Acute Pancreatitis

Gastroenterology (12%) Core Clinical Conditions

1B The Physician Associate is able to identify the condition as a possible diagnosis: may not have the knowledge/resources to confirm the diagnosis or to manage the condition safely, but can take measures to avoid immediate deterioration and refer appropriately.

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Definition Aetiology Pathophysiology Risk factor Sign and Symptoms Investigations Management

Acute pancreatitis is a medical condition characterised by the sudden inflammation of the pancreas.

1. Gallstones: One of the most common causes of acute pancreatitis is the presence of gallstones. These stones may obstruct the common bile duct, leading to reflux of pancreatic enzymes into the pancreas itself, triggering inflammation. The severity of pancreatitis in gallstone-related cases tends to be milder compared to other causes.
2. Alcohol consumption: Chronic heavy alcohol consumption is another significant cause of acute pancreatitis. Prolonged alcohol intake can result in the accumulation of toxic metabolites within pancreatic cells, causing inflammation and damage to the pancreas. The severity of pancreatitis in alcohol-related cases tends to be more severe than in gallstone-related cases.
3. Trauma or injury: Trauma or injury to the abdomen, such as in a car accident or a severe fall, can also lead to acute pancreatitis. The force exerted on the abdomen can disrupt the blood supply to the pancreas, resulting in inflammation and an eventual cascade of events that lead to the development of acute pancreatitis.
4. Medications: Certain medications can induce acute pancreatitis as an adverse effect. Some examples include certain antibiotics, diuretics, immunosuppressants, and antiepileptic drugs. It is crucial for healthcare providers to consider medication-induced pancreatitis as a potential cause, especially when other causes are absent.
5. Infections: Certain infections can trigger acute pancreatitis as well. Viral infections, such as mumps or hepatitis viruses, can infiltrate the pancreas and cause inflammation. Bacterial infections, such as those associated with severe cases of cholecystitis or endoscopic procedures, can also lead to pancreatitis.
6. Genetic factors: In some rare cases, genetic factors may be responsible for the development of acute pancreatitis. Different gene mutations, such as those affecting the trypsinogen enzyme or the cystic fibrosis transmembrane conductance regulator (CFTR) gene, can predispose individuals to pancreatitis. This suggests a hereditary component in some cases.

• Acute pancreatitis is a severe inflammatory disorder that affects the pancreas. This condition arises due to the inappropriate activation of pancreatic enzymes, leading to autodigestion of the pancreatic tissue.

• The pancreas plays a vital role in digestion and glucose regulation. It produces and releases digestive enzymes such as amylase, lipase, and proteases, along with insulin and glucagon, into the small intestine. In healthy individuals, these enzymes remain inactive within the pancreas until they reach the small intestine, where they are activated to aid in digestion.

• However, in acute pancreatitis, something disrupts this normal process, causing the enzymes to become activated prematurely within the pancreas itself.

• Activation of the pancreatic enzymes within the pancreatic tissue leads to the destruction of the very structures responsible for their production and storage. The inflammatory response is triggered, resulting in the infiltration of immune cells and an excessive release of cytokines and inflammatory mediators. This cascade of events amplifies the inflammatory process, causing further damage to the pancreas.
  The autodigestion of the pancreatic tissue leads to the breakdown of proteins, lipids, and carbohydrates within the pancreas itself. This process creates local tissue damage and disrupts the integrity of blood vessels, giving rise to haemorrhage. The release of free fatty acids and damaged cellular components into the bloodstream can further complicate matters, leading to systemic inflammation, multi-organ dysfunction, and potential life-threatening complications.

• As acute pancreatitis progresses, the inflammation can spread beyond the pancreas. It may affect adjacent structures such as the bile duct, causing biliary obstruction, or involving the surrounding tissue, resulting in the formation of pseudocysts or abscesses. Furthermore, systemic complications can arise, including respiratory failure, renal dysfunction, and coagulation abnormalities, due to the release of inflammatory mediators into the bloodstream.

1. Gender: Women are more susceptible, particularly those who are overweight or have a sedentary lifestyle.
2. Alcohol Consumption: Excessive and chronic alcohol consumption is another significant risk factor for acute pancreatitis. The exact mechanism by which alcohol causes pancreatic inflammation is not fully understood, but it is believed to be linked to the toxic effects alcohol has on the pancreas. Regular alcohol abuse can lead to recurrent episodes of acute pancreatitis and increase the risk of chronic pancreatitis in the long run.
3. Smoking: Studies have shown a strong association between smoking and the development of acute pancreatitis. Cigarette smoke contains toxic compounds that can damage the pancreatic tissue and impair its normal functioning. Chronic smokers have a higher risk of recurrent episodes and may progress to chronic pancreatitis.
4. Certain Medications: Some medications have been associated with an increased risk of acute pancreatitis. These include certain antibiotics, diuretics, oestrogen therapy, and medications used to treat HIV/AIDS. It is essential for individuals taking these medications to be aware of this risk and report any unusual symptoms to their healthcare provider promptly.
5. Medical conditions: Several medical conditions can predispose individuals to acute pancreatitis. These include high triglyceride levels (hypertriglyceridemia), autoimmune diseases, hereditary factors, infections, and certain genetic disorders such as cystic fibrosis. Managing these underlying conditions and monitoring pancreatic health is crucial in reducing the risk of acute pancreatitis.
6. Trauma or Surgery: Trauma to the abdomen, such as a severe injury or surgical procedures involving the pancreas or surrounding organs, can trigger acute pancreatitis. It is important for healthcare professionals to closely monitor patients who have undergone abdominal trauma or surgeries to detect any signs of pancreatic inflammation promptly.

