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Acute Pancreatitis
Definition of acute pancreatitis: Inflammation of the pancreas, ranging from mild, self-limiting disease to complete necrosis of the entire organ.
By definition, acute pancreatitis occurs on the background of a normal pancreas and can return to normal on resolution (cf. chronic pancreatitis, which has irreversible changes)
Epidemiology of acute pancreatitis: About 300 cases per million per year Of these, 20% are mild and resolve without serious complications
Causes of acute pancreatitis: I – Idiopathic (most common) G – Gallstones E – Ethanol T – Trauma S – Steroids M – Mumps A – Autoimmune (eg. PAN) S – Scorpion Venom – black Trinidadian scorpion (tityus trinitatis) H – Hyperlipidaemia, Hypercalcaemia E – ERCP D – Drugs (azathioprine, thiazides, valproate, asparaginase, allopurinol) And Pregnancy
Presentations of acute pancreatitis: History: o Severe epigastric pain, radiating through to the back o Pain worse on lying down and relieved sitting forward o Vomiting o Recent excess alcohol intake o Previous gallstone disease o FHx gallstones
Examination: o Tachycardia o Fever o Abdominal/epigastric tenderness o Jaundice o Rigid abdomen o Reduced bowel sounds o Periumbilical staining (Cullen’s sign) o Flank staining (Grey-Turner’s sign) o Shock
Differential diagnosis of acute pancreatitis:
Any other cause of an acute abdomen Myocardial infarction Pericarditis Aortic dissection
Scoring systems for severity of acute pancreatitis:
Glasgow criteria for predicting severity: PANCREAS mnemonic PaO 2 <8Kpa Age < 55yrs Neutrophils (WBC > 15) Calcium <2mmol/L Renal function (Urea > 16) Enzymes (LDH > 600, AST > 200) Albumin < 32g/L Sugar > 10mmol/L
3 or more positive factors predicts a severe pancreatitis and the patient should be managed in an HDU/ITU setting.
Initial management of acute pancreatitis: Current BSG guidance http://www.bsg.org.uk/images/stories/docs/clinical/guidelines/pancreatic/pancreatic.pdf Blood tests: o Amylase – often >1000 but CAN be normal initially (esp if acute on chronic) o Lipase – more sensitive and specific than amylase but less readily available as a test o FBC (for neutrophils), U+Es (assess renal function), LFTs (for albumin and transaminases/bilirubin), Calcium Arterial blood gas Intravenous fluids – patients need prompt and adequate fluid resuscitation Oxygen supplementation Analgesia – patients usually require regular opiates Feeding – if nutritional support is required then the enteral route should be the preferred option if this is tolerated.
Further management of acute pancreatitis: Antibiotics – Current evidence is not conclusive regarding prophylactic antibiotics to prevent infection of necrosis. Antisecretory agents – there is no evidence to support the use of these in acute pancreatitis. CT abdomen – current guidelines recommend this be done after 6-10 days if persisting signs of organ failure, ongoing sepsis or clinical deterioration. This can be performed earlier if there remains significant diagnostic uncertainty. ERCP – urgent therapeutic ERCP with sphincterotomy should be performed within 72 hours in patients with acute severe pancreatitis and evidence of jaundice/common bile duct dilatation/cholangitis. Surgical intervention – all patients with infected necrosis will require radiological or surgical drainage and/or surgical debridement.
Complications of acute pancreatitis: Early: o Shock o Acute kidney injury
o Acute kidney injury o Acute respiratory distress syndrome o DIC o Sepsis o Hypocalcaemia o Hyperglycaemia o Pancreatic necrosis Late: o Pancreatic necrosis o Pancreatic pseudocyst o Pancreatic fluid in lesser sac Fluid in lesser sca Presents > 6 weeks later Abdominal mass may be present May need internal (via stomach) or external drainage o Abscess o Thrombosis – splenic/gastroduodenal arteries o Fistulae
