Pancreatitis

Question 1

What is pancreatitis

Answer 1

Inflammation of the pancreas

Question 2

Clinical presentation of acute pancreatitis

Answer 2

PAN:
epigastric or upper abdominal Pain radiating through to the back
Anorexia
Nausea and vomiting

Grey Turners sign - flank bruising
Cullen’s sign - peri-umbilical bruising
Coma and multiple organ failure are possible, and may delay diagnosis.

Question 3

Pathophysiology of acute pancreatitis

Answer 3

The pancreas releases exocrine enzymes that cause auto-digestion of the organ.
Final common pathway; increased intracellular calcium -> activation of intra-cellular proteases and release of pancreatic enzymes.
This can lead to acinar cell injury and necrosis -> Inflammatory cells and release of mediators and cytokines to produce local inflammatory response.
Can progress to multiple organ failure.
Gallbladder: Gallstones block the bile duct, causing back pressure in the pancreatic duct.

Question 4

Aetiology of acute pancreatitis

Answer 4

Gallbladder disease and excess alcohol consumption
I GET SMASHED:
Idiopathic
Gallstones
Ethanol (alcohol)
Trauma
Steroids
Mumps
Autoimmune
Scorpion sting
Hyperlipidemia
ERCP (Endoscopic retrograde cholangio-pancreatography)
Drugs e.g. azathioprine

Gallstones and Ethanol are most common

Question 5

Epidemiology of acute pancreatitis

Answer 5

150-452/1 mil

Increasing

Question 6

Diagnosis of acute pancreatitis

Answer 6

Serum amylase: 3x more than normal.

Lipase levels rising more sensitive.

Question 7

Treatment of mild acute pancreatitis

Answer 7

Pain relief/analgesics e.g. tramadol
IV fluids (keep nil by mouth - NBM)
Monitor for complications and treat underlying causes e.g. gallstones
Usually symptomatic relief

Question 8

Treatment of severe acute pancreatitis

Answer 8

IV antibiotics if necrotising, feed with enteral nutrition. Monitor for complications.

Question 9

Complications of acute pancreatitis

Answer 9

HDAMN:
Haemorrhage
Disseminated intravascular coagulation
Acute respiratory distress syndrome (ARDS)
Multiorgan failure
Necrosis
others:
Pancreatic abscess (may require surgery)
Recurrence

Question 10

Clinical presentation of chronic pancreatitis

Answer 10

Severe epigastric abdominal pain 
Pain radiating through to the back
Recurrent
Relieved by sitting forward
Worse when eating/drinking heavily

Severe weight loss possible. 
Diabetes and steatorrhoea (due to insulin and liapse deficiency). 
Jaundice possible (due to obstruction of the CBD).

Question 11

Subtypes of chronic pancreatitis

Answer 11

Large and small duct pancreatitis

Small duct tends not to be associated with calcification

Question 12

Pathophysiology of chronic pancreatitis

Answer 12

Inappropriate activation (possibly prompted by alcohol) of enzymes within the pancreas leads to precipitation of protein plugs within the duct lumen, forming a nidus for calcification.
This leads to ductal hypertension, and therefore pancreatic damage.
In addition to cytokine activation, this causes pancreatic inflammation, morphological change and possible permanent loss of function.
End result is pancreatic fibrosis.

Question 13

Aetiology of chronic pancreatitis

Answer 13

CAMP:
Cystic fibrosis
Alcohol
Malnourishment
Pancreatic duct obstruction

Question 14

Epidemiology of chronic pancreatitis

Answer 14

3/100,000 but rising

Question 15

Diagnosis of chronic pancreatitis

Answer 15

Xray/CT: Displays calcification (not valid in small duct)

Secretin stimulation test: Detects if pancreatic exocrine function is damaged.

Question 16

Treatment of Chronic pancreatitis

Answer 16

Pain relief.
Cessate alcohol.
Replace pancreatic enzymes (aids functionality and pain by down regulating release of pancreatic enzymes)
Surgery: Local resection to aleviate duct dilatation/duct stones

Question 17

Complications of Chronic pancreatitis

Answer 17

PODS:
Pseudocysts
Obstruction (pancreatic)
Diabetes mellitus
Steatorrhoea

Question 18

Conservative treatment of chronic pancreatitis

Answer 18

Alcohol cessation

Question 19

Medical treatment of chronic pancreatitis

Answer 19

Analgesics e.g. tramadol and pancreatic enzyme replacement therapy
Start insulin therapy if diabetes has developed

Question 20

What is acute pancreatitis

Answer 20

Inflammation of the pancreatic parenchyma, with biochemical associations of increased amylase and raised lipase enzymes on blood test.

Question 21

What is chronic pancreatitis

Answer 21

Where the structural integrity of the pancreas is permanently altered as a direct result of chronic inflammation.

Question 22

Acute pancreatitis investigations

Answer 22

Raised serum amylase and lipase
Detect cause e.g. ultrasound scan to detect presence of gallstones
CT scan to rule out complications (not within <72h of acute presentation unless clinically indicated)

Question 23

Chronic pancreatitis investigations

Answer 23

Decreased faecal elastase
CT scan - shows calcification (may also be seen on abdominal X-ray)
Magnetic resonance cholangiopancreatography (MRCP)