Pancreatic disorders

12 Pancreatic disorders





Questions



image What are the common causes of acute pancreatitis?

image How is the severity of acute pancreatitis assessed?

image What is the prognosis for pancreatic cancer?



Acute pancreatitis


Acute pancreatitis ranges from mild to severe and life- threatening; mortality is 5–10%. The incidence is rising, closely linked to increased alcohol consumption and gallstone disease (the main causes). Surgery is rarely required (unless as salvage for complications of haemorrhagic pancreatitis).





Pathology

Following insult to the pancreas, pancreatic enzymes leak into the pancreatic parenchyma. The systemic inflammatory response syndrome (SIRS) may be activated; the most severe complications of pancreatitis are haemorrhagic pancreatic necrosis and infected pancreatic necrosis. The causes of acute pancreatitis can be remembered by the acronym GET SMASHED: gallstones, ethanol, trauma, steroids, mumps, autoimmune, scorpion venom, hyperlipidaemia, endoscopic retrograde cholangiopancreatography (ECRP), drugs (diuretics, immunosuppressants). Gallstones and ethanol are common causes (80% of all cases); the rest are rare. After investigations, some cases remain idiopathic.



Clinical features

These are:


image pain: severe, constant epigastric pain that may radiate to the back; right upper quadrant, central abdominal or chest pain may also be present

image nausea and vomiting

image jaundice: may indicate gallstones or oedematous pancreatic head

image Grey–Turner’s sign (bruising in the left flank) and Cullen’s sign (periumbilical discolouration) may be found in haemorrhagic pancreatitis.


Differential diagnosis:

perforated peptic ulcer and mesenteric infarction.



Investigations

Key investigations are:


image amylase: diagnostic when 3× upper limit of normal (although this may be normal and raised amylase levels are also seen in acute cholecystitis, peptic ulcer disease, aortic aneurysm and ectopic pregnancy); serum lipase is raised and more accurate but the test is less available

image ACRP > 210 at 96 h is the best predictor of acute, severe pancreatitis.

image liver function tests: may help to identify a biliary cause

image ultrasound: identifies gallstones; ERCP should be avoided in the acute setting

image radiography: abdominal radiograph may show an isolated loop of proximal jejunum caused by local ileus (a sentinel loop); chest radiograph may show a pleural effusion

image intravenous enhanced CT: if symptoms persist for longer than 7–10 days to identify areas of necrosis.


Early complications

Early complications are hypovolaemic shock, hypocalcaemia, diabetes mellitus, disseminated intravascular coagulation and respiratory and renal failure.

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Jul 3, 2016 | Posted by in MUSCULOSKELETAL MEDICINE | Comments Off on Pancreatic disorders

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