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hbp > Pancreatitis > Flashcards

Pancreatitis Flashcards

1
Q

Causes of pancreatitis

A

I - idiopathic

G - gallstones
E - ethanol
T - trauma

S - steroids
M - mumps
A - autoimmune
S - scorpion sting (Trinidad)
H - hypercalcaemia & hyperlipidaemia
E - ERCP
D - drugs (sulphonamides, azathioprine, NSAIDs, diuretics)

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2
Q

Typical pain distribution of pancreatitis?

A

Central abdo pain (epigastric) that radiates to the back

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3
Q

What are the signs o/e for pancreatic haemorrhage?

A

Cullen’s & Grey-Turner’s

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4
Q

What is the Glasgow-Emery score? (PANCREAS)

A

Prognostic indicators for pancreatitis:
P -
A -
N -
C -
R -
E -
A -
S -

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5
Q

What are the key factors on presentation with pancreatitis that indicate potential necrotic processes?

A

Haemorrhagic
ARDS

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6
Q

What are the key functions of the pancreas?

A

Endocrine

  • alpha cells
  • beta cells - insulin

Exocrine - digestive enzymes released as zymogens stored as zymogen granules (protease vs protease inhibitors)

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7
Q

Why do pancreatic enzymes only work once they reach the duodenum?

A

Enteropeptidases in the duodenum convert trypsinogen to trypsin which is then able to convert all the zymogens to their active forms.

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8
Q

What are the most common causes of acute pancreatitis?

A
  • GSD
  • Alcohol
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9
Q

How does alcohol cause pancreatitis?

A

Alcohol

  • increases zymogen secretion from acinar cells
  • decreases fluid & bicarb in ducts = viscous pancreatic juices;
    Plugs form, block ducts = increased ductal pressure & distension
  • zymogen granules fuse with lysosomes (release trypsin = autodigestion)
  • stimulates cytokine release (neutrophils release superoxides & proteases)
  • oxidative metabolism of alcohol = ROS
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10
Q

How do gallstones cause acute pancreatitis?

A

Block sphincter of Oddi - bile backs up pancreatic duct = inflammation

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11
Q

How does pancreatitis progress to Liquefactive Haemorrhagic Necrosis?

A

Proteases & inflammatory response = tissue destruction & blood vessel leaks/rupture
Lipases-destroy prepancreatic fat
= liquefies tissue

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12
Q

What is a pancreatic pseudocyst and how does it present?

A

Fibrous tissue surrounding liquefactive necrotic tissue

  • abdo pain
  • loss of appetite
  • palpable mass
    (Raised amylase, lipase & bilirubin)
    Abdo CT
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13
Q

What is the main complication of pancreatic pseudocysts?

A

Pancreatic abscess = high fever, WCC

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14
Q

What are the complications of acute pancreatitis?

A
  • chronic pancreatitis
  • pancreatic pseudocysts
  • pancreatic abscesses
  • hypovolaemic shock
  • DIC
  • ARDS (most lethal; inflammation, leaky vessels, difficulty breathing)
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15
Q

What are the signs/symptoms of acute pancreatitis?

A
  • epigastric pain radiates to back
  • N+V
  • hypocalcaemia (fat necrosis)
  • Cullen’s sign
  • Grey Turner’s sign
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16
Q

What blood results are characteristic of acute pancreatitis?

A
  • low calcium
  • raised amylase, lipase
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17
Q

What findings would be on imaging for acute pancreatitis?

A

CT

  • inflammation
  • necrosis
  • pseudocysts

USS

  • gallstones
18
Q

How is acute pancreatitis treated?

A
  • treat ULC
  • pain management
  • hydration
  • electrolytes

Rest bowels - NBM, IV/NG tube
Treat complications

  • O2Tx
  • Abx
19
Q

What characterises chronic pancreatitis?

A

Irreversible structural changes

  • fibrosis
  • atrophy
  • calcification
20
Q

Causes of acute pancreatitis that often lead to chronic disease:

A
  • alcohol
  • trauma
  • tumours
  • CF
21
Q

How does CF cause pancreatitis?

A

CFTR gene mutation disrupts ion transport = viscous & sticky

  • main cause in children
22
Q

What is the pathophysiology of chronic pancreatitis?