1. Abdominal Pain: The hallmark symptom of acute pancreatitis is intense abdominal pain, which often starts suddenly and persists for hours or days. The pain is typically located in the upper abdomen and may radiate to the back or shoulder. The severity of the pain can vary from severe and debilitating to mild discomfort.
2. Nausea and Vomiting: Many individuals with acute pancreatitis experience nausea and vomiting. These symptoms can be persistent and may worsen after eating or drinking. Vomiting might not provide relief from the pain experienced.
3. Tenderness and Swelling: Upon physical examination, tenderness and swelling may be observed in the upper abdomen. The area might be sensitive to touch and can feel warm. In severe cases, this tenderness may also extend to the lower abdomen.
4. Fever and Rapid Pulse: Acute pancreatitis can lead to an elevated body temperature, resulting in fever. Additionally, an increased heart rate or pulse rate is often observed. This can occur as a response to the inflammation and other associated complications.
5. Digestive Problems: Due to the disruption in the normal functioning of the pancreas, individuals might experience digestive issues. These can include diarrhoea, oily stools (steatorrhea), and a reduced appetite or feeling of early satiety.
6. Jaundice: In some cases, acute pancreatitis can cause jaundice, which is characterised by yellowing of the skin and eyes. This occurs when the swelling or inflammation blocks the bile duct, leading to a build-up of bilirubin in the bloodstream.
7. Shock or Hypotension: In severe cases, acute pancreatitis can cause a drop in blood pressure, leading to shock. This can result in dizziness, rapid breathing, confusion, and cold, clammy skin. It is a serious complication requiring immediate medical attention.

History and Physical examination:

Enquire about the patient's medical history, including previous episodes of pancreatitis, alcohol consumption, gallstone disease, and any recent abdominal trauma or surgeries.
Moreover, the PA will perform a physical examination to assess specific signs of acute pancreatitis, such as tenderness over the abdomen or back, elevated heart rate, and low blood pressure. The severity of the patient's symptoms and signs can indicate the extent of pancreatic inflammation.

Cullen Sign and Grey Turner Sign in Acute Pancreatitis:

Cullen Sign refers to the presence of or bruising, around the umbilicus. When acute pancreatitis occurs, inflammation ensues within the pancreas, causing the release of digestive enzymes into the surrounding tissues and bloodstream. This release can lead to the breakdown of blood cells, causing discoloration and the deposition of blood pigments. Consequently, this hematological activity can result in the appearance of bruising around the navel area, manifesting as the Cullen Sign.

Grey Turner Sign, on the other hand, refers to the phenomenon of bruising or observed around the flanks of individuals with acute pancreatitis. Similar to Cullen Sign, Grey Turner Sign occurs due to the leakage of digestive enzymes into surrounding tissues, leading to hemorrhage and subsequent tissue damage. As a result, the breakdown of red blood cells causes the accumulation of blood pigments, giving rise to the distinct discoloration in the flank region.

Both Cullen Sign and Grey Turner Sign are considered important diagnostic findings in acute pancreatitis. Their presence suggests the extend of tissue damage caused by the inflammation of the pancreas and can aid in the early detection of severe cases. Additionally, these signs have the potential to indicate the progression of necrotizing pancreatitis, a more severe form of the condition.

Laboratory Tests

1. Amylase and Lipase Levels: Elevated levels of amylase and lipase enzymes in the bloodstream are indicative of pancreatic inflammation. However, these enzyme levels might take a few hours to rise after symptom onset, making early measurements less reliable.
2. Full Blood Count (FBC): This test measures various blood cell counts and can reveal abnormalities that may suggest pancreatic complications, such as infection or bleeding.
3. Liver Function Tests (LFTs): Evaluating liver function is crucial, particularly to rule out gallstone-related pancreatitis, as the liver and pancreas share a common bile duct. Elevated levels of liver enzymes can indicate biliary obstruction due to gallstones.
4. Renal Function Tests: Assessment of kidney function is important, especially when determining the severity of pancreatitis. Elevated blood urea and creatinine levels might indicate kidney dysfunction due to decreased blood flow from the inflammation.
5. C-reactive Protein (CRP): CRP is an inflammatory marker that can be elevated in acute pancreatitis. It helps assess the severity of inflammation and monitor response to treatment.

Imaging Techniques

1. Abdominal Ultrasound: This non-invasive and cost-effective test can identify gallstones, assess the pancreatic size, and detect certain complications such as fluid collection or abscess formation.
2. Computed Tomography (CT) Scan: A CT scan provides detailed images of the pancreas and surrounding structures. It helps confirm the diagnosis, identify the extent of inflammation, detect gallstones, and assess for complications like pancreatic necrosis or pseudocysts.

1. Hospitalisation: Patients with severe acute pancreatitis or those with complications such as organ failure, necrosis, or infection often require hospitalisation. This allows for close monitoring, administration of intravenous fluids, and appropriate medical interventions.
2. Pain management: Treating pain is an essential aspect of managing acute pancreatitis. Narcotic analgesics, such as morphine, are commonly given to alleviate severe pain. However, opioids must be used judiciously to avoid complications like respiratory depression or addiction.
3. Fluid resuscitation: Adequate fluid resuscitation is crucial for maintaining hydration and preventing organ damage. Intravenous fluids are administered to correct any dehydration, maintain blood pressure, and restore electrolyte balance. Continuous monitoring of fluid input and output is necessary to avoid complications like fluid overload.
4. Identification and management of underlying causes: Acute pancreatitis may have various aetiologies, including gallstones, alcohol consumption, medication use, or metabolic disorders. Identifying the underlying cause is crucial to prevent recurrences. Accordingly, the management may involve interventions such as gallstone removal, alcohol cessation, or adjustments in medication regimens.

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