Pancreatitis

Question 1

Symptoms of acute pancreatitis.

Answer 1

• sudden onset, progressive to severe pain
• epigastric, LUQ pain
• radiate to the back
• maybe relieved by sitting up and lean forward
• exacerbated by movement
• N/V
• pale and sweaty
• tachycardia
• hypovolaemic signs: low JVP, low BP

Question 2

Signs on examinations of acute pancreatitis

Answer 2

• RUQ & epigastrium tenderness, guarding
• tachycardia
• fever
• hypovolaemic shock
• paralytic ileus may develop; bowel sound decreases in this case
• Cullen’s sign , Grey-Turner’s sign (from retroperitoneal haemorrhage & blood vessel autodigestion)
• jaundice (if cause if gallstone or inflammed pancreas pressing on biliary tree)

Question 3

Causes of acute pancreatitis

Answer 3

I - idiopathic

G - gallstone

E - ethanol

T - trauma

S - steroids

M - Mump or coxsackie virus

A - autoimmune

S - scorpion

H - hyperlipidaemia, hypercalcaemia

E - ERCP

D - Drug

Question 4

Investigation for acute pancreatitis

Answer 4

CRP - >150mg/L at 36 hr post admission = severe pancreatitis

LFT - biliary tree block

serum Lipase - more than 2 fold upper limit of normal

ABG - monitor oxygenation and acid-base status

AXR - no psoas shadow = retroperitoneal fluid
- sentinel loop of prox. jejunum and ileum from ileus
(air-filled dilatation)

erect CXR - exclude other cause; perforation, air under diaphragm

CT - assess severity & complications

Question 5

Management of acute pancreatitis

Answer 5

1. Fasting
2. Analgesia
3. IV normal saline until vital signs are good and urine flow stays > 30 mL/h.
4. Monitoring: hourly - pulse, BP, urine output
   daily - FBC, U&E, glucose, amylase, ABG
5. ERCP and gallstone removal once stable.
6. repeat CT to monitor progression

Question 6

Differential Dx of acute pancreatitis

Answer 6

1. AMI

2. any acute abdomen; PUD, acute cholecystitis, perforated oesophagus

Question 7

Complications of acute pancreatitis

Answer 7

Early
1. Shock (ARDs), renal failure - give lots of fluid!

2. sepsis
3. raised glucose level (transient) - need insulin

Late

1. Bleeding - eroded major vessel, need embolization
2. thrombosis -in SMA, splenic art, gastroduodeanal art. causing bowel necrosis
3. pancreatic necrosis
4. abscess - need drainage

Question 8

How to predict severity of pancreatitis

Answer 8

Modified Glasgow criteria - 3 or more positive within 48h or onset suggest severe pancreatitis, admit to ICU
valid for gallstone and alcohol induced pancreatitis

P - paO2  55
N - neutrophilia WCC > 15 x10^9
C - Ca   16mmol/L
E - enzyme; LDH >600, AST > 200
A - albumin   10 mmol/L