Surgery | EP1 | Acute Pancreatitis

You're listening to MedSimu Surgery. Today's focus is acute pancreatitis. Okay, imagine this scenario. Happens all the time, right? Patient comes in, boom, sudden... Really severe abdominal pain. Yeah. You immediately start thinking through the differential diagnoses. It's intense. Exactly. And one condition that's always high on that list is acute pancreatitis. that's what we're diving into today right it's a sudden inflammation of the pancreas can be you know relatively mild but sometimes

It's life-glattening. So our goal here is to pull out the really crucial info for recognition and initial management, stuff you can use. Precisely. Based on what we know, the key facts you need right away. Okay, so lay it on us. for doctors for students on the wards what are the like absolute basics on prevalence well it's actually pretty common in the uk figures are around uh 56 per 100 000 people per year yeah

Globally, maybe 13 to 45 per 100,000. 56 per 100,000. Wow. Yeah, but here's the slightly reassuring part about 80% of these cases. They're mild. Okay, 80% mild. That's good to know. It is. But our job really is spotting that other 20% early, the ones that could get nasty. Makes sense. So what actually causes this inflammation? I remember learning that mnemonic...

get smashed. That's the one. It's pretty handy for remembering the range of causes. Want to run through it quickly? Yeah, definitely. Okay, G is gallstones. That's number one. E is ethanol alcohol, obviously a big one too. Right. Gallstones and alcohol, the usual suspects. Then T for trauma.

S is steroids. M mumps or Coxsackie B virus. A is autoimmune causes. Then the other S. much rarer scorpion stings age is for hyperlipidemia so high fats or hypercalcemia high calcium er is ercp the procedure itself can sometimes trigger it and d is

Drugs, things like a sacaprine, sometimes steroids again, thiazide, diuretics. Wow, quite a list, but mainly gallstones and alcohol. Overwhelmingly, yes. Those are the two you'll see most often by far. So pathologically speaking, what's going wrong inside the pancreas? Well, in simple terms, the digestive enzymes the pancreas makes, they get activated too early, like while they're still inside the pancreas. So it starts digesting itself. Essentially, yeah.

Autodigestion. That leads to inflammation, tissue damage, and it can kick off a whole systemic inflammatory response. You know, fluid shifts, leaky capillaries. Right, leading to problems elsewhere, like the kidneys maybe. Exactly. Acute kidney injury is definitely a concern in severe cases. Okay, so patient presentation. What are the red flags, the classic symptoms we should be looking for?

The absolute classic triad is sudden onset, severe pain, usually epigastric, often radiating straight through to the back. That back pain is quite characteristic, isn't it? It really is. Plus, nausea and vomiting are very common. likely find upper abdominal tenderness, maybe some distension. And in the really sick ones. You're looking for signs of shock.

Basically, so hypotension, tachycardia. And keep an eye out for those rarer but important signs like Cullen's sign. Bruising around the umbilicus. Yep. And Gray-Turner sign, which is bruising on the flanks, indicates retroperitoneal hemorrhage. So more severe disease.

Okay, so we suspect it clinically. How do we confirm the diagnosis? What tests are key? The diagnostic cornerstones are really that clinical picture, plus, crucially, elevated serum. amylase or lipase. Lipase is generally preferred now, more specific. And how high are we talking? Usually the guideline is at least three times the upper limit of normal. That's a strong indicator. Okay, three times normal. What about imaging?

Ultrasound is often the first imaging test, mainly looking for gallstones as the cause. A CT scan can be really useful too, especially a bit later on, to assess the degree of inflammation, look for necrosis or other complications. And sometimes things like MRCP or ERCP. Yeah. but they're usually for more specific situations like if you strongly suspect a stone stuck in the bile duct or need a better look at the ducts themselves.

ERCP is therapeutic too, of course. Right, for removing stones. And we use scoring systems too, don't we? Like the Glasgow score. Yes, exactly. The Glasgow score or others like Ransom's criteria or Apache Tattoo help us assess severity early on. They look at things like age, white cell count, glucose, liver function, calcium, oxygen levels. Gives you a sense of prognosis. It helps predict who might develop severe disease. Yeah. And don't forget key bloods.

checking calcium urea and electrolytes lfts glucose is standard all right diagnosis confirmed maybe scored for severity what are the immediate management steps what do we do First things first, supportive care is critical. It sounds basic, but it's vital. Aggressive intravenous fluids are probably the most important initial step. Lots of fluids. Why so much?

Because these patients often get very intravascularly depleted due to that inflammation and fluid shifting out of the blood vessels. So fluid resuscitation is key. Plus oxygen, if their SATs are low, and careful monitoring vitals, urine output. Makes sense. What about feeding?

We used to keep patients NPO, nothing by mouth, for ages, but now the thinking is early enteral nutrition, so feeding via a tube into the gut is actually better if they can tolerate it. Usually start once the initial pain and nausea improve. it sounds incredibly painful oh it is good analgesia is essential usually IV opioids like morphine or fentanyl and anti medics for the nausea and vomiting of course okay

Antibiotics. Generally not routinely given unless there's evidence or strong suspicion of infected pancreatic necrosis. That's a specific situation. And insulin if they develop hyperglycemia. and surgery you mentioned ercp yeah for gallstone pancreatitis especially if there's evidence of cholangitis or biliary obstruction an early ercp to clear the duct is often needed and importantly the gallbladder usually needs to come out

cholecystectomy. When do they do the cholecystectomy? Ideally during the same hospital admission for mild gallstone pancreatitis or soon after discharge to prevent recurrence. Got it. So what's the outlook usually?

And what are the big complications we worry about? For most people, maybe 80 percent with mild pancreatitis, the prognosis is actually quite good. They usually recover within, say, three to seven days. It's encouraging. It is. But unfortunately, in severe cases, the mortality rate is still significant, maybe around seven to 10 percent. usually due to organ failure like kidneys or lungs or sepsis from infected necrosis. And long-term risks.

Definitely important to counsel patients, especially if alcohol was the cause. Continued drinking massively increases the risk of recurrent acute episodes or developing chronic pancreatitis. Smoking is also a risk factor. Okay. And specifically... complications to watch for early on you worry about systemic things like ARDS acute respiratory distress syndrome acute kidney injury DIC disseminated intravascular coagulation pleural effusions and

local complications like pancreatic necrosis, which can get infected. And later complications. Later on, things like pancreatic pseudocysts can form, which are collections of fluid. And of course, chronic pancreatitis, which can lead to long-term pain, diabetes, and difficulty absorbing food. malabsorption. Right. So wrapping this up then, for us seeing these patients, the absolute key takeaways seem to be know the main causes, especially gallstones and alcohol.

Definitely. Recognize that classic presentation, the severe epigastric pain radiating to the back, the nausea, vomiting. Yeah, the clinical picture. Confirm it with that lipase level, usually three times normal. And then jump on that initial management fluids, pain control.

monitoring oxygen if needed. Exactly. That supportive care is the foundation. Get that right early on. This has been super helpful, really clarifies the essentials. It makes you think, though, with gallstones maybe becoming more common and alcohol use patterns. How might things change? That's a great question. You know, how will the incidents shift? Will we need different management strategies or maybe more focus on, say, prevention or earlier detection in the future? Something to consider.