Pancreatitis-A

Question 1

define pancreatitis

Answer 1

acute inflammatory process of the pancreas with variable involvement of other regional tissues or remote organ systems

Question 2

what can pancreatitis be classified as?

Answer 2

mild- minimal organ dysfunction and uneventful recovery

severe- organ failire and/ or local complication such as necrosis, abcesses and pseudocysts

Question 3

explain the aetiology/ risk factors of pancreatitis?

Answer 3

insult results in activation of pancreatic proenzymes within pancreatic duct/acinii leading to tissue damage and inflammation causes- GET SMASHED

Question 4

What are the causes of pancreatitis?

Answer 4

Gallstones- most likely cause

Ethanol- Very likely cause

Trauma

Steroids

Mumps/ HIV/COXSACKIE

Autoimmune

Scorpion Venom

Hypercalcaemia/ hyperlipidaemia/ hypothermia

ERCP ( examining pancreatic and bile ducts)

Drugs ( sodium valproate, steroids, thiazides, azathioprine)

Question 5

summarise the epidemiology of pancreatitis?

Answer 5

common UK annual incidence- 10/10000 peak age- 60 years most common cause: - males= alcohol - females= alcohol

Question 6

what are the presenting symptoms of pancreatitis?

Answer 6

severe epigastric pain- better when leaning forward radiating to the back relieved by sitting forward aggravated by movement

associated with anorexia, nausea and vomiting

IMPORTANT- Check if patient has history of high alcohol intake and gallstones

Question 7

What are the signs of pancreatitis on physical examination?

Answer 7

epigastric tenderness

fever shock ( includes tachycardia and tachypnoea)

decreased bowel sounds ( due to ileus)

severe pancreatitis

• cullen’s sign
• preumbilical bruising
• grey-turner sign ( flank bruising)

Question 8

What are the appropriate investigations for pancreatitis?

Answer 8

bloods

• USS: check for evidence of gallstones in biliary tree – QUICK CHECK ON THIS BEFORE ERCP AS THIS SHOULD ONLY BE PERFORMED IF CONFIRMED GALLSTONES
• Erect CXR: may be pleural effusion. Also to check for bowel perforation - NOT USED FOR DIAGNOSIS
• AXR: exclude other causes of acute abdomen
• CT Scan: if diagnosis is uncertain/ rule our bowel ischaemia or if persisting organ failure or if CRP > 200 (high risk of pancreatic necrosis)
• usually go straight to ERCP MRCP may be used instead of CT in patients with renal insufficiency who cannot tolerate IV contrast.

Question 9

describe bloods for diagnosing pancreatitis?

Answer 9

very high serum amylase ( no correlation with severity)

High WCC

high U and Es ( dehydration)

high glucose

High CRP

Low calcium * saponification- calcium binds to digested lipids from pancreas to form soap)

LFTs ( may be deranged if gallstone pancreatitis or alcohol) ABG ( for hypoxia or metablic acidosis) - fundamental to pancreatitis scoring-> in turn guides management

Question 10

summarise prognosis for patients with pancreatitis?

Answer 10

• 20% follow severe fulminating course with high mortality • Infected pancreatic necrosis has a 70% mortality • 80% follow a milder course (but this still has 5% mortality)

Question 11

what are the local complicartions of pancreatitis?

Answer 11

o Pancreatic necrosis - increasing CRP, worsening pain; confirmed with CT (can happen a few days after)

o Pseudocyst (peripancreatic fluid collection which develops around 4 weeks after) -very common complication

o Abscess – pain and features of sepsis

o Ascites - v. high amylase content in ascites fluid

o Pseudoaneurysm

o Venous thrombosis

Question 12

what are the systemic complications of acute pancreatitis?

Answer 12

o Multiorgan dysfunction

o Sepsis

o Renal failure

o ARDS

o DIC

o Hypocalcaemia

o Diabetes

Question 13

what are the long term complications of acute pancreatitis?

Answer 13

could result in chronic pancreatitis

Question 14

what are the 2 scales to assess the severity of pancreatitis?

Answer 14

o Modified Glasgow Score (combined with CRP (> 210 mg/L)

o APACHE-II Score

Question 15

describe the glasgow score to assess the severity of pancreatitis?

Answer 15

The Glasgow score is used to assess the severity of acute pancreatitis. A score of 3 or more indicates severe pancreatitis (discuss with ICU as may need more invasive management of fluids). The criteria of the Glasgow scale can be remembered using the mnemonic PANCREAS. • PaO2 < 7.9 Age > 55 • Neutrophilia (WCC > 15 x 109/L) • Calcium < 2mmol • Renal function (urea > 16 mmol) • Enzymes (LDH > 600 U/L or AST > 200 U/L) • Albumin < 32 g/L • Sugar (glucose) > 10 mmol

Question 16

summarise the management for pancreatitis?

Answer 16

• Medical Management:

O Nil by mouth – stop patients eating – if there is no stimulus of food then less amylase should be produced!

o Urinary catheter and NG tube if vomiting – suck out all the contents so all the XS enzymes etc are out

o Fluid and electrolyte resuscitation

o Analgesia

o Blood sugar control, Calcium and magnesium replacement therapy

o HDU and ITU care

o Prophylactic antibiotics may be useful in reducing mortality

• ERCP and Sphincterotomy:

o Used for gallstone pancreatitis, cholangitis, jaundice or dilated common bile duct

o Ideally performed within 72 hours – but not performed until the pt has stabilised

o All patients presenting with gallstone pancreatitis should undergo definitive management of gallstones during the same admission or within 2 weeks

• Early detection and treatment of complications:

o For example if there are persistent symptoms or > 30% pancreatic necrosis or signs of sepsis –> image guided fine needle aspiration for culture

• Surgical:

o Necrotising pancreatitis should be managed by specialists

o Necresectomy (drainage and debridement of necrotic tissue) may be necessary