AcutePancreatitis

JKoh&DCheng

AcutePancreatitis

ACUTEPANCREATITIS

Acutepancreatitis
Acuteinflammationofthepancreascharacterisedbysevereabdominalpain,
accompaniedbyelevationofserumpancreaticenzymes
Unpredictablediseasewithmortalityof1015%
Sx&Cxareduetoautodigestionofthepancreasandsurroundingtissue
causedbyleakingpancreaticenzymes
ThereispotentialforarapidERsituationduetoselfperpetuatingpancreatic
inflammation(andofotherretroperitonealtissues)
LitresofECFcanbetrappedinthegut,peritoneum,andretroperitoneum
fromwidespreadinflammationandoedema
SevereInflammatoryResponseSyndrome(SIRS)canresultandpatientscan
dieofshock,renalfailure,sepsisorrespiratoryfailure
Acuteonchronic
o Discreteepisodeofacutepancreatitisepisodeonbackgroundof
chronicpancreatitis,includingchronicabdominalpain,steatorrhoea,
diarrhoea,pancreaticendocrinedysfunction
o TypicallyinthesettingofchronicETOHuse

Pathophysiology
- Acutepancreatitisoccursasaconsequenceofprematureactivationof
zymogengranules,releasingproteaseswhichdigestthepancreasand
surroundingtissue
- Adjacentstructures,includingthecommonbileduct,duodenum,splenicvein
andtransversecolonarecommonlyinvolvedintheinflammatoryprocess
- Severityofacutepancreatitisisdependentuponbalancebetweenactivityof
releasedproteolyticenzymesandantiproteolyticfactors
- Acutepancreatitisisusuallymildandselflimiting,withminimalorgan
dysfunctionanduneventfulrecovery

Causes/RiskFactors(GETSMASHED)
- Gallstones*
- ETOH(Alcohol)*
- Trauma
- Steroids
- Mumps
- Autoimmune(PolyarteritisNodosa)
- Scorpionvenom
- Hyperlipidaemia
- Emboli/ERCP
- DrugsegAzathioprine,Sulphonamides,Valproate,Thiazides,Pentamidine

Gallstonerelated
ETOHrelated
- Usuallycharacterisedbypresenceof - Chronic/recentheavyalcoholintake
acutepancreatitisinthesettingof
- Presenceofchronicpancreatitis
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AcutePancreatitis

gallstones
CholestaticLFTs:GGT&ALP
Dilatedintra/extrahepaticbiliary
ductalsystem
Commonbileductstoneonimaging
Age>50yo;Female
Amylase>4000,AST>100,ALP>300

Clinicalfeatures
ElicitriskfactorsintheHx
- Gallstones:AnyHxofpainintherighthypochondriumafterfattymeals?
- ETOH:AnypainafterconsumingETOH?TakeETOHHx
- Drugs:Whatmedicationsandforwhatconditions?

Symptoms
- Nauseaandvomiting:inflamedpancreascausesgastroparesisandgastric
distension&vomiting
- Epigastricorcentralabdominalpainradiatingtotheback
o Mayrangefromgradualonsettosuddenandsevere
o Oftenaggravatedbyfoodintake,especiallyfattyfood
o Aggravatedwhenpatientsupine
o Relievedbysitting/leaningforward(pressurealleviatedoffpancreas)
o Backpainoftenduetoretroperitonealinvolvement

Signs
- Tachycardia
- Fever
- Jaundice
- LowBP/Shock
- Signsofperitonitis
o Absentbowelsounds(duetoileus)
o Localtenderness
- Oliguria(withrenalinvolvement)
- CullensSign
o Yellowbluediscolourationoftheskinaroundtheumbilicus
o Causedbypancreaticenzymesthathavetrackedalongthefalciform
ligamentanddigestedsubcutaneoustissuesaroundtheumbilicus
o Mayalsooccurwithectopicpregnancies
- GreyTurnersSign
o Bruisingoftheflanksthatoccurduetosubcutaneoustrackingof
inflammatory,peripancreaticexudatefromthepancreaticareaofthe
retroperitoneum
o Alsoseeninsevereabdominaltrauma(egMVAs,rupturedAAA)
- Lungs(1020%):Cracklesandeffusions,especiallyleftsidedcanoccur

