10/8- Pancreatitis Flashcards Preview

MS2 GI > 10/8- Pancreatitis > Flashcards

Flashcards in 10/8- Pancreatitis Deck (54)
1

Familiarize yourself with this picture

Vasculature:

- Splenic a down body/tail of pancreas

- Hepatic a

- Portal v

- Superior/inferior pancreatico-duodenal a

- Superior mesenteric a/v 

2

What is acute pancreatitis?

- Mild vs. severe

- Mortality rates

Acute inflammatory process of the pancreas

- 80% mild, 20% severe

Mortality

- 25-33% mortality with severe pancreatitis

- Two peaks of morality:

  • Half within 1-2 wks from multiorgan failure
  • Late peak from infection

3

What is the pathophysiology of acute pancreatitis?

- Conversion of trypsinogen to trypsin in acinar cells in sufficient quantity

- Trypsin catalyzes conversion of proenzymes to active enzymes

- Active enzymes autodigest the pancreas

- Cycle of releasing more enzymes

- Microcirculatory injury with resulting edema and ischemia

- Disruption of pancreatic ducts

- Cytokine release from PMNs and macrophages

- Systemic inflammatory response and systemic effects

4

70% of US cases of acute pancreatitis are related to either _____ or _______

70% of US cases of acute pancreatitis are related to either gallstones or chronic alcohol abuse

5

Gallstones are related to __% of acute pancreatitis cases but only __% of pts with gallstones will get pancreatitis

- More common with ____

- Process/pathogenesis

Gallstones are related to 40% of acute pancreatitis cases but only 3-7% of pts with gallstones will get pancreatitis

- More common with stones < 5mm

Process/pathogenesis:

- Stone obstructs pancreatic duct 

- Stone passage -> edema

- Reflux of bile

6

What is seen here?

Gallstone throwing shadow

7

Describe the anatomy of the gallbladder

- Fundus (most distal)

- Body

- Hartmann's pouch (proximal)

- Neck

8

Describe the outflow path from the gallbladder

- Cystic duct (with spiral valves), which joins with the common hepatic duct

-> Bile duct, which combines with the pancreatic duct

-> Ampulla of Vater

Dumps into duodenum (2nd stage)

9

Ethanol is related to __% of cases of acute pancreatitis; it affects a ____ (small/large) percentage of alcoholics

- Often occurs in the setting of _____

- Possible mechanisms

Ethanol is related to 30% of cases of acute pancreatitis; it only affects a  small percentage of alcoholics

- Often occurs in the setting of chronic alcoholic pancreatitis

Possible mechanisms:

- Relaxatin or spasm of sphincter of Oddi

- Higher protein concentration in pancreatic juice

- Direct toxic injury

10

What are other predisposing factors of acute pancreatitis? (not alcohol or gallstones)

- Hypertriglyceridemia (> 100 mg/dL)

- Microlithiasis and biliary sludge

- Drugs:

  • Azathioprine
  • Valproate
  • Tetracycline
  • Furosemide..

- Hypercalcemia

- Post-ERCP pancreatitis (5-25% of ERCPs)

- Trauma (blunt or penetrating)

- Infections:

  • Mumps
  • CMV
  • VZV
  • Mycoplasma
  • Aspergillus
  • Toxoplasma

- Hereditary (trypsinogen gene)

- Autoimmune pancreatitis (IgG4 elevated)

11

What is necessary to establish acute pancreatitis diagnosis?

Combo of at least 2 of the 3:

- Typical symptoms

- Elevated amylase/lipase

- CT findings of pancreatitis

12

What are typical symptoms of acute pancreatitis?

Abdominal pain

- Steady and moderate to severe

- Upper abdomen, epigastric

Nausea and vomiting

13

What are physical exam findings in acute pancreatitis?

- Abdominal tenderness

- Estravasation fo hemorrhagic exudate (rare)

  • Grey Turner's sign: ecchymoses in flanks
  • Cullen's sign: periumbilical ecchymoses

- Tachycardia, fever

- Respiratory distress, altered mental status in severe pancreatitis

14

What is Grey Turner's sign?

Ecchymoses in flanks

- (rare) finding in acute pancreatitis

15

What is Cullen's sign?

Periumbilical ecchymosis 

- (rare) finding in acute pancreatitis

16

What is seen here?

Acute pancreatitis: Cullen’s sign?

– periumbilical ecchymosis

17

What are lab values expected in acute pancreatitis?

Amylase

- 3x serum elevation

- Rises within 6-12 hrs; half life 10 hrs

Lipase

- 3x serum elevation

- