QuestionSBA
QuestionChoice
The white cell count is slightly raised. However, it is not raised above the levels required to score a point in the Glasgow score. The Glasgow score is used to assess whether a patient needs to be treated in the intensive care unit
32805
c
White cell count
QuestionChoice
Although the Haemoglobin is slightly low, it does not indicate a poor prognosis. Haemoglobin is not one of the Glasgow score criteria used to assess whether a patient needs to be treated in the intensive care unit
32804
b
Haemoglobin
QuestionChoice
The albumin is slightly low. However, it is not at the level where it would score a point in the Glasgow score. The Glasgow score is used to assess whether a patient needs to be treated in the intensive care unit
32807
e
Albumin
QuestionChoice
The calcium is the only marker in this example where the value would score a point on the Glasgow score. A Glasgow score of more than 3 indicates severe pancreatitis, and the patient may need to go to the intensive care unit. The values used to calculate the Glasgow score can be remembered by the PANCREAS mnemonic.

- P - PO2 <8 kPa
- A - Age > 55
- N - Neutrophils: WCC > 15x109/L
- C - Calcium, < 2mmol/L
- R - renal function: urea >16 mmol/L
- E - Enzymes: LDH > 600iu/L or AST >200iu/L
- A - Albumin <32g/L
- S - sugar: blood glucose > 10mmol/L

Therefore, it is important to request all of these investigations when assessing a patient with suspected pancreatitis because it will inform you next stages of management
32803
a
Calcium
QuestionChoice
The urea is raised. However, it is not raised above the levels required to score a point in the Glasgow score. The Glasgow score is used to assess whether a patient needs to be treated in the intensive care unit
32806
d
Urea
Concept
Chapter
# Summary
 
Acute pancreatitis refers to inflammation of the pancreas; there are a wide variety of causes and severity ranges from mild and self-resolving pancreatitis to life-threatening multi-organ failure. The main symptom is acute-onset epigastric pain which radiates to the back, which may be accompanied by nausea and vomiting. Diagnosis is primarily with bloods showing an elevated amylase or lipase. Abdominal ultrasound is another important investigation to look for gallstones (the commonest cause of acute pancreatitis). General management includes aggressive fluid resuscitation, analgesia, antiemetics and nutritional support. 

# Definition

Acute pancreatitis refers to an inflammatory process affecting the pancreas as well as local or distant tissues and organs in some cases.
 

# Epidemiology
 
- Acute pancreatitis has an incidence of approximately 30 cases per 100,000 people per year
- There are many causes as detailed below
- Half of cases are caused by gallstones, and around a quarter of cases by alcohol
- 10% of cases are idiopathic
- The majority of cases (around 80%) are mild and self-limiting, with low mortality rates (1-3%)
- The 20% of patients with moderate or severe disease have a higher risk of death (estimated at 13-35%)

# Aetiology

Causes of acute pancreatitis can be remembered using the mnemonic GET SMASHED:
 
 -  Gallstones 
 -  Ethanol (alcohol)
 -  Trauma
 -  Steroids
 -  Mumps
 -  Autoimmune disease (e.g. systemic lupus erythematosus, Sjogren's syndrome)
 -  Scorpion stings
 -  Hypercalcaemia, hypertriglyceridemia, hypothermia
 -  ERCP
 -  Drugs (e.g. thiazides, azathioprine, sulphonamides)

Other causes include blunt abdominal trauma or local surgery, microlithiasis (tiny gallstones and biliary sludge), pancreatic tumours and cholangiocarcinomas and congenital abnormalities such as pancreas divisum. 

# Classification

Severity of pancreatitis is stratified using the Glasgow Score - each of the following scores 1 point and a score of **3 or more** predicts severe pancreatitis:

- PaO2 < 8kPa
- Age > 55 years
- Neutrophils > 15
- Calcium < 2
- Renal i.e. Urea > 16 
- Enzymes i.e. LDH > 600 or AST > 200
- Albumin < 32
- Sugar i.e. Glucose > 10

This should be calculated on admission and at 48 hours.
 
# Signs and Symptoms

- The main symptom of acute pancreatitis is epigastric pain which may radiate to the back
- Nausea and vomiting are also common symptoms
- Diarrhoea can occur
 
On examination, signs may include:

- Abdominal tenderness
- Peritonism, rebound tenderness and guarding may be seen
- Abdominal distension 
- Fevers (which may be due to inflammation or superadded infection)
- Tachycardia and hypotension if shocked
-  Haemorrhagic pancreatitis may present with Grey-Turner's sign (bruising in the flank area), Cullen's sign (bruising around the umbilicus) or Fox's sign (bruising over the inguinal ligament)

[lightgallery]
 
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# Differential Diagnosis
 
- **Acute Coronary Syndrome** may present atypically with epigastric rather than chest pain with nausea and vomiting - an ECG should be done to look for ischaemic changes.
-  **Perforated Peptic Ulcer** may present with sudden onset  severe abdominal pain with nausea and vomiting and signs of peritonitis; amylase may be raised and a chest X-ray may show air under the diaphragm.
-  **Ruptured Abdominal Aortic Aneurysm** shares features of abdominal pain radiating to the back; patients are typically very unwell with haemodynamic instability. A bedside ultrasound can be done for rapid diagnosis.
-  **Bowel Obstruction** causes abdominal pain and distension with nausea and vomiting, constipation is seen rather than diarrhoea and pain is usually colicky in nature.
-  **Cholecystitis** typically presents with right upper quadrant pain and fever with a positive Murphy's sign on examination, also commonly related to gallstones 

# Investigations
 
**Bedside tests:**

- **ABG** if low oxygen saturations to help with risk stratification (the pO2 is needed for the Glasgow criteria)
- **ECG** to rule out acute coronary syndrome as a cause of pain
- **Pregnancy test** in women of child-bearing age to rule out causes of abdominal pain such as ectopic pregnancy
- **Capillary blood glucose** as hyperglycaemia indicates severe pancreatitis

**Blood tests:**

- **FBC** and **CRP** for inflammatory markers
- **U&Es** to look for kidney injury; urea is part of the Glasgow criteria
- **LFTs** are often deranged; a low albumin and high AST indicate severe pancreatitis
- **Amylase** is the key diagnostic test, with levels over 3x the upper limit of normal indicating acute pancreatitis
- **Lipase** is not usually measured but can also be used to diagnose pancreatitis - it is more sensitive and specific than amylase
- **LDH** and a **bone profile** for calcium are also required for the Glasgow criteria with hypocalcaemia being a poor prognostic factor
- **Blood cultures** in patients with fevers or other signs of infection 
- **Coagulation screen** as a baseline - may be deranged in severe illness
- **Lipid profile** if hypertriglyceridaemia is suspected as a cause of pancreatitis
- **Autoimmune markers** if the cause of pancreatitis is unclear
 
**Imaging:**
 
- **Abdominal ultrasound** looking for gallstones and duct dilation
- **Chest X-ray** for complications such as pleural effusions or acute respiratory distress syndrome
- **CT pancreas with contrast** should be done in patients who are deteriorating or have signs of sepsis or organ failure after 6-10 days - may detect complications such as pseudocysts or necrotising pancreatitis
- **Magnetic Resonance Cholangiopancreatography (MRCP)** may be required in cases of pancreatitis secondary to gallstones 
 
# Management

**Conservative:**

- Ensure patients with severe pancreatitis (e.g. Glasgow score 3+, hypotension, oliguria, respiratory distress) are referred for intensive care assessment and input
- Catheterise and monitor input-output
- Insert an NG tube if significant vomiting
- If the patient can eat, encourage oral intake as tolerated - they should not be made nil by mouth unless there is another reason for this
- Enteral nutrition should be started within 72 hours of presentation (e.g. NG feeding) - if this fails parenteral nutrition should be considered

