Acute pancreatitis: Difference between revisions
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This is the sort of thing they like to ask so learn it. | This is the sort of thing they like to ask so learn it. | ||
===Clinical Features=== | ===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). | 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). | ||
Revision as of 14:59, 30 March 2010
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
- Blood glucose
- ABG
Imaging
- AXR - 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
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:
- PaO2 - <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.
- 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.
- Analgesia: pethidine or morphine.
- 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.