Spotlight – Acute Pancreatitis

Firstly, what is acute pancreatitis(1)?

Acute pancreatitis is an acute inflammatory process of the pancreas; it can be associated with a systemic inflammatory response (SIR) and therefore affect the function of other organs. SIR can be followed by CARS (Compensatory Anti-inflammatory Response Syndrome). CARS, the systemic deactivation of the immune response, can result in a patient being more susceptible to opportunistic or reactivation of infections. In this case report, the patient experienced CARS secondary to trauma (gunshot wound to the abdomen). The patient then developed pancreatitis secondary to infection.

What defining features of acute pancreatitis should you be thinking about?

The presenting symptoms/signs of pancreatitis (1,2,3)

Severe constant abdominal pain, often radiating through to the back. In 80% cases, this is associated
with vomiting. The pain may be worse on movement and alleviated by assuming the ‘fetal position.’

On examination, the patient may be peritonitic. There may be epigastric tenderness and guarding. In
late presentations (i.e. haemorrhagic pancreatitis), there may be bluish discolouration around the
umbilicus (Cullen’s sign) or in the flank (Grey Turner’s sign).

Other differentials to consider include: ruptured peptic ulcer, myocardial infarction, ruptured AAA or
cholecystitis.

List the causes of pancreatitis in the order of prevalence (1)

Gallstones (50%), alcohol (25%), rare (<5 %). Rare causes include trauma, drugs, ERCP, viral
infections e.g. mumps, Coxsackie B4.

Which investigations do you need to perform (4) ?

  • Bloods: FBC (raised inflammatory markers), U&E including calcium, LFTs (evidence for
    causation), raised serum amylase and/or lipase, LDH, Arterial Blood Gas (used to calculate the severity of acute pancreatitis, see the PANCREAS score at https://www.mdcalc.com/glasgow-imrie-criteria-severity-acute-pancreatitis)
  • Ultrasonography: to look for gallstones
  • Computed Tomography: to look for pancreatic and peri pancreatic necrosis (particularly when symptoms persist for more than 7 days).

How will you manage this patient (3,4 )? Go back to basics…

  • Airway- patent?
  • Breathing- supplemental oxygen (to maintain oxygenation of vital organs, check saturations and the ABG).
  • Circulation- is the patient haemodynamically stable? Look for evidence of fluid depletion, including tachycardia, hypotension, poor CRT. Obtain adequate IV Access/bloods and fluid resuscitate the patient.
  • Disability- if the patient is pyrexical, consider treating with antibiotics for a suspected infective cause (e.g. cholangitis). Give adequate analgesia and anti emetics.
  • ‘DEFG’- Don’t Ever Forget Glucose!
  • Exposure- examine the patient, looking for the clinical signs mentioned above (Cullen’s, Grey Turner’s etc.).
  • Escalate… to your Registrar, Consultant or ITU/ HDU depending on severity (use the PANCREAS scoring tool).

What complications of acute pancreatitis could the patient develop (2)?

  • Pancreatic pseudocyst: Encapsulated collection of fluid with a well-defined inflammatory wall usually outside pancreas with minimal or no necrosis (4 weeks after the onset of pancreatitis)
  • Necrotising pancreatitis (within the first 4 weeks of symptom onset, and absence of pseudocyst): Pancreatic parenchymal necrosis or peripancreatic necrosis

References

1) Apelt N, Thompson E, Brown E et al (2018). In trauma, expect the unexpected: a rare case of
post traumatic pancreatitis associated with salmonellosis and enterocolitis. BMJ Case
Reports. Published online First: [November 2018]. doi:10.1136/bcr-2018226286
2) Johnson C, Besselink B and Carter R (2014). Acute pancreatitis. BMJ. 349: 4859. doi:
10.1136/bmj.g4859.
3) NICE Clinical Knowledge Summaries: Pancreatitis- acute (2016). [Online]. Available at:
https://cks.nice.org.uk/pancreatitis-acute#!topicsummary.
4) MRCS Part B questions website (2018). [Online]. Available at:
https://www.mrcspartbquestions.com/News/files/MRCS-Knowledge-Acute-Pancreatitis.php