Makindo Medical Notes

Related Subjects: | Acute Cholecystitis | Acute Appendicitis | Chronic Peritonitis | Abdominal Aortic Aneurysm | Ectopic Pregnancy | Acute Cholangitis | Acute Abdominal Pain/Peritonitis | Assessing Abdominal Pain | Penetrating Abdominal Trauma | Acute Pancreatitis | Acute Diverticulitis

🧪 Lipase vs Amylase: Lipase is more useful than amylase as it is equally sensitive but more specific, and it remains elevated for longer. - ⏳ Lipase half-life: 8–14 days (vs 3–5 days for amylase). - 🚫 Lipase levels do not correlate with severity. - ✅ Particularly useful in delayed presentation of acute pancreatitis.

⚡ Initial Management of Acute Pancreatitis

🫁 ABC: Airway, Breathing, Circulation 💧 IV fluids: ≥3L/day resuscitation (Hartmann’s/NaCl), catheter for strict input-output 🩸 O₂ if hypoxic; Monitor sats, consider HDU if unstable 💊 Analgesia: Morphine 5–10 mg IV + antiemetics 🧾 Bloods: FBC, CRP, U&E, LFT, Amylase, Lipase, Ca²⁺, Lactate 🧪 ABG, CXR, AXR, blood & urine cultures 🦠 Consider antibiotics if septic (NOT routine prophylaxis) 🥤 NG tube if persistent vomiting; start enteral feeding once assessed 🏥 Consider HDU/ITU for severe disease (multi-organ involvement)

ℹ️ About

• 📉 Poor correlation between amylase level and severity.
• 🔥 Acute inflammation releases amylase, lipase, trypsin → autodigestion.
• ⚠️ Significant morbidity & mortality; may trigger SIRS and multi-organ failure.
• 📈 Incidence rising due to ↑ alcohol use & improved detection.

🎯 Causes

• 🪨 Gallstones (most common UK)
• 🍷 Alcohol
• 🧬 Pancreatic cancer, post-ERCP
• 📈 Hypertriglyceridaemia, hyperparathyroidism
• 💊 Drugs: steroids, thiazides, azathioprine, sulphonamides, fibrates, statins, ART drugs, valproate, cisplatin, erythromycin
• 🦟 Infections: HIV, CMV, EBV
• 🪲 Trauma, snake bite (rare)

🩺 Diagnosis (need 2 of 3)

• Severe epigastric pain radiating to back
• ↑↑ Amylase or Lipase (>3 × ULN)
• Imaging (USS/CT/MRI) consistent with pancreatitis

🧬 Aetiology / Pathophysiology

• Premature activation of pancreatic enzymes (trypsin, lipase, amylase) → autodigestion → fat necrosis, haemorrhage, inflammation → SIRS.

🩹 Clinical Features

• 🔥 Severe epigastric pain radiating to back, relieved by sitting forward
• 🤢 Nausea, vomiting
• 📉 Shock: tachycardia, hypotension, fever
• ⚠️ Grey Turner’s sign (flank bruising), Cullen’s sign (periumbilical bruising)

📊 Prognosis – Ranson’s Criteria

• At admission: Age >55, WCC >16,000, Glucose >11, LDH >350, AST >600
• At 48h: Hct fall >10%, Ca²⁺ <2, PaO₂ <8 kPa, BE < -4, Urea rise >1.8, Fluid needs >6L

📉 Mortality by Criteria

• 0–2: <5%
• 3–4: 20%
• 5–6: 40%
• 7–8: ≈100%

🔬 Investigations

• FBC, U&E, Ca²⁺, LFTs, LDH, Albumin, CRP, ABG
• Lipids (↑ triglycerides)
• Amylase (↑ but non-specific); Lipase (↑, more specific)
• USS: within 24 hrs for gallstones
• CT: within 7–10 days for severe cases, contrast-enhanced
• ERCP: if gallstone pancreatitis + cholangitis or obstruction

⚠️ Complications

• 🫀 Local: necrosis, pseudocyst, abscess
• 🫁 Systemic: ARDS, sepsis, renal failure, hypocalcaemia
• ➡️ Chronic pancreatitis if recurrent

💊 Ongoing Management

• 🔄 ABC resuscitation, IV fluids, catheter
• 💊 Analgesia (opioids), antiemetics
• 🥤 NBM initially; enteral feeding if prolonged
• 🧪 Antibiotics only if proven infection
• 🩻 ERCP + sphincterotomy within 72 hrs if gallstone pancreatitis
• 🔪 Necrosectomy for infected necrosis/abscess
• 🏥 HDU/ICU if organ dysfunction

🩺 Case 1 — Gallstone Pancreatitis

A 52-year-old woman presents with sudden severe epigastric pain radiating to the back, nausea, and vomiting. She has a history of gallstones. Labs: amylase 900 U/L, lipase elevated, ALT high. USS shows gallstones without duct dilatation. Management: 🏥 Admit, IV fluids, analgesia, antiemetics, and monitor for systemic complications. ERCP if cholangitis or obstructive jaundice. Definitive management = laparoscopic cholecystectomy. Avoid: ❌ Routine prophylactic antibiotics; avoid oral intake until pain and vomiting controlled.

🩺 Case 2 — Alcohol-Related Pancreatitis with Pseudocyst

A 45-year-old man with chronic alcohol use presents with acute epigastric pain and vomiting. He is managed supportively but continues to have persistent abdominal fullness 4 weeks later. CT abdomen shows a 6 cm pancreatic pseudocyst. Management: 💊 Supportive care during acute phase (fluids, analgesia, electrolyte balance). Large or symptomatic pseudocyst → endoscopic or surgical drainage. Refer to alcohol services. Avoid: ❌ Draining a pseudocyst too early (<4 weeks) as the wall may not be mature; avoid NSAIDs in renal impairment from pancreatitis.

🩺 Case 3 — Severe Pancreatitis with Necrosis

A 63-year-old man presents with severe pancreatitis due to hypertriglyceridaemia. He develops hypotension, tachycardia, hypoxia, and rising CRP. CT scan shows necrotising pancreatitis with areas of non-enhancing pancreas. Management: 🚑 Admit to HDU/ICU, aggressive IV fluid resuscitation, oxygen support, nutritional support (NG feeding). If infected necrosis, consider broad-spectrum antibiotics and surgical or radiological debridement. Avoid: ❌ Prophylactic antibiotics for sterile necrosis; avoid morphine derivatives that may cause sphincter of Oddi spasm (pethidine historically preferred, though in practice morphine still used with care).