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FRS: Pancreatitis

What are the causes of acute pancreatits?


Gallstones, alcohol, idiopathic (80%) of cases
o AP due to alcohol is rare in pts <30yrs
Other
o Infections
o Post ERCP
o Trauma
o Drugs azathioprine, NSAIDs
o Hyperlipidemia
o inherited
What are the presenting features of AP in hx and examination?
Pain epigastric, LUQ, chest pain which is severe and constant with radiation to the back
Associated sx: nausea, vomitting, abdo distension
Hx of PC: gallstones, excess alcohol, recent ERCP, recent trauma, drugs and viral illness
Family hx: possible
On examination: -hydration, postural BP, JVP and capillary refill
o Fever
o Resp distress
o Pleural effusions
o Abdo exam: distension, guarding, tenderness, ascites, flank bruising, silent abdomen
o Signs of underlying disorder: eg. CF, malignancy hypercalcaemia, jaundiced
carcinoma
What are the local and systemic complications of acute pancreatits in the early and late phase?

Local Systemic
Early Ileus, pain Renal failure, hypokalaemia,
hypocalcaemia, ARDS
Late Necrosis, infected necrosis,
pseudocyst, abscess
Intestinal failure, muscle
wasting

How is pancreatitis diagnosed clinically?
Clinical hx, signs
Confirm pancreatic enzymes 3x ULN Lipase
o Imaging US for gallstones, CT

What other conditions can be associated with a high serum lipase?
Acute pancreatitis
Chronic pancreatitis
Acute cholecystitis
Duodenal ulcer
Pancreatic calculus
Diabetic ketoacidosis
HIV
Post-ERCP/trauma
Coeliac disease
Drugs
Idiopathic
What MDT members are involved in the mx of acute pancreatiits?
Gastroenterologist
Surgeons
Intensive care
Endoscopists
Radiologists
Pathologists
What is the management for acute pancreatiis?
Resuscitate: ABCD
o Line bore IVC, IDC (if in ICU art line and CVC)
o O2 aim for O2sats >95%
Analgesia narcotic via PCA or epidural
Rehydrate balanced electrolyte solutions
Reassess regularly temp, HR, BP, UO, JVP
IV fluids titrate to volume status
o Once gorss vol status corrected, set infusion rate for basal fluid requirements
(35ml/kg/day), plus ongoing third space loses
o KCl should be added to IVF aim for 100mmol/day
Proton pump inhibitors prevent stress ulcers
Fasting and refeeding
o Pancreas exocrine organ which secretes in response to oral diet
Fasting until resolution established
No clear protocols for when to restart oral intake use clinical judgement
for resolution of sx, but prolonged fasting adverse outcomes due to gut
disuse mucosal atrophy
Stat clear fluids, graduate to solid foods as tolerated
Start enteral refeeding (jejunal feeding tube) if oral refeeding not
established after 5 days
Monitor closely
o Labs: FBC, CRP, UEC, glucose, arterial pH, lipids
Magnesium and calcium monitoring and replacement if required
If glucose >13.9 start insulin
Blood transfusion if Hb <100, haematocrit <25%
o Monitoring: O2 sats, aim >95%
If resp insufficiency urgent CXR for APO or ARDS
Vomitting if protracted AXR to assess for ileus, NGT for comfort and to
prevent aspiration
What is the ranson score? What does it determine? How is it calculated?
Ranson score for predicting severity of acute pancreatitis
It can determine both severity and predict mortality
11 points, scored at admission and 48 hours after admission
Score >3 severe pancreatitis, score <3 severe pancreatitis unliekly
Mortality
o 0-2 = 2% mortality
o 3-4 = 15% mortality
o 5-6 = 40% mortality
o 7 8 = 100% mortality
Criteria:
o On admission (GALAW)
Glucose >11.1mM
AST > 250 u/L
LDH > 350 u/L
Age > 55yrs
WCC > 16,000/mm3
o At 48hrs (CHOBBS)
Calcium <2 mM/L
Haematocrit drop >10%
PO2 <60mmHg
Base excess >-4Meq/L
BUN >1.8mM/l despite fluids
Sequestration of fluid >6L
What other factors are useful in determining severity?
Mortality predictors multiple organ failure, elderly, shock on arrival, SIRS
o SIRS: temp >38.5 or <35, HR>90, RR >20 or PO2 <32mmHg, WCC >12,000 or <4000,
or >10% immature bands
o Body weight: obesity, BMI >40kg/m2
o CRP tends to rise slowly and peaks day 3-4, if >300mg/L necrosis likely
Do not send the pt home!
o Imaging CT
What is the utility of CT scanning in acute pancreatits? When should it be performed? What is the
CT scan severity index?
IV contrast-enhanced CT can distinguish from oedematous and necrotising pancreatic tissue
more accurate than U/S
CT scanning should be ordered at 72hrs unless critically ill, in need of emergency surgery, or
to rule out other diagnoses takes time for necrosis to develop, may be equivocal in 24-
48hrs
Follow-up CT scanning should be performed at 7-10 days if change in pts clinical status that
suggests complications
o Psuedocysts can take several weeks to develop, repeat/prorgess scan at time of
hospital discharge
CT severity index:
o Stage A: normal pancreas score 0
o Stage B: intrinsic pancreatic changes Score 1
Focal or diffuse gland enlargement, mild heterogenity of the gland
parenchyma, small intrapancreatic fluid collections
o Stage C: Intrinsic and mild extrinsic changes Score 2
Inflammatory changes
o Stage D: Extrinsic inflammation Score 3
But not more than one ill defined fluid collection
o Stage E: Multiple extensive extra-pancreatic fluid collections of abscesses Score 4
o Plus necrosis percent score
0% necrosis 0
<33% necrosis 2
33-50% necrosis 4
>or=50% necrosis -6
Index Morbidity rates Mortality rates
0-3 8% 3%
4-6 35% 6%
7-10 92% 17%

