pancreatitis

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					What the GP should know
   about pancreatitis




        Andrew M Smith
  St James’ University Hospital
 Pancreatitis
“The scorpion”




 Tityus serrulatus
     Trinidad
               Aim


To provide a working knowledge of the
management of pancreatitis – acute and
                chronic
     What is the pancreas?
• The pancreas is an elongated, tapered
  gland that is located behind the stomach
  and secretes digestive enzymes and the
  hormones insulin and glucagon

• 75 – 125g
• 15 – 20cm in length
Where is the pancreas?
What are the parts of the
      pancreas?
   LIVER
                              Functions
  • The pancreas has digestive and hormonal
    functions:




Hormonal (endocrine). Secretes:        Digestive (exocrine)

Insulin and glucagon - which           Produces enzymes that break down
regulate the level of glucose in the   carbohydrates, fats, proteins, and acids
blood                                  in the duodenum

Somatostatin - which prevents
the release of the other two
hormones
The exocrine pancreas
Regulation pancreatic exocrine
          secretion
             Pancreatic protective
                mechanisms
•   Synthesis of enzymes as inactive precursors
•   Segregation of enzymes in membrane bound compartments
•   Enterokinase only found in duodenal mucosal cells
If these mechanisms are present
    why do we get pancreatitis?
• The honest answer is that we don’t exactly know
• 2 main proposed mechanisms:
 1. Direct Acinar damage:                   2. Pancreatic duct obstruction:

 e.g. alcohol                               e.g. gall stones




                Both result in pancreatic acinar cell damage
  What happens after the initial
          cell insult
• Damaged cells release uncontrolled
  activated enzymes
• This results in the generation of
  inflammatory mediators:
    • Leading to pancreatic cell death
          LOCAL PANCREATIC COMPLICATIONS
    • Potential systemic inflammation
          SYSTEMIC COMPLICATIONS
Individual response to cell insult
                   Cell insult




                                 Damaged cell leaks enzymes
                                   Inflammatory mediators


                                    Local Inflammation




                                                              Systemic inflammatory response
 Pancreatic cell death                                               Syndrome (SIRS)


                                                                 Multiple Organ dysfunction

Infected necrosis and abscess
                                                                           Death
    Pancreatitis 2 main types


    Acute pancreatitis       Chronic pancreatitis

• Acute reversible       • Chronic inflammation
  inflammation           • Chronic abdominal pain
• Abdominal pain         • Progressive loss of
• Elevated pancreatic      pancreatic endocrine and
  enzymes in serum         exocrine function
• Self-limiting
Acute pancreatitis - Incidence
• 3% of all cases of abdominal pain
  admitted to UK hospitals

• UK: 21-283 cases per 1,000,000
  population

• Japan: 121 cases per 1,000,000
  population
Aetiology Acute Pancreatitis
Aetiology Acute Pancreatitis
Drug induced pancreatitis sorted
         by incidence



  azathioprine      corticosteroids
      Hypertriglyceridaemia
Rare, but increasing in
frequency

High triglyceride levels

Can be missed as high level of
triglycerides interfere with
laboratory amylase assay
           “GET SMASHED”
• Gallstones
• Alcohol
• Trauma / ischaemia / posterior duodenal ulcer
• Surgery
• Mumps & other viral aetiologies
• Autoimmune e.g. PAN, SLE
• Scorpion bites
• Hypothermia, Hypovolaemia, Hypertriglyceridaemia,
  Hypercalcaemia
• ERCP
• Drugs – azathioprine, antiretrovirals, thiazides,
  sulfonamides, tetracycline
         Causes to remember
•   Gallstones
•   Alcohol
•   Azathioprine
•   High triglycerides
   How may pancreatitis present?
• Pain
  –   Epigastric / RUQ pain
  –   Continuous & Severe
  –   Radiates to back
  –   Better sitting forward

• Vomiting
  – Intermittent
  – Bilious

• Dehydrated / Shocked. VERY UNWELL!

