- Acute inflammation of the pancreas with significant morbidity and mortality.
- Inflammation of the pancreas can lead to the release of activated proteolytic enzymes with localised tissue damage.
- Local tissue injury and a marked inflammatory response which can lead to a systemic inflammatory response.
- Gallstones or Alcohol and Post ERCP complication.
- Less common causes include hypertriglyceridaemia - look at fundi for lipaemia retinalis
- Hyperparathyroidism - check calcium
- Pancreatic cancer, Trauma, Infections - HIV, CMV, EBV
- Drugs - steroids, azathioprine, sulphonamide
- Epigastric pain through to back eased with sitting up and forwards.
- May be peritonitis with guarding. Symptoms of gallstones, alcoholism.
- A more severe haemorrhagic pancreatitis causes shock, septsis, bruising in flanks suggest retroperitoneal bleeding - Grey Turner's sign and Periumbilical bruising - Cullen's sign (haemorrhagic pancreatitis)
Prognosis - Ranson's criteria: At admission or diagnosis
- Age > 55
- WCC > 16,000/mm^3
- Glucose > 11 mmol/L (200 mg/dl)
- LDH > 350 iu/L
- AST > 600 iu/L
First 48 hours
- Hct fall > 10%
- Low Calcium < 2 mmol/L
- Low Pa O2 < 8 Kpa
- BE > -4 mmol/L
- Urea increase > 1.8 mmol/L
- Fluid needs > 6 L
- 0-2 criteria < 5% mortality
- 3-4 criteria 20% mortality
- 5-6 criteria 40% mortality
- 7-8 criteria 100% mortality
- Hypovolaemic shock
- Renal failure
- FBC U&E ABG Calcium, Lipids - increased Trigs (can cause falsely low amylase)
- Amylase - A raised Amylase is not unique to Pancreatitis but may also be seen in abdominal pain due to perforation of a viscus, small bowel obstruction, Leaking abdominal aortic aneurysm, Ectopic pregnancy
- Lipase - has a higher sensitivity and specificity than amylase
- Erect CXR/AXR - exclude perforation/ileus
- USS Abdomen - mass, gallstones, pseudocyst
- CT abdomen or more commonly now MRI
- Initial management should focus on ABC's with fluid replacement - accurate management of fluid balance is necessary in all but the mildest cases with CVP monitoring if needed, urinary catheter and clinical assessments of hydration, oxygenation etc.
- All patients who are vomiting require an NG tube
- Analgesia - pethidine preferred (concerns that Morphine increases tone at the sphincter of Oddi)
- Enteral feeding should not be avoided early on and is an important mode of acute treatment. It is cheaper , safer and there are less septic complications when compared with parenteral feeding. Nasogastric or nasojejunal feeding are equally useful.
- Broad spectrum antibiotics are given where sepsis is suspected
- ERCP considered where there is a cholangitis or jaundice and a common duct stone which requires removal
- Surgery may be required where there is a severe necrotizing pancreatitis or if there is an abscess or pseudocyst
- Common typically lethal cancer
- Coffee intake
- Painless jaundice - Cancer of the head of pancreas presents earlier with obstructive jaundice
- Weight loss, Ascites
- Distended gallbladder not typically seen in chronic cholecystitis due to gallstones (Courvoisier's law)
- Venous thrombosis - DVT , PE sometimes in atypical sites
- Secondary Diabetes
- FBC U&E LFT'S
- USS abdomen - biliary obstruction, mass at head of pancreas
- ERCP allows biopsy and stenting
- CT and biopsy in some cases
- Prognosis has changed little over 20 years and out come for those who are inoperable is poor
- Surgical resection in a few with limited disease
- Palliative chemotherapy can prolong survival in advanced disease
- Palliation - ERCP and stenting
- Prognosis is very poor with typical survival of 12 months or less