Topic: Acute pancreatitis/Chronic pancreatitis

Ddx
Acute pancreatitis
Perforated DU
AAA
Acute cholecystitis
choledocholithiasis
Acute Cholangitis
MI

History:
1. Acute/ chronic/ acute on chronic
2. Epigastric pain, radiating through the back, constant
3. Worse after food and alcohol
4. Relieved by sitting forward (pancreatic position)
5. Patient tends to sit still
6. Nausea, vomiting/haemetemesis
7. Anorexia
8. Jaundice
9. Fever
10. SOB
11. Palpitation
12. Confusion
13. Syncope
14. Decreased urine output
15. Weight loss
16. Steatorrhoea (floating stool)
17. Polyuria, polydipsia, fatigue (DM)

Risk Factors: GETSMASHED

1. Gallstones (60%)
2. Alcohol (30%)
3. Trauma (ERCP, direct trauma, cardiopulmonary bypass)
4. Steroids
5. Mumps, Hep A B C, HIV, Coxackie virus
6. Autoimmune (PBC/PSC)
7. Scorpion venom
8. Hyperlipidaemia, hypothermia, hypercalcaemia
9. ERCP/Emboli
10. Drugs (metronidazole, tetracycline, azathioprine, mercaptopurine, H2-blockers)
11. Pregnancy, neoplasia, idiopathic

**Additional points for chronic pancreatitis

** Additional points for SIRS/MOD

Physical exam
Epigastric tenderness
Grey-Turner sign (left flank ecchymosis)
 Cullens sign (periumbilical ecchymosis)

Investigations :

Disease Investigations
Acute 1. Carry out SEPSIX 6 if SIRS/MODS
2. ABG pH, po2, lactate
3. ECG
4. Urinalysis Urine dipstick leucocytes, nitrates, glucose
urinary amylase and lipase
5. Bloods
FBC raised WCC, low Hb
u&e high urea
LFTs obstructive pattern
Serum amylase (3-fold increase/ >300) support dx, but x determine severity
CRP > 150 severe
CPMA decreased calcium
Glucose increased
LDH increased
Coag coagulopathy, DIC
Group and xmatch

6. Imaging -
Erect CXR perforated PUD, pleural effusion
PFA SBO, peritoneal exudates (ground-glass appearance)
Abdominal US within 24hr, r/o gallstone
Contrast CT abdo 4-5 days after mild-moder acute
presentation
pancreatic masses,local invasion,mets (chr)
Endoscopic US smaller pancreatic lesions and peripancreatic
nodes
MRCP
ERCP relieve biliary obs

Chronic 1. Carry out SEPSIX 6 if SIRS/MODS

2. ABG pH, po2, lactate
3. ECG
4. Urinalysis Urine dipstick leucocytes, nitrates, glucose
urinary amylase and lipase
5. Bloods
FBC raised WCC, low Hb
u&e high urea
LFTs obstructive pattern
Serum amylase (3-fold increase/ >300) support dx, but x determine severity
CRP > 150 severe
CPMA decreased calcium
Glucose increased
LDH increased
 Tumour marker CA 19-9
Coag coagulopathy, DIC
Group and xmatch

6. Imaging -
Erect CXR perforated PUD, pleural effusion
PFA SBO, peritoneal exudates (ground-glass appearance)
Abdominal US within 24hr, r/o gallstone
CT scan pancreatic protocol pancreatic anomalies, tumor, cyst
US/CT-guided FNAC tissue diagnosis
MRCP ductal abn
ERCP relieve biliary/pancreatic duct obs

Cancer 1. ABG pH, po2, lactate

2. ECG
3. Bloods
FBC
U&E
LFTs
Tumour marker CA 19-9
Serum amylase
CRP
CPMA
Glucose
LDH
Coag coagulopathy, DIC
Group and xmatch

