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Pancreatitis

From Mediwikis

This is a variable condition, from mild through to severe and life threatening, and therefore should not be taken lightly. Pancreatitis patients will often be looked after by surgical teams. Remember that the pancreas is a retroperitoneal strucutre.

Presenting Complaint

  • Abdominal pain in the epigastric region radiating to the back which may improve on sitting forward
  • Nausea & Vomiting, worse with food
  • Anorexia

Types

On Examination

Signs include:

  • Tachycardia and hypotension
  • Fever with cold peripheries
  • Abdomen - tender, may be distended with reduced bowel sounds
  • If there is pancreatic haemorrhage - Grey Turners (flank bruising) and Cullen's (bruising around the umbilicus) signs may be present
  • If the pancreatitis has been caused by a gallstone obstructing the common bile duct then the patient is also at risk of infection in the form of ascending cholangitis which causes a nasty sepsis - they will then present with signs of septic shock
Cullen's Sign

Causes

A useful mnemonic to causes is:
GET SMASHED (Common causes in bold)

  • Gallstones
  • Ethanol
  • Trauma
  • Steroids
  • Mumps
  • Autoimmune
  • Scorpion stings (in Trinidad[1]- don't mention it if the patient hasn't been there, you'll look daft)
  • Hyperlipidemia/ Hypercalcemia
  • ERCP
  • Drugs (Steroids, Thiazide Diuretics, Sodium Valproate)

Aetiology

Not always clear, but premature activation of digestive enzymes leads to cellular necrosis- Trypsinogen is converted to trypsin.

Investigations

  • Serum amylase - diagnostic if 3x upper limit of normal
    • NB: the serum amylase may be normal or <1000 but still raised in some patients who have got pancreatitis - these can be split into 2 groups, the first do not have enough pancreas to mount a large enough amylase e.g. partial pancreatectomy, the second are late presenters - after the initial insult on the pancreas the amylase level may begin to fall before the patient starts to feel any better
  • C Reactive Protein
  • Abdo USS (ultrasound) - may show inflammation - may also show the cause e.g. gallstones sitting in the common bile duct (CBD)
  • Contrast Enhanced CT scan if unclear on diagnosis or complications (including necrosis of the pancreas) are suspected. Performed after 72 hours
  • MRCP - MRI looking at the biliary tree to try and help identify the cause of pancreatitis if it is not initially identified

Severity Scoring

The Glasgow criteria[2] for the prediction of pancreatitis severity is usually used to guide management. Each one of the following gets a point if present and if more than 3 are present the pancreatitis is classed as severe and should be treated in HDU:

  • PaO2 < 8
  • Age > 55
  • Neutrophils - WCC > 15
  • Calcium < 2
  • Renal Function - Urea > 16
  • Enzymes - ALT > 100 or LDH > 600
  • Albumin < 32
  • Sugar - Glucose > 10

Management

There is no role for the use of antibiotics in pancreatitis (unless there is proven infection which is uncommon).

Treat the underlying cause- ERCP for gallstones, alcohol abstinence, treat infection, plus:

  • Nil by mouth until resolution - eating stimulates the pancreas to secrete more enzymes - worsening symptoms
  • Morphine for pain
  • Mild pancreatitis is self-limiting after five days or more
  • HDU care if severe
  • IV Fluids - pancreatitis causes third spacing of fluids and therefore a hypovolaemic state - patients with acute pancreatitis may need a lot of IV fluids to prevent dehydration
  • Oxygen if required

Complications

Early include:

  • Systemic Inflammatory Response Syndrome
  • DIC (disseminated intravascular coagulation)
  • Failure - Renal or Respiratory (in the form of ARDS - Acute respiratory distress syndrome)
  • Haemorrhage
  • Thrombosis
  • Dehydration

Mid term complications include:

  • Pancreatic Necrosis - around 4–6 days after the start of the acute pancreatitis - identified on CT
    • This is a very serious complication as necrosis of the pancreas and release of the pancreatic enzymes can lead to massive and sudden autodigestion of the contents of the abdomen (including bowel which then has to be resected)

Later complications include:

  • Abscess formation - identified as the patient gets worse/does not improve with treatment
  • Pancreatic pseudocyst - fluid filled sac in the lesser sac of the abdomen containing pancreatic material and enzymes (it is a pseudocyst as the walls are not lined iwth epithelium as in a normal cyst) - identified on CT
  • Chronic pancreatitis

References

  1. Acute Scorpion Pancreatitis in Trinidad http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1700547/
  2. http://www.themastersurgeon.com/toolkit/calculators.aspx?calcID=6