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Acute Pancreatitis - Coggle Diagram
Acute Pancreatitis
CAuses of Raised Serum Amylase
Upper GIT perf
Mesenteric infarction
Torsion of intra-abdominal visus
Retroperitoneal haematoma
Ectopic preganancy
Macroamylasaemia
Renal failure
Salivary gland inflammation
Epidemiology
Incidence
10-20 / 100,00o in western word
54% increased over 7 yr
Cause
VAries depending on catchment are
In IRE more common is C2H5
Severity
80% mild
20% severe
Morbidity / Mortality
5-10% mortality
20-30% mortality
Gender
M - C2H5 more common
F - gallstone pancreatitis more common
Aetiology
40% Alcohol
40% Gallstones
10% Unknown
10 less common
ACquired
Metabolic
Hyperlipidaemia
HyperCA
Malnutrition
Trauma
Abdominal
ERCP
Surgery
Infection
Mumps
Coxsackie viru
Drugs
Metronidazole
Steroids
Sulphonamides
Furosemide
Thiazides
Valproate
Azathioprine
Neoplastic
Pancreatic caner
Autoimmune Pancreatitis
Hereditary pancreatitis - Spink 1, CFTR
Memory Aid
I GET SMASHED
Diagnosis
Requires 2/3 of these criteria
Adominal pain consistent with acut pancreatitis
Serum amylase or lipase
greater tha 3 times the upper limit of normal
Characteristic findings on abdominal imaging (CT)
Assessing Severity
Glasgow Imrie Score
Ranson Criteria
APACHE Score
CRP
Severity
Mild
No organ failure
No local / systemic complications
Moderately Severe
Transient organ failure
or
Local / systemic complications without persistent organ failure
Severe
Persistent organ failure, single or multi
or
Mortality for htose with persistent organ failure or SIRS as high as 36-50%
Evolving dynamic condition - severity may change
Necrotising Pancreatitis
Inlammation associated with pancreatic parenchymal necrosis and / or peripancreatic necrosis
CECT criteria
Lack of pancreatic parenchymal enhancement by IV contrast
And / Or
Presence of findings of peripancreatic necrosis
WON Walled Off Necrosis
Heterogeneous with liquid and non-liquid density
A mature, encapsulated collection of pancreatic and / or peripancreatic wall
Usually occurs > 4 weeks after onset of necrotising pancreatitis
Management
Infected Necrosis
Can be suspected by clinical course
CAse within collection in CT
In case of doubt - FNAc
Investigations
Diagnosis
BLoods
Sertum amylase
During first 24h
May not r/o pancreatitis with normal amylase if high clinical suspicion
Does not predict disease severity
Urinary amylase remains elevated for longer
More than 3-4x upper limit of normal
Lipase
Reported;y more sensitive ans specific
Longer peak
Nor routinely performed here
Imaging
CT
day 5-7
Necrosis
Odeoma
Severity
Bloods
FBC
LFTS
IF elevated bilirubin consider biliary pathology
U&E and Ca
ABG
CRP
if ≥ 150 - severe - TH protocol
Cause
U/S Gallbladder
+/0 ERCP
Mangement
Mild
Basic vitals
Oral fluids as toleraed
IVF
Electrolyte replacement
Analgesia
US abdo ?gallstones
Self-limiting
Nutrition
Severe
Severe pancreatic protocol in TUH
NPO
Strict ins and outs - urine cath
IVF
Analgesia
Blood sugar levels
? empirical abx
PPI
Regular ABGs
US day 1 CT day 3-5
10.Nutrition - JN feeding (preferable) or TPN
TX underlying cause
Ugent ERCP + sphincterotomy if GS pathology
Resus
Early resus reduces risk of necrosis
Mangement of Systemic Complication
General mx
Acute phase
ICU / HSU if organ support needed
Nutritional intervention - ideally enteral feeding
Abx
Long temr
Pancreatic enzyme therapy if exocrine insuff
Endocrine insuff
Chronic pancreatitis
Management of Local Complication
Radiological drainage of fluid collections
Endoscopic / radio management of bile duct complications
Surgical drainage todrain collections
The Pancreass
Development
Functions
Pathophysiology
Local Response
Injury to acinar cells
Premature trypsin activation
Fat necosis and local inflam
Interstitial oedema dnimpaired blood flow leading to ischaemic cell injury
Multiple organ systems
Amplication of the inital local pancreatic response
IL-1, IL-6, TNF alpha produced
Cytokine involed in progression beyond pancreas
Systemic inflam response
Symptoms
Abominal Pain
S: Epigastric Pain
O: Sudden
C: Sharp
T: To Upper back
A: Nausea, vomiting, anorexia
T: Constant intense
E: Relieved by sitting forward
S: VAry from mild discomfort to severe pain
Rule of thumb - acute abdo pain - r/o acute pancreatitis
Symptoms
Abdominal
Tender in epigastrium
Cullen sign (peri umbilical echymosis)
Grey Turner sign (flank echymosis)
Absent bowel signs
Vitals
Tachycardia
Tachypnoea
Decreased O2 stats
Hypovolaemia
SIRS
Defined by presence of 2+ criteria
HR > 90
Core temp <36 or >38
WBC < 40000 or >12000
Resp >20/min or PCO" <32mmHg 13
Admit to HDU
Persistent SIRS >48hr from admission
Glasgow score >3
APACHE score >8
RAnson score >3
Complications
Local
Necrosis
Bleeding / pseudoanuerysm
Fluid collection
Pseudocyst (mature fluid collection)
Bile duct obstruction
Fistula
Systemic
SIRS and multiorgan failure
Sepsis
Endocrine and exocrine deficiency
Nutritional deficity
Acute Pancreatitis Definition
An acute inflammatory process of the pancreas that frequtnly involves peri-pancreatic tissue and / or remote organ systems