AcutepancreatitisVSnonpancreaticabdominalpain
- Paindevelopsveryquickly,severe
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AcutePancreatitis

DDx
-

Butfluctuateslittleinintensity,persistsforfewdays
Relievedbysittingforward
Nausea&vomitingpresentforhours
Serumenzymes
Othercauses:painforhoursratherthandays,mildnausea&vomiting
Perforatedpepticulcer
o Painradiatestoback
o Severeabdominalrigidity
o Patientwillbestatuelikeasmovementcausespain
Peritonitis(inflammationorperforationofanyvisceramaycause)
o Acutecholecystitis/ascendingcholangitis
o Appendicitis
o MesentericIschaemia
o Diverticulitis/Bowelperforation
Acutesmallbowelobstruction
AcuteMyocardialInfarction(AMI)
AbdominalAorticAneurysm

Investigations
- SerumAmylase/Lipase
o Amylase:maybenormalasw/i2448hduetorenalclearance
(UrinaryAmylasecanalsobemeasured)
o Lipase:highersensitivityandspecificityforpancreaticinjury,remains
forupto714days
- AbdominalCTScanorMRI
o Allowsassessmentofseveritybydetectingswellingofpancreasand
pancreaticnecrosis
o Presenceofcalcificationimplieschronicpancreatitis
- Ultrasound
o Candemonstratepancreaticswellingandoedema
o Seedilatationofbiliarytreeduetogallstones(gallstonesw/ithe
gallbladderisNOTsufficienttojustifyDxofgallstonepancreatitis)
- FBE:WCC
- U&Es
o Assesshydrationandelectrolytestatus(importanttohavebaselineto
assessseverityofattackover2448h)
o Checkrenalfunction(asrenalinvolvementpossible)
- LFTs
o GGT+ALP=Posthepaticobstruction(gallstonecause)
o AST+ALT=Intrahepaticcause
- LactateDehydrogenase(LDH):foundinthecellsofalmostallbodytissues
andisreleasedintothebloodstreamwhencellsundergoinjury
- CRP:serialassessmentisanusefulindicatorofprogress
- CMP(Ca2+,Mg2+,PO43)
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o Saponification:processwheresoapisformedw/ithepancreaswhen
Ca2+combineswithHCO3
o [Ca2+]indicatesthisprocessisoccurringbutyoumustadjustfor
albumin(eachraisedalbumin=0.2inCa2+)
BloodGases:[HCO3]suggestssaponification
ECGtoexcludeAMI
CXR&AXR
o Gasunderthediaphragm(pneumoperitoneum)suggests
gastroduodenalperforation
o Gasnotalwaysbepresent;mustcombinewithclinicalexam
o Patientmayhaveperforatedpepticulcerandpancreatitisifthe
perforationisontheposteriorwallofthestomach!
o LackofpsoasshadowonAXRindicatesretroperitonealfluid
EndoscopicRetrogradeCholangiopancreatography(ERCP)
o AnInxandRxifgallstonesarethecause

ModifiedGlasgowCriteriaforPredictingSeverity
GlasgowCriteriahasbeenvalidatedforpancreatitiscausedbygallstones&ETOH.
3positivefactorsdetectedw/i48hrsindicateseverepancreatitisandthepatient
shouldbeadmittedtoICU.Topredictseverity,rememberPANCREAS:
- PaO2<8kPa(60mmHg)
- Age>55y.o
- Neutrophils(WCC)>15x109/L
- Calcium<2mmol/L
- RenalFunction:Urea>16mmol/L
- Enzymes:LDH>600iu/L;AST>200iu/L
- Albumin<32g/L(serum)
- Sugar:Bloodglucose>10mmol/L

Management
Thereisnocureforpancreatitis,andalthoughdifferentiatingbetweenanacute
episodeandanexacerbationofchronicpancreatitiscanbedifficult,Mxisthesame.
Fluidlossesareoftenlargeandfluidsinandout(+renalFx)mustbemaintained.