**Medical:**

- IV fluid resuscitation is the mainstay of treatment - crystalloids should be used and should be titrated to achieve an adequate urine output
- Ensure adequate analgesia is given - opioids may be required
- Antiemetics for nausea and vomiting
- Antibiotics should not be given routinely - in some cases (e.g. confirmed pancreatic necrosis) broad-spectrum antibiotics should be given
- Monitor for and treat any complications
- For alcohol-related pancreatitis, alcohol withdrawal treatment may be required (i.e. benzodiazepines and pabrinex)

**Surgical:**

- The underlying cause of pancreatitis should be treated; an ERCP may be required for gallstones in cases of jaundice, cholangitis or a dilated common bile duct on imaging
- Laparoscopic cholecystectomy for gallstone pancreatitis should ideally be done in the same admission unless the patient is not fit for surgery
- Surgical or interventional management may be required for complications e.g. drainage of large pancreatic pseudocysts or debridement of pancreatic necrosis

# Complications

**Local complications include:**

- A **pancreatic pseudocyst** is a fluid-filled sac that lacks a true epithelial lining (the wall is vascular and fibrotic); typically these form weeks after an episode of acute pancreatitis and can become infected, rupture, haemorrhage or cause compression of surrounding structures
- **Pancreatic necrosis** occurs due to ischaemia of the pancreas and may become infected causing systemic inflammation and multi-organ failure
- **Peripancreatic fluid collections** may occur, which can get infected leading to abscess formation
- **Haemorrhage** from local vessels (e.g. pancreatic or splenic arteries or veins) can occur due to inflammation and enzyme release
- **Pancreatic fistulae** may form due to pancreatic duct disruption, causing these to communicate with for example the skin, the abdominal cavity or the pleural space
 
**Systemic complications include:**

- **Acute Respiratory Distress Syndrome (ARDS)** which is a severe lung injury with non-cardiogenic pulmonary oedema and respiratory failure
- **Acute kidney injury** is a common complication which may require renal replacement therapy; often secondary to intravascular volume depletion due to third spacing 
- **Disseminated intravascular coagulation** 
- **Sepsis** for example secondary to infected pancreatic necrosis
- **Multi-organ failure** which may lead to death
- **Hypocalcaemia** occurs due to free fatty acids reacting with serum calcium to form salts, a process called saponification; this can cause tetany if severe
- **Hyperglycaemia** due to disruptions in insulin production due to pancreatic destruction as well as systemic inflammation
 
# NICE Guidelines

[NICE CKS - Acute Pancreatitis](https://cks.nice.org.uk/topics/pancreatitis-acute/)

[NICE - Pancreatitis](https://www.nice.org.uk/guidance/ng104/)
 
# References

[UK guidelines for the management of acute pancreatitis](https://gut.bmj.com/content/54/suppl_3/iii1)

[British Society of Gastroenterology - Practical Guide to Acute Pancreatitis](https://www.bsg.org.uk/clinical-resource/practical-guide-to-the-acute-pancreatitis)
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Cullen's sign seen in acute pancreatitis.
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Grey-Turner's sign seen in acute pancreatitis.
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Acute pancreatitis - GTs.jpeg
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Acute pancreatitis
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General Surgery
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Acute pancreatitis
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Quesmed Tutorial: General and Vascular Surgery SBAs 
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Acute pancreatitis
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Gastrointestinal including liver
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Acute pancreatitis
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Surgery
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A low calcium level in a patient with suspected pancreatitis is a sign of severe disease requiring closer monitoring and potential intensive care unit admission.
A 63-year-old woman attends A&E due to abdominal pain. The pain was sudden onset and is localised to the epigastric region and radiates to the back. The patient has also vomited twice whilst in the department. The consultant suspects pancreatitis and orders some investigations.


||||
|--------------|:-------:|---------------|
|Haemoglobin|109   g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|12x10<sup>9</sup>/L|3.0 - 10.0|
|Calcium|1.9 mmol/L|2.2 - 2.6|
|Urea|11 mmol/L|2.5 - 7.8|
|Albumin|33 g/L|35 - 50|


Which of these most indicates a poor prognosis?
a