Pancreatitis

• Acute pancreatitis presents with a rapid onset of inflammation and symptoms. After an episode of acute pancreatitis, normal function usually returns.
• The three key causes of pancreatitis to remember are:

  • Gallstones
  • Alcohol
  • Post-ERCP
• The inflammation in acute pancreatitis is typically caused by hypersecretion or backflow (due to obstruction) of exocrine digestive enzymes, which results in autodigestion of the pancreas.
• I GET SMASHED is a popular mnemonic for remembering a long list of causes of pancreatitis:

  • I – Idiopathic
  • G – Gallstones
  • E – Ethanol (alcohol consumption)
  • T – Trauma
  • S – Steroids
  • M – Mumps
  • A – Autoimmune
  • S – Scorpion sting
  • H – Hyperlipidaemia
  • E – ERCP
  • D – Drugs (furosemide, thiazide diuretics and azathioprine)
• Acute pancreatitis typically presents with an acute onset of:

  • Severe epigastric pain
  • Radiating through to the back
  • Associated vomiting
  • Abdominal tenderness
  • Systemically unwell (e.g., low-grade fever and tachycardia)
• Acute pancreatitis is a clinical diagnosis, based mainly on the presenting features and the amylase level.
• Initial investigations are required as with any presentation of an acute abdomen. Importantly these need to include those required for calculating the Glasgow score:

  • Urinalysis
  • Pregnancy test
  • ECG - rule out MI
  • FBC (for white cell count)
  • CRP
  • U&E (for urea)
  • LFT (for transaminases and albumin)
  • Calcium
  • ABG (for PaO2 and blood glucose)
• Amylase is raised more than 3 times the upper limit of normal in acute pancreatitis. In chronic pancreatitis it may not rise because the pancreas has reduced function.

  Lipase is also raised in acute pancreatitis. It is considered more sensitive and specific than amylase.
• USS is the 1st line initial investigation for gallstones causing acute pancreatitis

  Contrast enhanced CT abdomen can be used to assess complications of pancreatitis:

  • Necrosis
  • Abscesses
  • Fluid collections
• If pancreatitis is caused by a gall stone that is blocking the flow of bile into the duodenum, the patient can also present with post-hepatic jaundice. They will have dark urine and pale stool.
• The Glasgow score is used to assess the severity of pancreatitis. It gives a numerical score based on how many of the key criteria are present:

  • 0 or 1 – mild pancreatitis
  • 2 – moderate pancreatitis
  • 3 or more – severe pancreatitis
• The criteria for the Glasgow score can be remembered using the PANCREAS mnemonic (1 point for each answer):

  • P – Pa02 < 8 KPa
  • A – Age > 55
  • N – Neutrophils (WBC > 15)
  • C – Calcium < 2
  • R – uRea >16
  • E – Enzymes (LDH > 600 or AST/ALT >200)
  • A – Albumin < 32
  • S – Sugar (Glucose >10)
• Management of acute pancreatitis involves:

  • Initial resuscitation (ABCDE approach)
  • IV fluids
  • Nil by mouth
  • Analgesia
  • Careful monitoring
  • Treatment of gallstones in gallstone pancreatitis (ERCP / cholecystectomy)
  • Antibiotics if there is evidence of a specific infection (e.g., abscess or infected necrotic area)
  • Treatment of complications (e.g., endoscopic or percutaneous drainage of large collections)
  • Calculate Glasgow-Imrie score daily to assess response to treatment
• Complications of Acute Pancreatitis

  • Necrosis of the pancreas
  • Infection in a necrotic area
  • Abscess formation
  • Acute peripancreatic fluid collections
  • Pseudocysts (collections of pancreatic juice) can develop 4 weeks after acute pancreatitis
  • Chronic pancreatitis
• Chronic pancreatitis refers to chronic inflammation in the pancreas. It results in fibrosis and reduced function of the pancreatic tissue. Alcohol is the most common cause. It presents with similar symptoms to acute pancreatitis, but generally less intense and longer-lasting.
• Acute pancreatitis is mostly a clinical diagnosis, based on the presenting features and amylase/lipase levels
• Diagnosis of chronic pancreatitis:

  · USS +/- CT – pancreatic calcifications confirm the diagnosis

  · MRCP + ERCP – risks acute attack

  · AXR= speckled calcification

  · Raised glucose

  · Breath tests

  · Deficient in fat soluble vitamins
• Management of chronic pancreatitis:

  • Abstinence from alcohol and smoking
  • Analgesia
  • Replacement pancreatic enzymes- Creon
  • Subcutaneous insulin regimes
  • ERCP with stenting to treat strictures and obstruction to the biliary system and pancreatic duct
  • Surgery may be required for: Severe chronic pain (draining ducts and removing inflamed pancreatic tissue), Obstruction of the biliary system and pancreatic duct