SupportiveRx
- Closemonitoring:pulse,BP,urineoutput,dailybloodtests
- FluidReplacement&Monitoring:insertIVdripandIDC
- NasogastricSuction:insertNGTbutconsiderparenteralnutrition
- Feeding:totalparenteralnutrition(IVfeeding)hasbeena/whighriskof
infection.Evidencesuggeststhatenteralnutritionvianasojejunaltubeis
welltoleratedandcanmaintainadequatenutrition.

Pharmacotherapy
- Analgesia:Morphine+Metoclopramide
o MorphinecancausefurthercontractionofOddissphincter
- BroadspectrumantibioticscanbehelpfulforinfectiveCx:egcephalosporins,
imipenem

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AcutePancreatitis
-

ProtonPumpInhibitors:Pancreatitis+NGT=riskofulcers

ICU:if3+vefactorsfromGlasgowCriteria

Surgery
- Laparotomywithdebridementofnecrosedpancreatictissue
- ERCPwithsphincterotomy&stoneextraction(gallstonepancreatitis)

Complications
Pancreatic
- Malabsorptionsyndrome:VitaminsA/D/E/K(fatsolublevitamins),folate,
B12,iron
- Necrotisingpancreatitis
o Mostsevereformofpancreatitiswherebyintracellularproteasesare
activatedandcausecellularnecrosis(thoughttobefromCa2+)
o Mortality>80%inthisgroupduetomultiorganfailurefollowing
- Pseudocyst:acutefluidcollectionssurroundedbygranulationtissue
o Lossofintegrityinwall
o Leadstochronicpain
o Obstructiontocommonbileduct/duodenum
o Dissection,bleeding,infection,leakage,rupture
- Ascites/pleuraleffusion
- Abscess
- Diabetes
- Steatorrhoea

Intestinal
- Paralyticileus
- GIhaemorrhage
- Fistula
- Biliaryobstruction

Systemic
- RenalFailureduetohypovolaemia
- SIRS:highconcentrationsofproteolyticenzymesandinflammatory
mediatorscancausethepatienttogointoshock
- AcuteRespiratoryDistressSyndrome(ARDS)
o Canbecausedbydirectlunginjuryorseveresystemicillness
o Lungdamageorreleaseofinflammatorymediatorscausestissue
permeabilityandnoncardiogenicpulmonaryoedema
o Diagnosiscriteria
Identifiableassociatedcondition
Acuteonset
Pulmonaryarterywedgepressure18mmHgorabsenceof
clinicalevidenceofleftatrialhypertension
PaO2/FiO2ratio200
CXR:bilateralinfiltrates(mayshowcompletewhiteout)
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o Oftenaccompaniedbymultiorganfailure
o Rx:intubationandintraalveolarpressuretoforcefluidoutofthe
interstitiumandbackintobloodvessels
DisseminatedIntravascularCoagulation(DIC)
o Pathologicalactivationofcoagulationmechanisms,withreleaseof
procoagulantfactorscausingconsumptionofclottingfactors&
platelets
o Fibrinstrandsfillsmallvessels,haemolysingpassingRBCs
o Occursinmalignancy,trauma,sepsis,obstetrics

References
AcknowledgementstoPNgu,MBBS
th
Davidson,PrinciplesandPracticeofMedicine,20 Edition
th
Longmoreetal,OxfordHandbookofClinicalMedicine,7 Edition

JKoh&DChengAug2010
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