painkillers are you taking What do you take for diabetes ? If you have it What crions are you taking ?
30
What are the 3 types of surgical resection for chronic pancreatitis
Head of pancrease resection Tail of pancreas resection whole pancreas resection - there could still be phantom pain
31
What are the 4 principles for management of patients with acute pancreatitis ? Firstly what must you do BEFORE?
Firstly check ABC- airway, breathing , circulation 4 principles include: * Fluid resuscitation * Analgesia * Pancreatic rest with or without nutritional support(TPN or NJ feeding) ; depending if recovery is prolonged' * Determine underlying causes
32
What's the % of pt with acute pancreatitis that settle with conservative treatment? However, some do not. What are the other options for management depending on the progression of the disease
95% if pancreatitis is severe on scoring then send to High dependency unit Give antibiotics if necrotic pancreatitis/infected necrosis , but not routinely surgery is only RARELY REQUIRED-
33
What are the other causes of elevated amylase (not necessarily acute pancreatitis)