Please enable JavaScript.
Coggle requires JavaScript to display documents.
GIHEP Surgery - Pancreatitis + Pancreatic Carcinoma (i) Acute pancreatitis
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
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
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)
Causes
"I GET SMASHD"
idiopathic (approx 20%)
gallstones (raised bili)
ERCP
trauma
steroids
mumps/certain other infections
AI
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)
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
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
obstructive jaundice
cholestasis
can be fatal
RUQ pain
in haemorrhagic patients
stigmata of bleeding (rare)
Cullen's sign (peri-umbilical bruising)
Grey turners sign (flank bruising)
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