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
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)
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