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Acute pancreatitis

Aetiology

  • Idiopathic
  • Obstruction
    • Choledocolithiasis
    • Ampullary or pancreatic tumours
  • Pancreatic structural anomalies
  • Toxins
    • Alcohol
    • Drugs - salicylates, azathioprine, cimetidine
  • Trauma
    • Accidental
    • Iatrogenic
  • Metabolic abnormalities
  • Infection
  • Vascular anomalies

Diagnosis

  • Serum amylase has low sensitivity and specificity
  • 20% cases of pancreatitis have normal serum amylase (particularly alcoholic aetiology)
  • Serum lipase more sensitive

Cullen's sign

Grey Turner's sign

Pictures provided by Vikram Kate, Jawaharial Institute of Postgraduate Medical Education and Research, Pondicherry, India

Causes of hyperamylasaemia

  • Perforated peptic ulcer
  • Cholecystitis
  • Generalised peritonitis
  • Intestinal obstruction
  • Mesenteric infarction
  • Ruptured AAA
  • Ruptured ectopic pregnancy

Prognostic factors

  • 80% of patients have mild pancreatitis with good recovery
  • Mild disease accounts for less than 5% of the mortality form pancreatitis
  • Mortality from pancreatitis due to:
    • Early multiple organ failure
    • Late infected pancreatic necrosis
    • Haemorrhage
    • Associated co-morbidity
  • Aim of prognostic scores is to identify patients with severe pancreatitis
  • Need to have high sensitivity and specificity
  • Ideally should be applicable on admission

Ranson's criteria

  • On admission 
    • Age > 55 yrs
    • WCC > 16,000
    • LDH > 600 U/l
    • AST >120 U/l
    • Glucose > 10 mmol/l
  • Within 48 hours
    • Haematocrit fall >10%
    • Urea rise >0.9 mmol/l
    • Calcium < 2 mmol
    • pO2  < 60 mmHg
    • Base deficit > 4
    • Fluid sequestration > 6L
  • Can not be applied fully for 48 hours
  • Also poor predictor later in the disease
  • 'Single snapshot in a whole feature length film'

APACHE II score

  • Multivariate scoring system
  • Measure objective parameter - vital signs and biochemical analysis
  • Account for premorbid state and age
  • Can be used throughout course of illness

Contrast-enhanced CT scoring system

Grade Criteria
A Normal
B Focal or diffuse glandular enlargement
Small intra-pancreatic fluid collection
C Any of the above
Peripancreatic inflammatory changes
Less than 25% gland necrosis
D Any of the above
Single extrapancreatic fluid collection
25-50% gland necrosis
E Any of the above
Extensive extrapancreatic fluid collection
Pancreatic abscess
More than 50% gland necrosis

Early treatment

  • Aims of treatment are to :
    • To halt progression of local disease
    • Prevent remote organ failure
  • Requires full supportive therapy often on ITU or HDU
  • Urinary catheter, CVP line and possibly arterial line
  • Regular assessment of U+Es, Ca, blood sugar, LFTs
  • Patients require:
    • Fluid resuscitation with both colloid and crystalloid
    • Correction of hypoxia with an increased inspired oxygen or ventilation
    • Adequate analgesia - opiate or epidural
  • Increasing evidence that antibiotic prophylaxis useful in severe pancreatitis

Contrast enhanced CT showing oedema and necrosis of most of the body and tail of the pancreas

Nutritional support

  • Pancreatitis is associated with a catabolic state
  • The benefit of pancreatic 'rest' by limiting oral intake is unproven
  • Evidence that early enteral nutrition is safe
  • Nasojejunal feeding limits pancreatic secretion
  • Preferable to oral or nasogastric feeding

Complications of acute pancreatitis

Local

  • Necrosis +/- infection
  • Pancreatic fluid collections
  • Colonic necrosis
  • Gastrointestinal haemorrhage
  • Splenic rupture

Systemic

  • Hypovolaemia and shock
  • Coagulopathy
  • Respiratory failure
  • Renal Failure
  • Hyperglycaemia
  • Hypocalcaemia