  Pseudocysts/abscesses
• Offer people with chronic pancreatitis monitoring of HbA1c for diabetes at least every 6 months.
• Offer people with chronic pancreatitis monitoring by clinical and biochemical assessment, to be agreed with the specialist centre, for pancreatic exocrine insufficiency and malnutrition at least every 12 months
• Risk factors for pancreatitis include:

  • Male gender
  • Increasing age
  • Obesity
  • Smoking
• Clinical findings:

  • Epigastric tenderness
  • Abdominal distention: due to local reactive ileus or retroperitoneal fluid
  • Reduced bowel sounds: if an ileus has developed
  • Evidence of a systemic inflammatory response: indicative of severe pancreatitis.
  • Cullen's sign - intraabdominal haemorrhage
  • Grey-Turner's - retroperitoneal haemorrhage
• systemic inflammatory response syndrome (SIRS) is an inflammatory state affecting the whole body. It is the body's response to an infectious or non-infectious insult.
• Patients withdrawing from alcohol should be managed according to severity scores, for example, the CIWA score. The general principles are:

  • Benzodiazepines to treat withdrawal agitation and seizures
  • Thiamine, folate, and vitamin B12 replacement
• Acute respiratory distress syndrome (ARDS): associated with the SIRS response of acute pancreatitis. Typical CXR appearance of widespread bilateral pulmonary infiltrates
• A late complication of acute pancreatitis is Portal vein/splenic thrombosis: secondary to ongoing inflammation, anticoagulation required
• Early complications of acute pancreatitis:

  • Necrotising pancreatitis 
  • Infected pancreatic necrosis: occurs when necrosing pancreatic tissue becomes infected, patients require antibiotics and necrosectomy
  • Pancreatic abscess: occurs when peripancreatic collections of fluid become infected, urgent drainage is required
  • Acute respiratory distress syndrome (ARDS): associated with the SIRS response of acute pancreatitis. Typical CXR appearance of widespread bilateral pulmonary infiltrates
• Late complications of acute pancreatitis:

  • Pancreatic pseudocysts: collections of fluid that are not surrounded by epithelium. They are typically amylase-rich and can become infected, rupture or bleed.
  • Portal vein/splenic thrombosis: secondary to ongoing inflammation, anticoagulation required
  • Chronic pancreatitis: repeated attacks of acute pancreatitis can lead to ongoing inflammation and fibrosis of the pancreas
  • Pancreatic insufficiency: the exocrine function of the pancreas is more commonly affected (whilst the endocrine function is typically maintained).
• Systemic complications of pancreatitis:

  • DIC
  • Acute respiratory distress syndrome
  • Renal failure
  • Hypocalcaemia
  • Hyperglycaemia
• DIC as a complication of acute pancreatitis:

  • Inflammatory response activates coagulation cascade
  • Lots of small thrombi lodge in vessels and damage organs
  • Uses up coagulation factors - consumptive coagulopathy
  • Risk of bleeding
• ARDS as complication of acute pancreatitis:

  • Associated with the systemic inflammatory response syndrome (SIRS) caused by acute pancreatitis
  • Typical CXR appearance of widespread bilateral pulmonary infiltrates
• Hypocalcaemia from acute pancreatitis:

  • Fat necrosis of omentum
  • Sequestration of calcium from blood
• Hyperglycaemia from acute pancreatitis:

  • Destruction of islets of Langerhans
  • Disturbance of insulin metabolism
• Local complications of acute pancreatitis:

  • Pancreatic necrosis
  • Pancreatic abscess - needs urgent drainage
  • Pancreatic pseudocyst
  • Portal vein/splenic thrombosis
  • Chronic pancreatitis
• Pancreatic necrosis:

  • Can become infected - needs antibiotics
  • Necrosectomy - surgical removal of infected or necrotic pancreas
• Pancreatic pseudocyst:

  • Peripancreatic collections of pancreatic fluid
  • Often sits behind the stomach in the lesser sac
  • Normally defined as being present for 4 or more weeks after acute pancreatitis
  • Called pseudo as does not have epithelial lining - lined by fibrotic granulation tissue
  • If symptomatic need drainage - radiological, endoscopic or surgical
• Portal vein/splenic thrombosis:

  • Secondary to ongoing inflammation
  • May require anticoagulation
• Grey turner and Cullen's sign are late signs of pancreatitis caused by severe intra-abdominal and retroperitoneal haemorrhage which can happen if vessels are damaged by pancreatic enzymes