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Pancreatitis

Pancreas - training.seer.cancer.gov

Acute Pancreatitis

This is where there's rapid onset of inflammation and symptoms, with function returning to normal after an episode. It can be caused by - I GET SMASHED:

  • Idiopathic

  • Gallstones

  • Ethanol (Alcohol)

  • Trauma

  • Steroids

  • Mumps

  • Autoimmune

  • Scorpion venom

  • Hyperlipidaemia

  • ERCP

  • Drugs (furosemide, thiazide diuretics, azathioprine)


Patients present with:

  • Stabbing-like, epigastric pain which radiates to the back and is relieved by sitting forward or lying in foetal position

  • Vomiting

  • Hx of gallstones or recent alcohol binge

    • O/E - Tachycardia, Dry mucous membranes, Grey-turners/Cullen’s sign (both signs of intra/retroperitoneal hemorrhage)


Differentials - Perforated peptic ulcer, AAA rupture, Ruptured ectopic pregnancy, MI in elderly/diabetics


N.B. If any elderly patient presents with epigastric pain, it's always wise to do an ECG as they can present atypically.


Complications:

  • Early

    • ARDS - massive pancreatic inflammation leads to widespread extravasation of fluid into the 3rd space

    • AKI and Shock - due to hypovolaemia

    • DIC

  • Late

    • Necrotising pancreatitis +/- infection - indicates inadequate fluid resuscitation during initial management

    • Pseudocyst - collections of pancreatic fluids after 4 wks

    • Abscess

    • Bleeding - elastase degrades major vessels (e.g. splenic artery)


N.B. There will be bilateral pulmonary infiltrates on CXR if the pt develops ARDS.


Glasgow Score

This is used to assess the severity of the pancreatitis episode.

A score of 3+ is indicate of severe pancreatitis.


Investigations:

  • ECG

  • FBC, U&E, LFT - Leukocytosis may indicate necrosis

  • Amylase! - x3↑ in acute pancreatitis

    • This is the best test in the acute phase as it stays elevated for the first 5 days

  • Lipase - Raised - It's more sensitive and specific for pancreatitis but not as readily available

    • This is a good test if it's a delayed presentation e.g. 1-2 weeks later

  • USS, ERCP, CXR, CT - look for cause and complications


Management:

  • Aggressive fluid resuscitation with crystalloids - Start with 1L bolus, followed by maintenance

  • Anti-emetics

  • Opioid analgesia

  • IV Abx if necrotising pancreatitis


Chronic Pancreatitis

This is where there's chronic inflammation and fibrosis of both the exocrine and endocrine components of the pancreas. The most common cause of it is Alcohol, but other causes include:

  • Idiopathic

  • Genetics (e.g. Cystic fibrosis)

  • Obstruction (e.g. pancreatic cancer)

  • Metabolic (e.g. raised triglycerides)


Patients present with:

  • Epigastric pain, classically worse after eating fatty food and relieved by sitting forward

  • Features of pancreatic insufficiency

    • Exocrine loss - Steatorrhoea and Malabsorption

    • Endocrine loss - Diabetes


Differentials - Peptic ulcer disease, Pancreatic insufficiency syndromes e.g. CF, pancreatic resection


Complications:

  • Obstruction

  • Pseudocyst

  • Abscess

  • Pancreatic cancer


Investigations:

  • Abdomen CT/MRI - shows calcifications

  • Faecal elastase - exocrine function

  • Fasting glucose/OGTT - endocrine function

  • Amylase


N.B. Amylase and lipase are not typically raised here, which differentiates it from acute pancreatitis.


Management:

  • No alcohol! and good diet

  • CREON (enzyme replacement) - for exocrine loss

  • Insulin - for endocrine loss

  • Analgesia

  • If no improvement, surgery may be done



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