Pseudocysts

  • Fibrous walled peri-pancreatic fluid collection
  • Present for more than 1 month
  • No epithelial lining. Fluid has high amylase content
  • Acute fluid collections are not pseudocysts
  • 35% patients with pancreatitis develop peri-pancreatic fluid collections
  • More than 50% resolve spontaneously over a 3 month period
  • Complication rate increases after 6 weeks
  • Diagnosis may be suggested by persistent elevation of serum amylase
  • Planned intervention at 6 weeks

Classification of pseudocysts

  • Type 1 - normal duct anatomy. No fistula between duct and cyst
  • Type 2 - abnormal duct anatomy - No fistula
  • Type 3 - abnormal duct anatomy and fistula

Investigation of pseudocysts

  • Ultrasound will allow assessment of changes in the size of the cyst
  • Endoscopic ultrasound increasingly used
  • CT to define relationship to adjacent organs

  • ERCP to define duct anatomy

Treatment options

Percutaneous drainage

  • Ultrasound or CT guided
  • 80% successful in type 1 cyst
  • Less successful if fistula to duct present
  • Occasionally associated with pancreatic abscess or fistula

Endoscopic drainage + insertion of pigtail catheter

  • Transpapillary or transmural

Surgical drainage

  • Cystogastrotomy
  • Roux Loop Cystojejunostomy
  • Allows adequate internal drainage
  • Biopsy cyst wall to exclude cystadenocarcinoma
  • Mortality similar to percutaneous drainage ( 5%)
  • Lower recurrence rate ( approximately 5 vs. 20%)

Timing of intervention in pancreatitis

  • All patients should undergo ultrasound within 24 hours of admission
  • If confirms gallstones and severe pancreatitis consider ERCP within 48 hrs
  • RCT confirm reduction in morbidity and mortality with early duct clearance
  • If patient fails to settle during first week of admission
  • Contrast enhanced CT to assess pancreatic necrosis
  • If suspicion of infection - CT guided aspiration
  • Consider pancreatic necrosectomy if
    • Clinical deterioration
    • Bacteriological proof on infection
  • Operative mortality >40%

pancreatic necrosis

Picture provided by Jean-Pierre Arsenault, University of Montreal, Coventry.

Bibliography

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Formela L J.  Inflammatory mediators in acute pancreatitis.  Br J Surg 1995; 82: 6 - 16.

Glazer G,  Mann D V et al.  United Kingdom guidelines for the management of acute pancreatitis.  Gut 1998;  42 (Suppl 2);  S1-S13.

Grace P A  Williamson R C.  Modern management of pancreatic pseudocysts.  Br J Surg 1993; 80: 573 581.

Gupta R,  Toh S K C,  Johnson C D.  Early ERCP is an essential part of the management of all cases of acute pancreatitis.  Ann R Coll Surg Engl 1999;  81:  46-50.

Johnson C D.  Timing of intervention in acute pancreatitis.  Post Grad Med J 1993; 69: 509 -515.

Johnson C D.  Severe acute pancreatitis:  a continuing challenge for the intensive care team.  Br J Intensive Med 1998;  8:  130-138.

Kingsnorth A.  Diagnosing acute pancreatitis: room for improvement ?  Hosp Med 1998;  59:  191-194.

Lobo D N,  Memon M A,  Allison S P,  Rowlands B J.  Evolution of nutritional support in acute pancreatitis.  Br J Surg 2000;  87:  695-707.

Moran B,  Rew D A,  Johnson C D.  Pancreatic pseudocysts should be treated by surgical drainage.  Ann R Col Surg Eng 1994; 76: 54 - 58.

Murphy J O,  Mehigan B J,  Keane F B.  Acute pancreatitis.  Hosp Med 2002;  63:  487-892.

Powell J J,  Parks R W.  Diagnosis and early management of acute pancreatitis.  Hosp Med 2003;  64:  150-155.

Powell J J,  Miles R,  Siriwardena A K.  Antibiotic prophylaxis in the initial management of severe acute pancreatitis.  Br J Surg 1998;  85:  582-587.

Skaife P,  Kingsnorth A N.  Acute pancreatitis: assessment and management.  Post Grad Med J  1996; 72: 277 -283.

Steinberg W  Tenner S.  Acute Pancreatitis.  N Eng J Med 1994; 330: 1198 - 1210.

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