Understanding Pancreatitis

Pancreatitis

• Pancreatitis is an inflammation of the pancreas, often associated with the release of inflammatory cytokines and pancreatic enzymes.
• It can occur at any age.
• Mortality rate for pancreatitis is approximately 10%.
• Accounts for 3% of hospital admissions with related abdominal pain.

Causes of Pancreatitis

• Gallstones are the most common cause, responsible for 80% of cases.
• Alcohol is also a significant contributor.
• Other causes include:
  • Trauma
  • Steroids
  • Mumps
  • Autoimmune disorders
  • Scorpion stings
  • Hypertriglyceridemia/Hypercalcemia
  • ERCP
  • Medications (e.g., thiazides)

Pancreatitis Pathogenesis

• It involves an autodigestive process where pancreatic enzymes are activated due to injury, causing inflammation and the release of cytokines.
• This leads to both local and systemic inflammatory responses.

Pancreatitis Symptoms

• Epigastric pain is a primary symptom, often rapid and radiating to the back, which can be relieved by leaning forward.
• Nausea and vomiting are also common.

Pancreatitis Signs

• Dehydration
• Epigastric guarding
• Tachycardia, tachypnoea, and mild pyrexia
• If cholangitis is present (bile duct inflammation due to gallstones), Charcot's triad may be present:
  • Jaundice
  • Pyrexia
  • Right upper quadrant pain
• Cullen's sign (peri-umbilical bruising) and Grey Turner's sign (flank bruising) can be seen in hemorrhagic pancreatitis.

Pancreatitis Severity Stratification

• The Glasgow (IMRIE) Criteria are used to determine severity.
• It assesses:
  • PaO2
  • Neutrophils
  • Calcium
  • Enzymes (Lipase, AST)
  • Albumin
• A score exceeding 3 indicates severe disease.

Workup & Investigations for Pancreatitis

• Physical examination, vital signs, and bedside investigations, including:
  • Blood glucose
  • Urine dipstick (+/- beta hCG)
• Imaging:
  • Chest X-ray (for free air under the diaphragm)
  • Ultrasound (for gallstones)
  • CT scan (after 3 days to assess severity and complications)
• Laboratory tests:
  • Serum amylase/lipase
  • Urinary amylase
  • FBC, CRP, LFTs, U&E, LDH, Calcium, Albumin, Glucose
  • Coagulation profile
  • ABG/VBG (lactate)

Acute Pancreatitis Management

• Oxygen
• Intravenous fluids with urine output monitoring
• Analgesia
• Monitoring vital signs
• Glasgow IMRIE score assessment (repeated at 48 hours)
• Management of systemic and local complications
• Introduction of feeding once possible
• Antithrombotic prophylaxis
• Awareness of alcohol withdrawal (chlordiazepoxide + pabrinex)
• Antibiotics for pancreatic necrosis (e.g., meropenem)

Pancreatitis Complications

• ARDS
• Pseudocyst formation
• Pancreatic abscess
• Necrotizing pancreatitis
• Acute kidney injury
• Pancreatic hemorrhage
• Chronic pancreatitis
• Mortality
• Metabolic (hyperglycemia, hypocalcemia)
• Necrosis of transverse colon

Necrotizing Pancreatitis

• Characterized by two phases:
  • Phase 1-2 weeks: Severe systemic inflammatory response syndrome (SIRS) due to cytokine release
  • Phase 2+ weeks: Sepsis-related complications due to infected pancreatic necrosis

Surgical Management of Necrotizing Pancreatitis

• Infected pancreatic necrosis is a significant contributor to mortality associated with acute pancreatitis.
• Management involves:
  • Severity assessments using Glasgow criteria and markers like C-reactive protein and APACHE II score
  • Dynamic CT scanning
  • Percutaneous needle aspiration to determine if necrosis is infected or sterile
  • Surgical intervention for infected necrosis, while non-operative management may be considered for sterile necrosis.

Preventing Further Pancreatitis Episodes:

• For gallstone-related pancreatitis, there is a 30% risk of recurrence within three months.
• Management includes:
  • Endoscopic ultrasound (EUS), magnetic resonance cholangiopancreatography (MRCP), and endoscopic retrograde cholangiopancreatography (ERCP)
  • Cholecystectomy, usually performed 6 weeks after an acute gallstone-induced pancreatitis episode.
• For alcohol-related pancreatitis, alcohol withdrawal is crucial using psychological and pharmacological approaches.
• Screen for underlying conditions such as hypercalcemia, hyperlipidemia, or pancreatic neoplasms as they may cause pancreatitis.

Chronic Pancreatitis

• Characterized by fibrosis affecting pancreatic nerves (causing pain) and pancreatic ducts, leading to obstruction and ductal dilation.
• This fibrosis can damage the islets and glandular tissue, causing exocrine and endocrine failure.
• Common complications include:
  • Pseudocyst formation
  • Stones in the pancreatic duct
  • Strictures

Cause of Chronic Pancreatitis

• Recurring episodes of acute pancreatitis
• Pancreatic duct obstruction due to:
  • Pancreatic head tumors or cysts
  • Pancreatic duct strictures
  • Congenital anomalies
  • Cystic fibrosis
• Autoimmune diseases
• Idiopathic causes

Chronic Pancreatitis Treatment

• Addressing the underlying cause:
  • Discontinuation of alcohol
  • Cholecystectomy
  • Management of autoimmune diseases
• Dietary modifications:
  • Limiting fat intake
• Enzyme supplementation:
  • Creon
• Analgesia
• For intractable pain:
  • Endoscopic therapy
  • Celiac nerve block
  • Surgical intervention, including Whipple's procedure.

Whipple's Procedure

• A surgical intervention commonly performed in patients with chronic pancreatitis experiencing intractable pain.

Pancreatic Cancer

• The tumor doubling time is 60 days.
• 85% of cases are unresectable at diagnosis.
• Patients with pancreatic cancer who undergo bypass surgery typically have a mean survival of only six months.
• 90% of patients with pancreatic adenocarcinoma die within 12 months.

Courvoisier's Law

• A palpable, painless gallbladder in a jaundiced patient is less likely due to gallstone disease and may suggest pancreatic cancer.

Risk Factors for Pancreatic Cancer

• Age: 80% of cases occur in the 6th and 7th decades of life.
• Smoking
• Alcoholism
• Diabetes
• Chronic pancreatitis

Clinical Features of Pancreatic Cancer

• Progressive jaundice
• Vomiting (due to duodenal obstruction)
• Ascites
• Back pain
• Anorexia
• Weight loss
• Sister Mary Joseph nodule

Pancreatic Cancer Management

• Palliative care:
  • Biliary stent
  • Gastro-jejunostomy
  • Coeliac axis block
• Surgical intervention:
  • Whipple's procedure: Resection of the head and neck of the pancreas, part of the stomach, duodenum, gallbladder, and bile duct, along with lymph node clearance.

Pancreatitis Causes

• Gallstones are the most common cause of pancreatitis, accounting for 80% of cases.
• Alcohol abuse is the second most common, responsible for around 20% of cases.
• Other causes include:
  • Trauma
  • Steroids
  • Mumps
  • Autoimmune disorders
  • Scorpion stings
  • Hypertriglyceridemia/Hypercalcemia
  • ERCP (Endoscopic Retrograde Cholangiopancreatography)
  • Medications (e.g., thiazides)
  • Idiopathic (unknown cause)

This quiz covers the essential aspects of pancreatitis, including its causes, pathogenesis, and symptoms. Explore the factors contributing to inflammation of the pancreas and the implications of various risk factors. Test your knowledge of this significant medical condition.