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Chapter 5: Disorders of the pancreas 219

due to proteases, fat necrosis due to lipases and phos- Table 5.7 Glasgow system to predict severity of
pholipases and haemorrhage occur. Translocation of gut pancreatitis
bacteria can result in local infection and septicaemia. Within 48 hours of admission
Shock may result from the release of bradykinin and Age >55 years
prostaglandins, or secondary to sepsis. Glucose >10 mmol/L (not diabetic patient)
9
White blood cell count >15 × 10 /L
LDH >600 i.u./L
Clinical features
Transaminases >100 i.u./L
Patients present with severe abdominal pain, which is Hypocalcaemia (serum Ca <2.0 mmol/L)
continuous epigastric pain radiating to the upper back, Blood urea >16 mmol/L despite adequate fluid therapy
often associated with vomiting. On examination there is Low arterial Pa0 2 (<8kPa)
epigastric guarding. Less commonly, the patient may be Serum albumin <32g/L
jaundiced and shocked. Haemorrhage may cause Grey–
Turner’s sign, which is bruising around the left loin
and/or Cullen’s sign, bruising around the umbilicus. Ultrasound (to look for gallstones) of the gallbladder
and biliary tract should be performed, but CT scanning
is the most useful imaging modality for the pancreas.
Macroscopy/microscopy
The pancreas appears oedematous with grey-white Other investigations are required to assess the sever-
necrotic patches. Bacterial infection leads to inflamma- ity and to monitor for complications: full blood count,
tion and pus formation. Healing results in fibrosis with clotting screen, urea and electrolytes, liver function tests,
calcification. lactate dehydrogenase, calcium levels, blood glucose, C
reactive protein and arterial blood gas (see Table 5.7).
Complications
In the most severe cases there is systemic organ failure: Management
Cardiovascularsystem:Shock(hypotension,tachycar- The early management depends on the severity of the

dia, arrhythmias). disease, and later management depends on the aetiology
Respiratory system: Adult respiratory distress syn- and any complications.

drome, respiratory failure. Mild attacks can be admitted to a general ward. Ini-
Kidney: Acute renal failure. tial treatment is supportive with correction of hypo-

Metabolic: Hypocalcaemia, hypoglycaemia. volaemia and electrolyte imbalances, insertion of a

Haematology: Altered haematocrit (raised or low- nasogastric tube and analgesia (opiates are often re-

ered), clotting abnormalities (thrombosis, dissemi- quired). Antibiotics should only be given if there are
nated intravascular coagulation). focal signs of infection, e.g. biliary sepsis or pneumo-
Central nervous system: Neurological symptoms in- nia.

clude confusion and irritability. Severe cases should be managed on a high dependency
Local complications include pancreatic haemorrhage, unit (or intensive care unit if they require respira-

pseudocyst (a collection of fluid and pancreatic en- tory support). Patients require careful fluid balance
zymes walled off by compressed tissue), pancreatic using central venous pressure monitoring and uri-
abscesses (which may contain gas indicating infection nary catheterisation to allow accurate urine output
withgas-formingbacteria)andduodenalobstruction. measurement. Regular arterial blood gases are needed
to detect early respiratory compromise. Prophylactic
Investigations broad-spectrumantibioticsaregiventoreducetherisk
When supportive clinical features are present the diag- of infective complications.
nosis can be made with a serum amylase more than four Gallstone-associated pancreatitis: in mild cases
times normal, or by a lipase activity greater than twice which settle with supportive therapy, early (within
normal. Patients with acute on chronic pancreatitis may 2–4 weeks) cholecystectomy should be performed,
have a smaller rise in serum amylase, in such cases a with operative cholangiography if ERCP is not per-
urinary amylase may be useful to confirm the diagnosis. formed perioperatively. In cases which do not settle,