4. Imaging -
Abdominal US within 24hr, r/o gallstone
Contrast CT abdo pancreatic masses,local invasion,mets (chr)
Endoscopic US smaller pancreatic lesions and peripancreatic
nodes
US/CT-guided FNAC tissue diagnosis
MRCP
ERCP brushing cytology, relieves biliary obs
PET scan benign vs malignant lesion, mets
Laparascopy staging

Management

Disease Management
Acute 1. Conservative and supportive
2. Close monitoring
3. Oxygen O2 sat >94%
 4. IV fluids urine output >0.5ml/kg/hr
5. Analgesia + antiemetic
6. PPI
7. DVT prophylaxis enoxaparin 40mg OD sc
8. NPO
9. NGT severe vomiting ileus
10. Dietitan review and consider enteral feeding (NGT/NJT) or TPN if cant tolerate enteral
feeding
11. Abx imipenem/meropenem if infected pancreatic necrosis or infectios aet
12. Urgent ERCP/stone extraction

Chronic 1. Treat causative agent:

- Stop alcohol
- Cholecystectomy
- Treat AI ds steroid
2. Dietary modification:
- Decrease fat intake
- Adequate carbs and protein
3. Pancreatic enzyme sup
- Creon 10,000
4. Vit ADEK sup
5. PPI
6. Insulin
7. Analgesia
8. If persistent pain, consider (EECD):
- Endoscopic tx
- ESWL
- Coeliac nerve block
- Denervation surgery
9. Surgery if failed medical therapy
- Whipples procedure
- Partial/distal pancreatectomy
- Gastrojejunostomy (puestow procedure)

Cancer 1. Most tumours are not amenable for surgery. Treat palliatively.
2. Palliative:
A. aims at relieve obstructive jaundice with
- ERCP
- PTC and internal stenting or internal-external drainage catheter
- Surgical drainage: choledocojejunostomy/cholecystojejunostomy
B. Relieve duodenal obstruction from locally advanced disease
- Gastrojejunostomy (bypass)
3. Opiate analgesia / coeliac plexus block
4. Curative surgery
- Whipples procedure
- Pylorus-preserving pancreaticoduodenectomy (periampullary/head of pancreas)
- Distal pancreatectomy (tumours in tail)
Questions

1. Prognosis? Overall prognosis is poor. 12% 5-yr survival with

resectable ds
2. Insulinoma?
endocrine tumour of pancreas, commonest type
benign, single, operable
Whipples Triad : symptomatic hypoglycaemia, low
serum insulin, relieves of symptoms on glucose
correction
Dx high serum insulin
CT scan
selective pancreatic angiography
Tx surgical excision

3. Presentation of pancreatic cancer?

Jaundice and palpable GB (courvoisiers Law)
Severe persistent epigastric pain
Nausea, vomiting, anorexia, weight loss
Back pain
Hepatomegaly
4. Causes of chronic pancreatitis?
Recurrent acute pancreatitis
Pancreatic duct obstruction GS, pancreatic head tumor,
cyst, CF, congenital anomalies
AI PBC, PSC
Idiopathic
5. Presentation of Chr pancreatitis
Recurrent or chr abdo pain
Malabsorption steatorrhea, weight loss, anorexia,
DM
6. Ransons criteria
A. On admission (AWGLA)
- Age > 55
- WCC > 16
- Glucose > 10
- LDH > 350iu/l
- AST> 250iu/l

B. After 48hr (3 decreased, 3 increased)

- Fall in haematocrit >10%
- Ca <2mmol/L
- pO2 <8kPa
- Increased BUN >1.98mmol/L
- Base deficit >4mmol/L
- Fluid sequestration >6L
7. Glasgow criteria: score 3 or more severe, admit ICU/HDU
PANCREAS
PO2 >8kPa
Age >55
Neutrophilia/WCC > 15
Ca <2
Renal/urea >16
Enzymes/ LDH >600, AST>200IU/L
Amylase <32g/L
Sugar > 10