Pancreatitis

10/05/2013 by admin | Gastroenterology

Acute pancreatitis:

  1. Acute destructive inflammation of pancreas
  2. Incidence 40-500/mil (varying with rate of alcohol consumption and incidence of GS)
  3. Incidence is increasing and mortality is falling
  4. p/c: jaundice (if deep = GS/cholangitis), cyanosis, ARDS (T1 RF), metabolic problems (hypo-/hyperglycaemia, hypocalcaemia), acute renal failure, Grey-Turner sign (=bruising in flanks), DIC and secondary bruising, abdo complications (=pseudocysts, ascites, abscesses, necrosis), Cullen’s sign
  1. (=periumbilical bruising), CBD obstruction, hypovolaemia, mild to severe epigastric pain radiating through to back.
  2. Pathophysiology:
    1. o IGETSMASHED: gallstones (30-50%), ethanol (10-40%), trauma (due to ERCP/post-op/blunt trauma = 5%), idiopathic (15%)
    2. o High alcohol = acute pancreatitis, chronic calcifying pancreatitis (if >10y of >150g/d = steatorrhoea, malabsorption, pain, biliary obstruction, diagnosed by ERCP/CT scan).
  3. I GET SMASHED
  4. I - Idiopathic
  5. G - Gall stones
  6. E – Ethanol (alcohol)
  7. T - Traumas
  8. S - Steroids
  9. M – Mumps (+cocsackie), Malignancy
  10. A - Auto-immune
  11. S - Scorpion bite
  12. H - Hypercalcemia, Hyperlipidemia (=Trigylcerides >10mmol/L)
  13. E - ERCP
  14. D – Drugs (=oestrogen, corticosteroids)

 

  1. Once the process has started there is a degree of pancreatic necrosis related to proteolytic auto-digestion of the gland.
  2. P/c: classic triad
    1. o Abdo pain: sudden onset (<30mins), epigastric, radiating through to back, diminishing in 72h, aortic dissection/rupture (esp if hypotensive).
    2. o Vomiting = hypokalaemia
    3. o Jaundice = presence of associated cholangitis and raises probability of GS
  3. Biochemistry suggestive of pancreatitis:
    1. o WCC >15, urea >16, calcium <2, albumin <32, glucose >10, Po2 <8, AST >200, LDH >600, CRP >150
  4. Ix:
    1. o Amylase (usually greatly raised)
    2. o AXR = ileus (reduced motility and small bowel obstruction)
    3. o CT with contrast = most valuable diagnostic test
  5. Mx:
    1. o Analgesia: opiates
    2. o Resus: IV fluids, CVP, O2, broad spectrum Abx
    3. o Tx cause: elevated AST or clinical cholangitis = GS impacted in ampulla (tx with early ERCP)/cholecystectomy
    4. o Shock = fluids
    5. o DIC = blood products
    6. o Pancreatic necrosis = operative resection
    7. o Pseudocyst/abscess = percutaneous drainage
  6. Complications:
    1. o Usually self-limit, but severe cases may have complications
    2. o Pancreatic pseudocysts/abscess: suggested by persistent pain/fever. Diag via CT
    3. o Adult respiratory distress syndrome
    4. o Portal vein/mesenteric thrombosis
    5. o Mortality: 2-50%

Chronic pancreatitis:

  1. On-going pancreatic dysfunction, prev 25/100,000, incidence 8/100,000
  2. Pathophysiology:
    1. o A recurrent acute pancreatitis
    2. o Alcohol use (most common cause in UK)
    3. o Idiopathic (20% of cases)
  3. P/c:
    1. o Pain (85%) – epigastric, radiating to back, precipitated by eating, variable severity
    2. o Exocrine pancreatic insufficiency: steatorrhoea, weight loss (late on id disease)
    3. o Diabetes (30%)
  4. Ix:
    1. o Pancreatic enzymes raised in acute attack and normal in chronic disease
    2. o ERCP: may demonstrate main pancreatic duct irregularity with side branch changes.
    3. o Abdo CT: shows pancreatic calcification
  5. Mx:
    1. o Analgesia (opiates / coeliac axis nerve block)
    2. o Remove underlying cause
    3. o Replace pancreatic exocrine and endocrine function
    4. o Pancreatic enzyme replacement with Creon and Pancrex often improves both the pain and malabsorption of chronic pancreatitis 
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