Pancreatitis

Question 1

what are the causes of acute pancreatitis?

Answer 1

I GET SMASHED

Idiopathic

Gallstones
Ethanol
Trauma

Steroids
Mumps and malignancy
Autoimmune 
Scorpion sting
Hyperlipidaemia or hypercalcaemia 
ERCP 
Drugs - azathioprine and pentamidine

Question 2

what are the S&S of acute pancreatitis ?

Answer 2

epigastric or LUQ pain

• sudden onset
• radiate to back
• constant and severe
• stabbing
• worsens with movement and relieved by fetal position

Severe N&V

fever, dehydration, hypovolaemia, hypotension and tachycardia (shock)

Guarding on abdo exam

signs of pleural effusion

Left flank ecchymosis (Grey-Turners sign) 
Periumbilical ecchymosis (Cullens sign)

Question 3

what InV are done in acute pancreatitis?

Answer 3

serum lipase and amylase

• > 3x upper limit of normal (amylase >1000)
• lipase remains elevated for longer so better in delayed presentation
• up to 25% are normal

FBC with differential

• leucocytosis with left shift (Increase in ratio of immature:mature)
• Haematocrit >44% = poor prog

Elevated CRP

Transabdominal US
- pancreatic inflammation or fluid collection

CT abdo
- diffuse or segmental enlargement of pancreas with irregular contour and obliteration of peri-pancreatic fat, necrosis or pseudocyst

Question 4

how is the severity of acute pancreatitis graded?

Answer 4

The Glasgow Imrie Criteria
- if >3 then its severe

PANCREAS

PaO2 <8kPa 
Age >55 
Neutrophils >15
Corrected calcium <2mmol/l 
Raised blood urea >16mmol/l 
Elevated Enzymes AST >200, LDH >600
Albumin <32 
Sugar - blood glucose >10mmol/l

Question 5

what is the treatment of acute pancreatitis?

Answer 5

IV crysalloid fluids

Analgesia
- usually morphine but prescribe appropiate for pain

O2

Anti-emetic
- Ondansetron

IV ABx - usually imipenem

calcium and magnesium replacement

ERCP for gallstone pancreatitis

CT guided pancreatic aspiration for infected necrosis

Question 6

what are the complications for acute pancreatitis?

Answer 6

systemic

• DIC
• ARDS
• Hypocalcaemia
• hyperglycaemia

Local

• pancreatic necrosis (CT and FNA - treat with pancreatic necrotomy)
• Pseudocyst (can become infected or haemorrhage. Wait 6 weeks then debride or drain)

Question 7

what is chronic pancreatitis?

Answer 7

Characterized by recurrent or persistent abdominal pain arising from the pancreas.
• Often associated with exocrine or endocrine pancreatic insufficiency.

• Characterized by irreversible destruction and fibrosis of pancreatic parenchyma.
• May arise following one or more episodes of acute pancreatitis or may be a chronic progressive process de novo.

Question 8

what are the causes of chronic pancreatitis?

Answer 8

Mostly alcohol (70-80%)

Recurrent acute pancreatitis of any cause

Secondary to pancreatic ductal obstruction:
• Pancreatic head cysts, tumours.
• Pancreatic duct strictures—post-surgery, ERCP, parasitic infestation.
• Congenital pancreatic abnormalities (pancreas divisum, annular pancreas).
• Cystic fibrosis.

Associated with autoimmune diseases (primary biliary cirrhosis, primary sclerosing cholangitis).

Congenital idiopathic chronic pancreatitis

Question 9

how can chronic pancreatitis present?

Answer 9

Features of chronic inflammation
• Recurrent or chronic abdominal pain:
• Typically epigastric, radiating to the back and requiring opiates.
• Worse with food, alcohol.

Features of exocrine failure
• Anorexia and weight loss (due to protein malabsorption).
• Steatorrhoea (due to fat malabsorption); soft, greasy, foul-smelling stools that typically float on water.

Features of endocrine failure
- Insulin-dependent diabetes mellitus (due to loss of β islet cells).

Question 10

how is chronic pancreatitis diagnosed ?

Answer 10

Ultrasound ± CT
- pancreatic calcifications confirm the diagnosis

mrcp + ercp (risks acute attack);
- may show the characteristic beaded appearance of the pancreatic duct as well as larger calcifications

axr
- speckled calcification

↑glucose

faecal elastase low and faecal fat high

Question 11

what are the management options for chronic pancreatitis?

Answer 11

Prevention of cause/progressive damage.

• Stop alcohol, deal with gallstones, treat autoimmune disease.
• Encourage a diet rich in antioxidants (vitamins A, C, E, selenium).

Control symptoms/complications

• Dietary modifications. Adequate carbohydrates and protein, reduced fat.
• Pancreatic exocrine enzyme supplements i.e lipase (creon) and fat soluble multivitamins
• Ocreotide
• Analgesia. May require opiates, tramadol or coeliac plexus block. beware of addiction
• Control of diabetes mellitus often requires insulin; control is often difficult due to variable pancreatic function.

Question 12

what are the surgical options for chronic pancreatitis?

Answer 12

Surgical treatment Indications include the following

Treatment of reversible cause (anatomical abnormalities, tumours, cysts, ductal strictures and stones).

• Pancreaticoduodenectomy (Whipple procedure).
• Partial pancreatectomy of the head (Frey procedure) or tail (distal pancreatectomy).
  .
  Treatment of severe intractable pain or multiple relapses. Operations are usually to resect affected portion:
• Partial pancreatectomy of the head (Frey procedure) or tail (distal
  pancreatectomy).
• Total pancreatectomy.

Complications
(pseudocyst, obstruction, fistula, infections, portal
hypertension).

Question 13

what are the complications of chronic pancreatitis and their treatments

Answer 13

pseudocyst - decompression via endoscopic drain

biliary obstruction - decompression via stenting or choledochojejunostomy and choledochoduodenostomy

pancreatic CA

fistula

opioid addiction