“Inflammation of the pancreas by enzyme-mediated autodigestion”

Risk Factors
  • Alcohol
  • Gallstones
  • Cancer
Aetiology

Mnemonic IGETSMASHED:

  • Idiopathic
  • Gallstones (most common cause)
  • Ethanol (most common cause)
  • Trauma
  • Steroids
  • Mumps – and other infections
  • Autoimmune
  • Scorpion venum
  • Hypercalcaemia, hyperlipidaemia
  • ERCP (iatrogenic)
    • Sphincterotomy in ERCP can cause localised inflammation and oedema which blocks pancreatic duct and cause backflow
  • Drugs
    • e.g. azathioprine, ACE-I, statins, metformin, antibiotics (metronidazole, tetracycline), valproic acid, diuretics, sulfasalazine/mesalazine
Pathophysiology
  • Premature activation of zymogen granules in pancreas → protease release and autodigestion of pancreatic tissue → inflammation of pancreas → ­ inflammation from activation of the complement cascade
  • Damage to pancreatic tissue results in high lipase and amylase concentrations in blood as pancreatic enzymes are released from pancreatic acinar cells
Clinical Presentation
  • Signs:
    • Low-grade fever
    • Tachycardia
    • Hypoxia
    • Shock/hypovolaemia (low BP, slowed cap refill)
    • Quiet/absent bowel sounds
    • Jaundice (if gallstone pancreatitis)
    • Epigastric tenderness
    • Guarding/rigidity
  • Symptoms:
    • Sudden severe epigastric pain radiating to back
    • Pain may be relieved by sitting forwards
    • Nausea and vomiting
Investigations
  • Initially:
    • ECG: indicated for every upper abdo pain and known cardiac Hx
    • ABG
    • FBC, LFT, U+Es, inflammatory markers
  • Diagnosis:
    • Ultrasound: to look for gallstones or biliary obstruction
    • CT/MRCP
    • ↑ Inflammatory markers (CRP, WBC)
    • ↑ Serum amylase, lipase
      • Serum amylase 3x above the normal upper range
  • Scoring systems:
    • APACHE II: Used in UHS on the ward and in ICU. Not specific for pancreatitis patients, used to stratify ICU patients
    • Modified Glasgow Score: score of 3 or more indicative of severe pancreatitis
      • PaO2 < 8 kPa
      • Age > 55
      • Neutrophils > 15
      • Calcium < 2mmol/L
      • Renal function – urea > 16
      • Enzymes – LDH > 600, AST > 200
      • Albumin <32
      • Sugar: BG > 10
    • Revised Atlanta criteria (for severity scoring) – based on organ failure, local complications, early prognostic signs
      • Mild – No organ failure, no local complications, no systemic complications
      • Moderate – Transient organ failure (<48hrs), local complications, exacerbation of comorbidity
      • Severe – Persistent Organ Failure (>48hrs)
Management
  • Supportive management:
    • O2
    • Aggressive fluid resus – due to SIRS
      • 1L bolus followed by 2-3L in 24hrs based on urine output, renal function
      • SIRS (systemic response to inflammation) à cytokine storm à leaky capillaries à fluid shift out of intravascular component and sequestration of fluid in third space à hypovolaemic shock
    • Urinary catheter – monitor urine output, fluid balance
    • Analgesia
    • NO EVIDENCE FOR NBM – early oral feeding in first 24h if tolerated
      • Essential to optimise nutrition to aid response to systemic inflammation
      • Helps pancreas function normally and keeps enterocytes healthy
    • NGT/NJT/TPN if oral feeding not tolerated
    • Consider early escalation to ITU
  • Surgical management:
    • ERCP with sphincterotomy, cholecystectomy – if gallstones implicated
      • Sphincterotomy: Small cut made in the sphincter of Ampulla of Vater to widen opening and aid drainage of debris/fluid/stones in the duct system
    • Surgery for complications e.g. Debridement of pancreatic necrotic tissue
  • Other management:
    • Alcohol avoidance
    • Smoking cessation
    • Oral pancreatic enzyme supplements (Creon) may be needed
Complications
  • Organ failure: SIRS, shock, renal failure, ARDS (pancreas inflammation can affect diaphragm and lungs above it)
  • Pancreatic oedema or collection
  • Pancreatic pseudocyst
  • Pancreatic necrosis
  • Haemorrhage (pseudoaneurysms) – can be life-threatening/catastrophic
    • Due to protease digestion of blood vessels or erosion of adjacent luminal organs around pancreas e.g. duodenum
    • Coeliac axis or gastroduodenal artery may be affected
    • Usually occurs later during hospitalisation or during procedures
  • Splenic or portal vein thrombosis
    • Occur due to localised inflammation giving rise to hyperthrombotic state
    • The very common and well-recognised complication occurs even in early disease
    • Prophylactic anticoagulation
  • DIC (disseminated intraarticular coagulopathy)

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