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Pancreatitis (Diagnosis & Investigations ((C-Reactive Protein (CRP).…
Pancreatitis
Diagnosis & Investigations
Serum Amylase 3 x upper limit of normal range. Beware false positive or negative results - up to 25% with acute pancreatitis have normal amylase levels
C-Reactive Protein (CRP). Indicator of severity.
Other blood tests: FBC, LFTs, ABG
Abdominal and chest x-ray
Abdominal CT scan
Magnetic resonance cholangiopancratography (MRCP)
Endoscopic ultrasound (EUS)
faecal elastase test
[secretive pancreatic function test)
regular diabetic screening in chronic pancreatitis
Aetiology
Acute
Gallstones present in 40% of patients
Alcohol (in Scotland 30% of cases)
Approx 5% of patients undergoing ERCP
Other causes: hypertriglyceridamia, hypercalcaemia, pancreatic malignancy, trauma, infection, drugs, autoimmune disease, parasites, obstruction
Idiopathic in 10-20% of cases
Chronic
Alcohol. Implicated in 60-80% of cases
Cigarette smoking. (Coffee drinking has been shown to lower risk in this group)
Genetic predisposition
High fat/protein diet
Clinical features
Severe epigastric pain with radiation to back
Pain in right or left hypochondrium
Nausea & vomiting
Peritonisim
Tachycardia, hypotension, tachypnoea
Obstructive jaundice
Anorexia
Ecchymosis on flanks or periumbilical (rare)
Additional features in Chronic Pancreatitis
Weight loss
Steatorrhoea
Diabetes mellitus
Duodenal obstruction
Splenic vein thrombosis (leading to splenomegally, hypersplenism and gastric and oesophageal varices)
classification
Revised Atlanta classification Acute
. Severity: Mild Acute Pancreatitis
A.No organ failure
B.No local complications (e.g. peri-pancreatic fluid collection, pancreatic necrosis)
C.No systemic complications
Severity: Moderate Acute Pancreatitis
A.Transient organ failure (<48 hours) or
B.Local complications or
C.Exacerbation of comorbidity
Severity: Severe Acute Pancreatitis
A.Persistent organ failure (>48 hours)
Cambridge classification for Chronic pancreatitis
The Cambridge classification grades the severity of pancreatic structural changes based on abnormalities of the main duct and side branches observed on ERCP, transcutaneous abdominal ultrasound, or CT . classed from 1-5, 5 most severe.
BISAP score. Bedside indicator severity of acute pancreatitis
Altered Mental Status
B. Blood Urea Nitrogen (BUN) >25
C. SIRS Criteria positive for 2 or more
D.Age over 60 years
A.Score 0: Mortality 0.1%
B.Score 1: Mortality 0.4%
C.Score 2: Mortality 1.6%
D.Score 3: Mortality 3.6%
E.Score 4: Mortality 7.4%
F.Score 5: Mortality 9.5%
APACHE II score not exclusive to acute pancreatitis. Commonly used in intensive care settings and for research comparisons
Glasgow Imre Score Acute pancreatitis severity
age> 55
WCC > 15X109/litre
paO2 < 60mmhg (7.9 kpa)
Ca2+ < 2.0mmol/L
Glucose > 10mmol/L
Urea > 16mmo
lactate > 600 iu
Albumin < 32g/l
min acore 0, max score 8
< 3 severe pancreatitis unlikely
3 severe pancreatitis likely
treatment
ACUTE
IV fluids: NICE guidelines for fluid resuscitation.caution over 4l.preferred fluid ringers lactate or hartmanns. Analgesia(morphine, ibuprofen) antiemetic if required Ondansetron. DO NOT FAST AS Routine. Determine cause. Abdominal U/S.
Chronic
omeprazole, analgesia, pancreatin for pancreatic insufficiency.
Epidemiology
Acute Pancreatitis
increasing in incidence. increasing by 3.1% annually
100-400 new admissions per million of population per year in UK
Largest increase in women under 35 years and men aged 35 to 45
Incidence higher in areas with high social deprivation
Mortality rate between 1-25% depending on severity
Gallstone pancreatitis more common in women > 60 years
Alcohol related pancreatitis is seen more frequently in men
Chronic Pancreatitis
2 -14 cases per year per 100,000 people
Prevalence of chronic pancreatitis after an acute attack - 10%, then 36% after multiple attacks
Age at presentation varies with aetiology.
Hereditary pancreatitis - peak age: 10 - 14 years
Juvenile idiopathic - peak age: 19 -23 years
Alcoholic chronic pancreatitis - peak age: 36-44 years
Senile idiopathic - peak age: 56 - 62 years
Prognosis
chronic
chronic: 70% @ 10 years . falling to 45% at 20 years.
Acute. 85% mild, 15% severe with 30% mortality within the severe group
E. Pleural Effusion on CT Scan