A
  • structural changes to ducts
  • fibrosis
  • calcium deposits
23
Q

How does repeated bouts of acute pancreatitis lead to chronic disease?

A

Repeated bouts of acute pancreatitis =

  • ductal dilation,
  • stellate cells lay down fibrotic tissue = narrowed ducts & stenosis
24
Q

How does alcohol cause chronic pancreatitis?

A

Alcohol

  • calcium deposits on protein plugs
25
Q

Why is amylase not a good indicator of chronic pancreatitis?

A

Insufficient healthy tissue

26
Q

How to diagnose chronic pancreatitis

A

Calcifications

  • AXR
  • CT abdo (dense, fluid-filled mass, darker)

Ducts

  • ERCP/MRCP = chain-of-lakes pancreas (dilation & stenosis)
27
Q

What are the complications of chronic pancreatitis?

A

Pancreatic insufficiency - impaired acinar cells = malabsorption

  • WL
  • Vit ADEK deficiencies
  • steatorrhoea (undigested fat)

DM - alpha & beta damage

Pseudocysts - ductal obstruction = pressure, fluid accumulation

Pancreatic cancer - rare

28
Q

What is the treatment of chronic pancreatitis?

A
  • analgesia
  • risk factor control (alcohol, meat, obesity)
  • pancreatic insufficiency (exogenous enzyme replacement, nutritional supplements)
  • DM (insulin replacement Tx)
29
Q

How does pancreatitis cause SIRS?

A

Hypovolaemic shock = SOB, hypoxaemia, hypotension, fever

30
Q

Name 5 classic pancreatitis presentations

A
  • hepatomegaly (alcoholic)
  • xanthomas (hyperlipidaemia)
  • swollen parotids (mumps)
  • Cullen’s sign (necrosis)
  • Grey-Turner’s sign (necrosis)
31
Q

What blood results would be expected in an acute pancreatitis picture?

A
  • lipase & amylase 3x limit
  • FBC (leukocytosis, raised Hct)
    dehydration, acute haemorrhage
  • CRP & LDH raised
  • Cr
    dehydration
  • low calcium (fat necrosis)
  • hyper/hypoglycaemia
32
Q

What results on an abdo USS show pancreatitis?

A
  • pancreas enlarged & hypoechoic
  • gallstones
33
Q

What results on an A/CXR show pancreatitis?

A
  • sentinel loop (ileus inflammation)
  • pleural effusion
34
Q

How is an abdo CT used to stage pancreatitis?

A

Balthazar score

  • necrosis
  • inflammation
  • fluid collection around pancreas
35
Q

What are the two methods of staging pancreatitis?

A

Atlanta & Ranson’s criteria

36
Q

What comprises the Atlanta classification?

A

Mild - no organ failure or complications
Moderate - transient organ failure (resolves in 48h) +/- complications
Severe - organ failure >48h

37
Q

What are Ranson’s criteria?

A

Admission

  • 55
  • high WCC, LDH, AST
  • hyperglycaemia

48h after admission

  • low Hct, Ca, pO2
  • high urea, base defecit
  • fluid sequestration

1-3 = mild

> 3 = severe

38
Q

How to treat mild pancreatitis

A
  • fluid resus (saline 5-10 ml/kg/h for 12-24h)
    Risk: persistent hypo (ischaemia & necrosis)
  • oral nutrition in 24h
39
Q

How to treat severe pancreatitis

A
  • fluid resus (20 ml/kg/h for 30 mins then 3ml)
  • IV opioids (morphine, fentanyl)
  • parental/enteral feeding
40
Q

What potential complications can arise from pancreatitis?

A
  • ARDS
  • pleural effusions (pancreaticopleural fistula)
  • ascites
  • saponification of fatty tissue (enzymes)
  • acute peripancreatic fluid collection becomes acute necrotic collection
  • pancreatic pseudocyst
  • necrotic abscess
41
Q

How to treat ARDS

A

Intubation

42
Q

How to treat a necrotic abscess

A

Broad spectrum abx (meropenem, amoxicillin)

  • no improvement in 4w = necrosectomy/debridement

hbp (6 decks)

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