• Possibly jaundiced (obstructive) + its symptoms
How may pancreatitis present?
    How may pancreatitis present?
          Recent History
•    Preceding symptoms of gallstones eg
     biliary colic
•    History of alcohol misuse
•    Known hypertriglyceridaemia
•    Previous episodes of pancreatitis
•    Symptoms of other causal diseases eg
     mumps
                Examination
•   Looks well /unwell; ?confused
•   Febrile
•   Shocked
•   Tachypnoeic
•   Obstructive jaundice
•   Abdominal distension
•   Tender, +/- guarding, +/- rebound
•   Grey-Turner’s / Cullen’s signs (not
    pathognomonic – Cullen’s – ectopic)
                  Signs
• Ascites
• Epigastric mass
• Tetany – transient
  hypocalcaemia


• Shocked
• Respiratory distress
Examination – abdominal wall
      bruising (RARE)
            Flank
            bruising:
            Grey Turner’s
            sign




          Cullens sign
    Immediate Manangement
• May require resuscitation

• Supplemental O2 & iv fluids

• Analgesia and anti – emetic

• The majority need hospital admission
             Investigation
• Investigations required for 3 reasons:

  – To confirm the diagnosis
  – To identify the cause
  – To give the patient a prognosis and to attempt
    to allocate resources effectively
        Acute pancreatitis
     Confirming the diagnosis
• Blood Tests
     Amylase / Lipase
          Acute pancreatitis
       Confirming the diagnosis
                                  Other conditions resulting in a raised
                                  amylase




Increased specificity of lipase
           Acute pancreatitis
        Confirming the diagnosis
• Imaging
        • Plain abdominal film POOR




 Calcification          Sentinel loop   Colon ‘cut off’ sign
       Acute pancreatitis
    Confirming the diagnosis
• Imaging
  – CT Scan EXCELLENT – high specificity
                      - high sensitivity
        Acute pancreatitis
       Confirming the cause
• Abdominal ultrasound
    – gold standard for gallstones




• Triglycerides / Elevated Calcium
  Acute Pancreatitis
Providing a prognosis -
     Stratification
        • Why bother?
 Natural History of Pancreatitis


                 •   Given four patients with acute pancreatitis

                 •   3 will recover with supportive treatment alone

                 •   1 will suffer a complication and stand a 1 in 3
                     chance of dying
               Need for stratification
                   Cell insult




                                 Damaged cell leaks enzymes
                                   Inflammatory mediators


                                    Local Inflammation




                                                              Systemic inflammatory response
 Pancreatic cell death                                               Syndrome (SIRS)


                                                                 Multiple Organ dysfunction

Infected necrosis and abscess
                                                                           Death
         Need for stratification
       Cause and timing of death
               Early                    Late
          Up to one week       Greater than one week
Time



           50% Deaths              50% Deaths

       Systemic Inflammatory     Pancreatic Sepsis
       Response Syndrome
                                 Multiorgan failure
         Multiorgan failure
        Prognostic Indicators
•   Bedside assessment
•   Scoring systems
•   Serum markers
•   CT criteria
        Prognostic Indicators
•   Bedside assessment   Underestimates Severity

•   Scoring systems
                         Red flag Signs:
•   Serum markers
•   CT criteria          Tachycardia
                         Tachypnoea
                         Dyspnoea
                         Confusion


                         BMI > 35. Independent predictor
          Prognostic Indicators
•   Bedside assessment
•   Scoring systems           Ranson’s, Glasgow
                              Apache 2
•   Serum markers
•   CT criteria




          sensitivity   specificity
Ranson       70%          67%
Glasgow      55%          91%
        Prognostic Indicators
•   Bedside assessment
•   Scoring systems
•   Serum markers
•   CT criteria
        Prognostic Indicators
•   Bedside assessment
•   Scoring systems
•   Serum markers
•   CT criteria

        Balthazar Score - combination of degree of necrosis and
                          parechymal inflammation
          Prognostic Indicators
•   Bedside assessment
•   Scoring systems
•   Serum markers
•   CT criteria        Best combination only predicts 2/3 severe
                              Pancreatitis and misses a 1/3!

                              Hence if pancreatitis is within your differential
                              Diagnosis admit
    Treatment of acute pancreatitis
•   Best supportive care
•   Aggressive fluid and electrolyte replacement
•   Pain relief, anti-emetics
•   Monitoring
    – Vital signs
    – Oxygen saturations
    – Urine output
• Treat alcohol withdrawal
• Admit to a high dependency unit / ICU if
  necessary
 Does any medical treatment work?

