What the GP should know about pancreatitis

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What the GP should know about pancreatitis

• Andrew M Smith
• St James University Hospital

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PancreatitisThe scorpion

• Tityus serrulatus
• Trinidad

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Aim

• To provide a working knowledge of the management
  of pancreatitis acute and chronic

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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

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Where is the pancreas?
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What are the parts of the pancreas?
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Functions

• The pancreas has digestive and hormonal
  functions

Hormonal (endocrine). Secretes Insulin and
glucagon - which regulate the level of glucose
in the blood Somatostatin - which prevents the
release of the other two hormones
Digestive (exocrine) Produces enzymes that break
down carbohydrates, fats, proteins, and acids
in the duodenum
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The exocrine pancreas
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Regulation pancreatic exocrine secretion
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Pancreatic protective mechanisms

• Synthesis of enzymes as inactive precursors
• Segregation of enzymes in membrane bound
  compartments
• Enterokinase only found in duodenal mucosal cells

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If these mechanisms are present why do we get
pancreatitis?

• The honest answer is that we dont exactly know
• 2 main proposed mechanisms

1. Direct Acinar damage e.g. alcohol
2. Pancreatic duct obstruction e.g. gall stones
Both result in pancreatic acinar cell damage
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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

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Individual response to cell insult
Cell insult
Damaged cell leaks enzymes Inflammatory mediators
Local Inflammation
Systemic inflammatory response Syndrome (SIRS)
Pancreatic cell death
Multiple Organ dysfunction
Infected necrosis and abscess
Death
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Pancreatitis 2 main types

• Acute pancreatitis
• Acute reversible inflammation
• Abdominal pain
• Elevated pancreatic enzymes in serum
• Self-limiting

• Chronic pancreatitis
• Chronic inflammation
• Chronic abdominal pain
• Progressive loss of pancreatic endocrine and
  exocrine function

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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

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Aetiology Acute Pancreatitis
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Aetiology Acute Pancreatitis
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Drug induced pancreatitis sorted by incidence
corticosteroids
azathioprine
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Hypertriglyceridaemia
Rare, but increasing in frequency High
triglyceride levels Can be missed as high level
of triglycerides interfere with laboratory
amylase assay
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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

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Causes to remember

• Gallstones
• Alcohol
• Azathioprine
• High triglycerides

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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

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How may pancreatitis present?
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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

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Examination

• Looks well /unwell ?confused
• Febrile
• Shocked
• Tachypnoeic
• Obstructive jaundice
• Abdominal distension
• Tender, /- guarding, /- rebound
• Grey-Turners / Cullens signs (not pathognomonic
  Cullens ectopic)

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Signs

• Ascites
• Epigastric mass
• Tetany transient
• hypocalcaemia
• Shocked
• Respiratory distress

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Examination abdominal wall bruising (RARE)
Flank bruising Grey Turners sign
Cullens sign
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Immediate Manangement

• May require resuscitation
• Supplemental O2 iv fluids
• Analgesia and anti emetic
• The majority need hospital admission

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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

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Acute pancreatitisConfirming the diagnosis

• Blood Tests
• Amylase / Lipase

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Acute pancreatitisConfirming the diagnosis
Other conditions resulting in a raised amylase
Increased specificity of lipase
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Acute pancreatitisConfirming the diagnosis

• Imaging
• Plain abdominal film POOR

Calcification
Sentinel loop Colon cut
off sign
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Acute pancreatitisConfirming the diagnosis

• Imaging
• CT Scan EXCELLENT high specificity
• - high sensitivity

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Acute pancreatitisConfirming the cause

• Abdominal ultrasound
• gold standard for gallstones
• Triglycerides / Elevated Calcium

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Acute PancreatitisProviding 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

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Need for stratification
Cell insult
Damaged cell leaks enzymes Inflammatory mediators
Local Inflammation
Systemic inflammatory response Syndrome (SIRS)
Pancreatic cell death
Multiple Organ dysfunction
Infected necrosis and abscess
Death
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Need for stratificationCause and timing of death
Early Up to one week
Late Greater than one week
Time
50 Deaths Systemic Inflammatory Response
Syndrome Multiorgan failure
50 Deaths Pancreatic Sepsis Multiorgan failure
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Prognostic Indicators

