Acute pancreatitis

Medical Emergency - Acute pancreatitis is life threatening, and thus is probably worth worrying about!

This is former Pancrase star, Ken Shamrock. Pancrase is the brand name for a mixed martial arts tournament in Japan. It is an anagram of 'pancreas' and this information is likely to be tested in both medical finals and MRCP, MRCS and MRCGP exams. Or not.

Definition

Inflammation of the pancreas occuring over hours.

Epidemiology

It is important as it has a mortality of 12% and is common in people who drink a lot.

Pathophysiology

The big two are gallstones (38%)and alcohol (35%). However, the following is a mnemonic to remember the causes:

• Gallstones
• Ethanol
• Trauma
• Steroids
• Mumps
• Autoimmune
• Scorpion sting
• Hyplidaemia/hypercalcaemia/hypothermia
• ERCP
• Drugs

This is the sort of thing they like to ask so learn it.

Clinical Features

The main one is epigastric pain radiating to the back. Vomiting and sitting forward to relieve pain are also important. Remember that signs can be mild even in serious disease. Tachycardia, jaundice, pallor, ileus, rigid abdomen, abdominal tenderness, periumbilical/flank discolouration (Cullen's sign).

Investigations

Bloods

• Amylase (>1000) - this can be normal so it's more to confirm rather than rule out diagnosis. It will also be raised in renal failure so check:
• U+Es - for renal failure
• FBCs - epigastric pain can be caused by bleeds in the GI system
• Lipase - is actually more sensitive than amylase
• LFTs - to detect gallstones
• Albumin - assess nutritional status, particularly if vomiting
• Blood glucose - glucose abnormalities are common in pancreas disorders
• ABG - base excess, lactate and pO2 are all useful measures of severity

Imaging

• Abdo XR - psoas shadow (retroperitoneal fluid), 'sentinal loop' of proximal jejunum (solitary air-filled dilatation)
• CT - assess severity
• Erect CXR - can rule out perforation
• USS - rule out obstruction
• ERCP - if LFTs rise to rule out obstruction

Assessing severity

You need to give tonnes of fluid!

There are two criteria you can use to assess severity, Modified Glasgow (<48h since symptom onset) and Ranson criteria (>48h). Helpfully, the Modified Glasgow criteria were designed to spell PANCREAS:

• P_aO₂ - <8kPa
• Age - >55yrs
• Neutrophils - WBC > 15x10⁹/L
• Calcium - <2mmol
• Renal function - Urea > 16mmol
• Enzymes - LDH>600iu/L; AST >200iu/L
• Albumin - serum albumin <32g/L
• Sugar - blood glucose > 10mmol/L

3 or more require admission to HDU/ITU

Management

The two main things are fluids and analgesia.

1. Fluids: give 0.9% saline and insert a catheter to monitor urine output; maintain it at >30mL/h. Consider a central line for CVP monitoring. Keep pumping fluids in until vitals and urine output are satisfactory.
2. Analgesia: pethidine or morphine.
3. Observations: hourly - BP, pulse, urine output; daily - FBC, U&E, Ca²⁺, glucose, amylase, ABG

Take to ITU if worsening. May require ERCP and ggallstone removal with progressive jaundice. Repeat imaging to monitor progress.