What is the utility of ERCP in the diagnosis of acute pancreatitis? When should ERCP be used?
ERCP has no role in diagnosis of acute pancreatits
Alcohol and gallstone diease 80% of cases
Indications:
o Cholangitis or impacted stones
o Early ERCP and sphincterotomy within first 72hrs of onset of pain

What are the 4 commandments of ERCP in acute pancreatitis?
Acute pancreatitis with gallstones and elevated bilirubin early ERCP <72hrs
All pts undergoing early ERCP for severe gallstone pancreatitis require endoscopic
sphincterotomy regardless of whether stones are found in bile duct
Cholangitis should be treated with sphincterotomy and duct drainage by stenting to
decompress biliary obstruction
All pts with biliary pancreatitis need definitive management of gallstones after their recovery
for acute pancreatitis

What is the signifiance of infected pancreatic necrosis as a local late complication?
Is CT scan good at differentiating infected necrosis from non-infected, how can the diagnosis be
confirmed?
What bacterial strains are found in pancreatic tissue or blood cultures?
Infected pancreatic necrosis mortality increase (70-80%)
o 25-70% of pancreatic necroses become infected, gram negative gut organisms via
bacterial translocation
Frequently develops 2-4 weeks from onset
CT scan cannot determine if infected or not need to watch for signs of sepsis
o Diagnosis: guided FNA under CT /US
Gram stain or culture +ve surgical or percutaneous drainage
Bacterial strains:
o Escherichia coli
o Enterococcus
o Klebsiella
o Staphylococcus
o Pseudomonas
o
What is the role of prophylactic antibiotic use in acute pancreatitis? When ABs be initiated? What
ABs?
Prophylactic antibiotic treatment in mild AP no beneficial effect, leads to selection of AB
resistant bacteria
But, early AB treatment inidicated in pts with pancreatic necrosis significant beneficial
effect on outcome and mortality
Initiation of ABs:
o If there is CT evidence of necrosis and fever
Start carbepenem
o If CRP> 300 and fever
Start carpenem
o Culture positive collection drain
Anbibiotics:
o Carbepenems (imipenem, meropenem), metronidazole, fluoroquinolones,
cephalosporins
o Aminoglycosides (gent) does not reach pancreatitic tissue at high enough
concentration



Pathology of pancreatitis
What is the pathogenesis underlying acute pancreatitis?




What are the histological features macroscopically and microscopically of acute pancreatitis?
Macro: swollen, oedematous, fat necrosis and haemorrhage
Microscopic: neutrophils, focal fat necrosis (within, surrounding and occasionally distant
from pancreas), blood vessel damage and bleeding

What is a pancreatitic pseudocyst? What is the pathogenesis of the pseudocyst?
Localised collection of necrotic haemorrhage material rich in pancreatic enzymes
Pathogenesis: walling off of area of pancreatic haemorrhagic fat necrosis by fibrous tissue
What are the macro and microscopic features of pancreatic pseudocysts? What are the
complications of pancreatic pseudocysts?
Macro: range in size from 2-30cm in diameter
Micro: cyst wall has no epithelial lining, lining is a fibrous wall of granulation tissue
Complications: compression of surrounding structures (eg. Bile ducts), infection, abscess,
rupture (severe chemical peritonitis) and haemorrhage
What are the main causes of chronic pancreatitis? What are the other causes?
Common: alcohol, idiopathic and others
Causes: TIGARO
o Toxins (etoh, metabolic hyercalcaemia, hypertriglyceridaemia), idiopathic, genetic
(hereditary pancreatitis, CF), autoimmune, recurrent acute pancreatitis, obstruction
tumours, pseudocysts
What are the macroscopic and microscopic features of chronic pancreatitis?
Macro: dilated pancreatic ducts, calcification, firm
Micro:
o Early: fibrosis, exocrine gland atrophy, islet often preserved, blocked pancreatic duct
o Late: extensive fibrosis, exocrine gland atrophy, islets preserved

Micro: early
Late:

What are the complications of chronic pancreatitis?




Pancreatic tumours

What are the tumours of the pancreas?

Most are epithelial
o Exocrine origin
Ductal adenocarcinoma (90%)
Serous cystic tumours
Acinar cell carcinoma (unusual)
Mucinous neoplasms (unusual)

What are the risk factors of pancreatic carcinoma?
M>F
Smoking x2 non-smokers
Chronic pancreatitis
Diabetes
Hereditary pancreatitis

What are the macroscopic and microscopic features of pancreatic carcinoma?
Macro:
o Location: head 70%, body 20%
o Hard, grey-white mass
o Evidence of local infiltration and systemic mets liver, LNs
Microscopic
o Granular structures infiltrating stroma and lobules
o Desmoplastic reaction
o DD is chronic pancreatitis


What should be on the path report for pancreatic neoplasm?
Type of specimen
Location of tumour head/body/tail
o Unifocal/multifocal
Type of tumour
Tumour grade
Tumour size =<2cm
Tumour borders circumscribed/infiltrative
Surgical margins
o Clear/involved where there is extension
Lymphatic/vascular invasion
LNs
Other pathology chronic pancreatitis


Pancreatic anatomy

What is the blood supply to the pancreas?


What are the components of the pancreas?
Head, neck, tail and body

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