Q 10 Oct FRS Acute Pancreatitis

8/12/2019 Q 10 Oct FRS Acute Pancreatitis

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FRS: Pancreatitis

What are the causes of acute pancreatits?

Gallstones, alcohol, idiopathic (80%) of caseso AP due to alcohol is rare in pts


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What other conditions can be associated with a high serum lipase?

Acute pancreatitis Chronic pancreatitis Acute cholecystitis Duodenal ulcer Pancreatic calculus Diabetic ketoacidosis HIV Post-ERCP/trauma Coeliac disease Drugs Idiopathic

What MDT members are involved in the mx of acute pancreatiits?

Gastroenterologist Surgeons Intensive care Endoscopists Radiologists Pathologists

What is the management for acute pancreatiis?

Resuscitate: ABCDo Line bore IVC, IDC (if in ICU art line and CVC)o O2aim for O2sats >95%

Analgesianarcotic via PCA or epidural Rehydratebalanced electrolyte solutions Reassessregularlytemp, HR, BP, UO, JVP IV fluidstitrate to volume status

o Once gorss vol status corrected, set infusion rate for basal fluid requirements(35ml/kg/day), plus ongoing third space loses

oKCl should be added to IVFaim for 100mmol/day

Proton pump inhibitorsprevent stress ulcers Fasting and refeeding

o Pancreas exocrine organ which secretes in response to oral diet Fasting until resolution established No clear protocols for when to restart oral intakeuse clinical judgement

for resolution of sx, but prolonged fasting adverse outcomes due to gut

disusemucosal atrophy

Stat clear fluids, graduate to solid foods as tolerated Start enteral refeeding (jejunal feeding tube) if oral refeeding not

established after 5 days

Monitor closely


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o Labs: FBC, CRP, UEC, glucose, arterial pH, lipids Magnesium and calciummonitoring and replacement if required If glucose >13.9start insulin Blood transfusion if Hb 3severe pancreatitis, score 11.1mM AST > 250 u/L

LDH > 350 u/L Age > 55yrs WCC > 16,000/mm3

o At 48hrs (CHOBBS) Calcium 10% PO2 -4Meq/L BUN >1.8mM/l despite fluids Sequestration of fluid >6L

What other factors are useful in determining severity?

Mortality predictorsmultiple organ failure, elderly, shock on arrival, SIRSo SIRS: temp >38.5 or 90, RR >20 or PO2 12,000 or 10% immature bands

o Body weight: obesity, BMI >40kg/m2o CRPtends to rise slowly and peaks day 3-4, if >300mg/L necrosis likely

Do not send the pt home!o ImagingCT


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What is the utility of CT scanning in acute pancreatits? When should it be performed? What is the

CT scan severity index?

IV contrast-enhanced CT can distinguish from oedematous and necrotising pancreatic tissuemore accurate than U/S

CT scanning should be ordered at 72hrs unless critically ill, in need of emergency surgery, orto rule out other diagnosestakes time for necrosis to develop, may be equivocal in 24-

48hrs

Follow-up CT scanning should be performed at 7-10 days if change in pts clinical status thatsuggests complications

o Psuedocysts can take several weeks to develop, repeat/prorgess scan at time ofhospital discharge

CT severity index:o Stage A: normal pancreasscore 0o

Stage B: intrinsic pancreatic changesScore 1 Focal or diffuse gland enlargement, mild heterogenity of the gland

parenchyma, small intrapancreatic fluid collections

o Stage C: Intrinsic and mild extrinsic changesScore 2 Inflammatory changes

o Stage D: Extrinsic inflammationScore 3 But not more than one ill defined fluid collection

o Stage E: Multiple extensive extra-pancreatic fluid collections of abscessesScore 4o Plus necrosis percent score

0% necrosis0 or=50% necrosis -6

Index Morbidity rates Mortality rates

0-3 8% 3%

4-6 35% 6%

7-10 92% 17%

What is the utility of ERCP in the diagnosis of acute pancreatitis? When should ERCP be used?

ERCP has no role in diagnosis of acute pancreatits Alcohol and gallstone diease80% of cases Indications:

o Cholangitis or impacted stoneso Early ERCP and sphincterotomy within first 72hrs of onset of pain

What are the 4 commandments of ERCP in acute pancreatitis?

Acute pancreatitis with gallstones and elevated bilirubinearly ERCP


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o Aminoglycosides (gent) does not reach pancreatitic tissue at high enoughconcentration


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Pathology of pancreatitis

What is the pathogenesis underlying acute pancreatitis?


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What are the histological features macroscopically and microscopically of acute pancreatitis?

Macro: swollen, oedematous, fat necrosis and haemorrhage Microscopic: neutrophils, focal fat necrosis (within, surrounding and occasionally distant

from pancreas), blood vessel damage and bleeding

What is a pancreatitic pseudocyst? What is the pathogenesis of the pseudocyst?

Localised collection of necrotic haemorrhage material rich in pancreatic enzymes Pathogenesis: walling off of area of pancreatic haemorrhagic fat necrosis by fibrous tissue

What are the macro and microscopic features of pancreatic pseudocysts? What are thecomplications of pancreatic pseudocysts?

Macro: range in size from 2-30cm in diameter Micro: cyst wall has no epithelial lining, lining is a fibrous wall of granulation tissue Complications: compression of surrounding structures (eg. Bile ducts), infection, abscess,

rupture (severe chemical peritonitis) and haemorrhage

What are the main causes of chronic pancreatitis? What are the other causes?

Common: alcohol, idiopathic and others Causes: TIGARO

o Toxins (etoh, metabolichyercalcaemia, hypertriglyceridaemia), idiopathic, genetic(hereditary pancreatitis, CF), autoimmune, recurrent acute pancreatitis, obstruction

tumours, pseudocysts

What are the macroscopic and microscopic features of chronic pancreatitis?

Macro: dilated pancreatic ducts, calcification, firm Micro:

o Early: fibrosis, exocrine gland atrophy, islet often preserved, blocked pancreatic ducto Late: extensive fibrosis, exocrine gland atrophy, islets preserved


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Micro: early

Late:


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What are the complications of chronic pancreatitis?


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Pancreatic tumours

What are the tumours of the pancreas?

Most are epithelialo Exocrine origin

Ductal adenocarcinoma (90%) Serous cystic tumours Acinar cell carcinoma (unusual) Mucinous neoplasms (unusual)

What are the risk factors of pancreatic carcinoma?

M>F Smoking x2 non-smokers Chronic pancreatitis Diabetes Hereditary pancreatitis


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What are the macroscopic and microscopic features of pancreatic carcinoma?

Macro:o Location: head 70%, body 20%o Hard, grey-white masso Evidence of local infiltration and systemic metsliver, LNs

Microscopico Granular structures infiltrating stroma and lobuleso Desmoplastic reactiono DD is chronic pancreatitis

What should be on the path report for pancreatic neoplasm?

Type of specimen Location of tumourhead/body/tail

o Unifocal/multifocal Type of tumour Tumour grade Tumour size =


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Pancreatic anatomy

What is the blood supply to the pancreas?

What are the components of the pancreas?

Head, neck, tail and body

Q 10 Oct FRS Acute Pancreatitis

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