MRCS

Acute Pancreatitis

Aetiology:

Gallstones - 45% of cases.

Ethanol - 35% cases.
Trauma.
Steroids.
Mumps.
AUI - SLE, panarteritis.
Scorpion venom - native species to Trinidad.
Hyperlipidaemia, hypercalcaemia (calcium activates trypsinogen).
ERCP, abdominal surgery.
Drugs -azathioprine, NSAID, furosemide, sulphonamides.

Presentation:

Pain - severe acute epigastric, radiating to the back possibly relieved by leaning
forward.
SIRS - systemic inflammatory response syndrome.
Vomiting.
Loss of appetite.
Eponymous signs:
Grey-Turner's - flank bruising secondary to retroperitoneal haemorrhage
tracking from anterior para-renal space to the lateral edge of quadratus
lumborum.
Cullen's - peri-umbilical oedema and bruising secondary to pancreatic enzyme
tracking, via the gastrohepatic and falciform ligament to the anterior abdominal
wall.
Note: Both take 24-48 hours to appear and are associated with a poorer
prognosis.

Investigations:

Bedside - ECG, urine dipstick, BM.

Blood - FBC, LFTs, Electrolytes, Calcium, Urea, Albumin, Glucose.
Amylase - above 3 times normal level (i.e. >300) supports diagnosis. Level is not an
indicator of severity and can be normal on admission. In acute on chronic pancreatitis
amylase increase is often absent.
Lipase - can also be used and stays elevated longer.
CRP - > 150 indicates severe pancreatitis.
Arterial blood gas - pH, P02, Lactate.
Imaging:
USS - check for gallstones.
CT/ MRI - can be used to judge severity/complications.
ERCP - if gallstones present can be used to further delineate and provides intervention
through sphincterotomy.

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 MRCS Acute Pancreatitis

Prognostic scores (classic exam question):

Modified Glasgow Criteria

Used in both gallstone and alcohol related pancreatitis.
Both on admission and after 48hrs.
Mortality score <2 = 1%, 3-4 = 15%, >6 = almost 100%
Scoring:
P02 < 8kpa
Age >55
Neutrophils (WCC) >15
Calcium <2 mmol/l
Renal: Urea >16 mmol/l
Enzymes: AST>200 IU/l, LDH > 600 IU/l
Albumin <32 g/dl
Sugar: Glucose >10mmol/l

Ranson
2 versions for alcohol and gallstone aetiology.
Based on score at admission and 48 hours after.
Similar mortality scoring to modified Glasgow criteria.
Alcohol:
At admission:
Age > 55 years
WCC > 16
Glucose > 10 mmol/L
AST > 250 IU/L
LDH > 350 IU/L
At 48 hours:
Calcium < 2.0 mmol/L
Hematocrit fall > 10%
PO2 < 6 Kpa
BUN increased by 1.8 or more mmol/L after IV fluid hydration
Base deficit > 4 mEq/L
Sequestration of fluids > 6

Gallstones:
At admission:
Age > 70 years
WCC> 18
Glucose > 12.2 mmol/L
AST > 250 IU/L
LDH > 400 IU/L
At 48 hours:
Calcium < 2.0 mmol/L
Hematocrit fall > 10%
Oxygen PO2 < 6 Kpa
BUN increased by 1.8 or more mmol/L after IV fluid hydration
Base deficit > 5 mEq/L
Sequestration of fluids > 4 L

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 MRCS Acute Pancreatitis

Balthazar
Uses CT appearance to grade severity:
Grade A normal CT
Grade B focal or diffuse enlargement of the pancreas
Grade C pancreatic gland abnormalities and peripancreatic inflammation
Grade D fluid collection in a single location
Grade E two or more collections and/or gas bubbles in or adjacent to pancreas

APACHE-II - acute physiology and chronic health evaluation

Severity of disease scoring system used on ITU admission.
Score > 8 = severe.

Management

Mainly conservative/supportive:

1. Close monitoring.
2. Oxygen - maintain saturations above 95%.
3. IV fluid resuscitation:
Manages distributive shock and therefore reduces complications/organ failure.
Maintain urine output above 0.5ml/(kg/hr).
Note: Some advocate the avoidance of lactate containing solutions.
1. Analgesia
2. PPI
3. Anti-thrombotic
4. Moderate to severe - HDU/ITU admission for continuous monitoring and organ
support.
5. Nutrition - enteral or parenteral.
6. Treat cause e.g. ERCP and sphincterotomy for gallstones.
7. Role of antibiotics - rarely indicated unless infectious aetiology or concomitant
infection.

Surgical:

1. Necrosectomy - resection of necrotic pancreas can be open or laparoscopic. +/-

1. Open - Laparostomies for serial resections, drainage, abdominal
decompression and lavage.
2. Closed - Large drains post resection for lavage, drainage particularly of less
sac.

Note: Surgery rarely indicated unless severe = poor prognosis.

Complications:
Local:
Peri-pancreatic fluid collection.
Pseudocyst - collection of sterile fluid within lesser sac.
Abscess - either pancreatic or peri-pancreatic.
Necrosis/gangrene.
Splenic vein thrombosis (note also drains pancreas and in close contact posteriorly)

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 MRCS Acute Pancreatitis

Systemic:
Organ failure:
Renal - hypovolaemia + direct damage from vasoactive peptides and
inflammatory mediators.
Respiratory - ARDS, pleural effusions (transudative - low albumin or exudative -
inflammatory mediators).
Cardiac - hypovolaemia, arrhythmias.
Liver
Haematological - DIC
Metabolic:
Hyperglycaemia
Hypocalcaemia - saponification of calcium salts, reduced PTH, calcitonin release.
Intestinal - haemorrhage, ileus.
Death - 10%

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