• Bedside assessment
• Scoring systems
• Serum markers
• CT criteria

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Prognostic Indicators

• Bedside assessment
• Scoring systems
• Serum markers
• CT criteria

Underestimates Severity Red flag
Signs Tachycardia Tachypnoea Dyspnoea Confusion
BMI gt 35. Independent predictor
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Prognostic Indicators

• Bedside assessment
• Scoring systems
• Serum markers
• CT criteria

Ransons, Glasgow Apache 2
sensitivity
specificity Ranson 70 67 Glasgow 55 91
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Prognostic Indicators

• Bedside assessment
• Scoring systems
• Serum markers
• CT criteria

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Prognostic Indicators

• Bedside assessment
• Scoring systems
• Serum markers
• CT criteria

Balthazar Score - combination of degree of
necrosis and parechymal inflammation
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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
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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

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Does any medical treatment work?

• Antibiotics NO
• Inhibition of proteases NO
• Inhibition of cytokines NO
• Nutrition YES
• Analgesia YES
• Urgent ERCP YES

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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
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Treat the underlying cause

• Laparoscopic cholecystectomy same admission
• Lipid lowering agents
• Stop drugs - azathioprine

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Acute pancreatitis summary

• If acute pancreatitis is in your differential
  diagnosis admit the patient we cannot predict
  outcome

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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.

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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

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Causes of Chronic Pancreatitis
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Other causes of chronic pain
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Chronic effects of alcohol on the pancreas
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Management of Chronic Pancreatitis

• Chemical addiction Ethanol
• Narcotics
• Pain is the most difficult problem
• Chronic pancreatic insufficiency is a relatively
  late complication

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Management of Chronic Pancreatitis

• Requires a multi-disciplinary team
• Pain management
• Psychiatrist
• Nutrition team
• Gastroenterologist
• General practitioner
• Family
• Gastroenterologist/Surgeon

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Diagnosing chronic pancreatitis
Presenting Symptom Tests required (in
order) Pain Imaging Malabsorbtion Imaging
Trial of pancreatic enzymes Tests of
pancreatic insufficiency
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Diagnosing chronic pancreatitisImaging

• Abdominal X-ray
• Ultrasound
• CT
• EUS
• MRCP
• ERCP
• PET

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Diagnosing chronic pancreatitisTests of exocrine
function
Tests of exocrine function
Type Mesaured Assay
Stool Fat digestion and absorption Stool fat
Stool Protease secretion Faecal elastase
Duodenal tube/secretin-CCK stimulation Protease and electrolyte secretion Volume Enzymes,bicarb
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Medical ManagementPancreatic 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

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Medical ManagementPain
Treatment Effectiveness
No alcohol Low to moderate
Analagesia (narcotics, NSAIDs, Neuro-modulators) Moderate
Enzyme replacement low
Endoscopic duct decompression Moderate
Does it burn out, 85 of 145 patients Relived of
pain in 4.5 yrs, Amman 1985
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Management of Chronic Pancreatitis

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

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Indications for Surgery
Objectives

• To bypass or remove the complications of the
  disease
• To rule out suspicion of cancer
• To relieve intractable pain

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Risk of cancer in chronic pancreatitis
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Indications for intervention
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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
• gt7mm
• Small duct - 2. resect pancreatic tissue
• lt5mm 3. Interrupt the nerve supply

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Surgical options for the treatment of pain in
chronic pancreatitis

• Large duct
• Drainage procedures Peustow/Frey

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Surgical options for the treatment of pain in
chronic pancreatitis
Small duct Resectional procedures eg Whipples
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Surgical options for the treatment of pain in
chronic pancreatitis
Small duct Denervation Thoracoscopic
splachnicectomy
Afferent nerves interrupted Within the chest
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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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