• Antibiotics               NO

• Inhibition of proteases   NO

• Inhibition of cytokines   NO

• Nutrition                 YES

• Analgesia                 YES

• Urgent ERCP               YES
    Treat the complications!
Systemic           Pulmonary failure
                   Renal failure
                   Multiorgan failure
                   Hypocalcaemia
                   Hyperglycaemia

Local Pancreatic   Infected Necrosis
                   Pseudocyst
                   Pancreatic abscess
                   Erosion into adjacent structures – haemorrhage
                   Ascites


Social
  Treat the underlying cause
• Laparoscopic cholecystectomy same
  admission
• Lipid lowering agents
• Stop drugs - azathioprine
  Acute pancreatitis summary


• If acute pancreatitis is in your differential
  diagnosis admit the patient – we cannot
  predict outcome
Chronic pancreatitis
       Chronic pancreatitis
        represents a continuous,
        prolonged, inflammatory
        and fibrosing process of the
        pancreas with irreversible
        morphologic changes
        resulting in permanent
        endocrine and exocrine
        pancreatic dysfunction.
           Clinical Diagnosis
Symptom                      Features
Pain                 Intermittent or constant
                     Moderate to severe
                     Epigatric with radiation
                     to the back
Steatorrhoea         Visible oil droplets or
                     grease in the stool
                     Increased volume, pale,
                     foul odour
Diabetes
Narcotic Addiction
Causes of Chronic Pancreatitis
Other causes of chronic pain
Chronic effects of alcohol on the
            pancreas
     Management of Chronic
          Pancreatitis

•Chemical addiction       Ethanol
                          Narcotics

•Pain – is the most difficult problem

•Chronic pancreatic insufficiency is a
relatively late complication
      Management of Chronic
           Pancreatitis
• Requires a multi-disciplinary team:
  – Pain management
  – Psychiatrist
  – Nutrition team
  – Gastroenterologist
  – General practitioner
  – Family
  – Gastroenterologist/Surgeon
Diagnosing chronic pancreatitis

 Presenting Symptom   Tests required (in order)

 Pain                 Imaging

 Malabsorbtion        Imaging
                      Trial of pancreatic
                      enzymes
                      Tests of pancreatic
                      insufficiency
Diagnosing chronic pancreatitis
           Imaging
 •Abdominal X-ray
 •Ultrasound
 •CT
 •EUS
 •MRCP
 •ERCP
 •PET
Diagnosing chronic pancreatitis
   Tests of exocrine function



                              Tests of exocrine function
                 Type                Mesaured                 Assay

                                  Fat digestion and
                 Stool                                       Stool fat
                                     absorption


                 Stool           Protease secretion       Faecal elastase

               Duodenal                                      Volume
                               Protease and electrolyte
             tube/secretin-
                                      secretion           Enzymes,bicarb
            CCK stimulation
       Medical Management
      Pancreatic Insufficency
• Commence Creon (enteric coated
  pancreatic enzymes)
• 25,000 units with meals, 10,000U with
  snacks
• Take capsule just after commencement of
  eating
• If not effective consider adding PPI and
  increasing creon dose
  Medical Management
          Pain
Treatment             Effectiveness

No alcohol            Low to moderate

Analagesia            Moderate
(narcotics, NSAIDs,
Neuro-modulators)
Enzyme replacement    low

Endoscopic duct       Moderate
decompression

                        Does it burn out, 85% of 145 patients
                        Relived of pain in 4.5 yrs, Amman 1985
      Management of Chronic
          Pancreatitis:


• Chronic Pancreatitis is not primarily a
  surgical disease
• Surgery does not slow the course of the
  disease
       Indications for Surgery

 Objectives:

• To bypass or remove the complications
  of the disease
• To rule out suspicion of cancer
• To relieve intractable pain
Risk of cancer in chronic
      pancreatitis
Indications for intervention
Surgical options for the treatment of
    pain in chronic pancreatitis
• 3 choices
• Dependent on the size of the pancreatic
  duct
• Large duct - 1. drain the duct
  >7mm
• Small duct - 2. resect pancreatic tissue
  <5mm          3. Interrupt the nerve supply
Surgical options for the treatment of
    pain in chronic pancreatitis
Large duct
Drainage procedures – Peustow/Frey
Surgical options for the treatment of
    pain in chronic pancreatitis
Small duct
Resectional procedures   eg Whipples
Surgical options for the treatment of
    pain in chronic pancreatitis
Small duct
Denervation Thoracoscopic splachnicectomy




                                   Afferent nerves interrupted
                                   Within the chest
               Summary
• The approach to chronic pancreatitis must
  be multidisciplinary
• Diagnosis is often clinical and most often
  confirmed by a CT scan
• Pancreatic insufficiency well contolled by
  pancreatic replacement
• The patient should be informed of all the
  options when considering treatment for
  pain

				
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posted:3/28/2008
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