GIHEP Surgery - Pancreatitis + Pancreatic Carcinoma (i) Acute pancreatitis

Intro

inflamm process in pancreas - release of inflamm CKs + pancreatic enzymes (trypsin, lipase etc)

initiated by pancreatic injury

often presents with acute abdo pain + elevated levels of pancreatic enzymes in blood/urine

serum amylase x3 normal + abo pain

occurs @ any age

overall mortality = 10% (up to 40% if severe)

accounts for 3% of hosp admissions with abdo pain

sphincter of Oddi @ ampulla of Vater

Causes

"I GET SMASHD"

idiopathic (approx 20%)

gallstones (raised bili)

ERCP

trauma

steroids

mumps/certain other infections

scorpion bite

hypercalcaemia/hyperlipidaemia

hypercal often in hyperparathyroidism + bone malignancy

test lipid blood levels (hyperlipidaemia can often be seen macroscopically in blood samples)

Drugs incl alcohol

hx NB

thiazides

anti epileptics e/g/ sodium valproate

amlodipine (for HTN + CAD)

pathogenesis

autodigestive process

activation of pancreatic enzymes - pancreatic damage - local + systemic inflamm response

if severe usually affects other systems - end organ failure

usually sterile

no pathogens @ 1st

but then patient immunocompromised + vulnerable to OI colonisation + bacterial translocations

Signs + symptoms

depends on severity

pain

often sudden onset

radiates to back

relieved by sitting forward

nausea + vomiting

dehydration

one of the 1st signs of a severe inflamm condition

reduced skin turgor

sunken eyeballs

hypotension

increased Hb + haematocrit

epigastric guarding (entire abdo rigid + tender)

tachycardia, tachypnoea, mild pyrexia

if a/w ascending cholangitis due to gallstones

icterus

pyrexia

obstructive jaundice

cholestasis

can be fatal

RUQ pain

fever can also be present in absence of infection simply due to release of pyrogens (happens in any inflamm)

but if there's a pattern to the fever this suggests infection + necrosis

in haemorrhagic patients

stigmata of bleeding (rare)

Cullen's sign (peri-umbilical bruising)

Grey turners sign (flank bruising)

ddx: ruptured AAA, perforated duodenal ulcer, ischaemic bowel, aortic dissection (high index of suspicion needed)

can be classed as mild (minimal organ dysfunction) or severe (organ failure +/- local sequelae)

Severity stratification

3 scoring systems used to determine severe of attack + associated mortality

Glasgow scoring system (IMRIE)

P - art PaO2 < 8kPa (do ABG)

A - Age > 55

N - neutrophilia (WCC>15)

C - Ca < 2

R - renal function (urea>16)

E - enzymes (LDH>600, AST>200)

A - albumin (32)

S - sugar (blood glucose > 10)

move to ICU before deterioration if likely, with hrly monitoring of vitals

RANSON'S Score

@ presentation check

age>55

WCC>16

blood glucose>11.1

LDH>350

AST>250

48hrs later check

haematocrit fall by 10+%

blood urea nitrogen increase by 5+ mg/dL (1.8 mol/L) despite fluids

serum Ca < 60 mg/dL (2mmol/L)

pO2 < 60mmHg

base deficit > 4 Meq/L

fluid sequestration > 6000 ml

the presence of 1-3 criteria = mild, mortality significantly rises with 4+ criteria

APACHE

Investigations

bloods (FBC, CRP, LFTs, U+E, Ca, albumin, glucose)

ABG

to gauge severity

measures pH, lactate (if > 3-4 - poor prognosis, important to reverse, also high in dead bowel), electrolytes

CXR (free air under diaphragm = pathognomonic for perforated viscus, but absence of free air does not excl perforation)

US-abdo - gallstones, oedema, fluid, dilated CBD (normal = 6-8mm, any bigger is suggestive of gallstones)

CT-pancreas

can see pleural effusions

can judge severity/complications