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Path: Liver 6 - Gallstones + Pancreatitis (iii) (Acute pancreatitis (Tx…
Path: Liver 6 - Gallstones + Pancreatitis (iii)
Acute pancreatitis
acute inflamm of pancreas
mortality approx 5% (higher if severe)
single or recurrent attacks
premature (intra-pancreatic) activation of pancreatic enzymes
once initiated, irreversible cascade of autodigestion
may trigger SIRS if severe
widespread vasodilation
hypovolaemia
hypotension
ARDS
acute renal failure
DIC (depletion of coag factors)
obstructing stone @ lower end of CBD (near ampulla) causes reflux of bile/concentration of pancreatic juices
alcohol has direct toxic effect
80% = mild
self-limiting
interstitial oedematous acute pancreatitis on imaging
non-necrotising
20% = severe
necrotising inflamm of pancreas + surrounding tissue (peripancreatic fat)
SIRS
hypocalcaemia (increased FAs chelate calcium)
hyperglycaemia
ileus
local complications
extensive necrosis (acute necrotic collection)
secondary infection
later: pseudocyst, fistula
2 phases of mortality
50% occur in 1st wk: SIRS + complications
50% occur in 2nd wk: necrosis + sepsis
causes
gallstones (F>M)
alcohol (M>F)
post-ERCP (5%) - iatrogenic
10% idiopathic - possibly biliary microlithiasis?
5% due to miscellaneous uncommon causes
trauma
ischaemia
major surgery
drugs
viral
hypoercalcaemia
hyperlipidaemia
hereditary
Dx
symptoms
epigastric pain, may radiate to back
acute abdo
if severe, dDx = MI, ruptured AAA, perforated/ischaemic abdo organ
bloods
amylase > x3 normal (amylase has a short T1/2)
lipase maybe in future?
radiology if equivocal
try identify cause, avoid immediate laparotomy (incision into abdo cavity)
Tx
difficult to pick course/severity @ onset
aim: early identification of those with severe disease for tx in HDU/ICU (scoring systems - triaging)
age, WCC, pO2, haematocrit (increased in hypovol)
albumin, urea, Ca, glucose, AST, LDH
resuscitation, analgesia, IV fluids, enteral feeding (NPO)
look for + tx systemic complications
CT after interval: look for necrotic tissue
possible guided FNA to look for infection
consider antibiotics if necrotic tissue
possible debridement of necrotic tissue - necrosectomy
Chronic pancreatitis
patchy irreversible fibrosis, ongoing inflamm
pancreatic function impaired (esp exocrine)
distortion of ductal system
strictures (dilation + cysts behind these)
pancreatic ductal stones
causes
alcohol
idiopathic
childhood causes incl CF (ducts tend to block with mucus, more typically a/w pancreatic insufficiency due to damage, without clinical chronic pancreatitis, PO pancreatic enzymes supplements NB to prevent failure to thrive)
extensive fibrosis + numerous dilated ductal spaces + cysts (containing amorphous pink material), loss of functional glandular acini
symptoms
pain (dull, epigastric, radiating to back)
weightloss
steatorrhoea + malabsorption
secondary DM
Tx: analgesia (opiates) + enzyme supplements
Dx
difficult - sometimes dx of exclusion
amylase not useful
test of pancreatic function not routine
imaging in advanced disease
Pancreatic pseudocyst
collection of pancreatic fluid in disrupted tissue in or adjacent to pancreas
defined wall but not a true cyst (no epithelial lining)
causes: pancreatitis (acute or chronic), pancreatic surgery/trauma
complications: pain/pressure, infection, erosion with fistula or blood vessel damage
tx: aspirate or drain by endoscopy or surgery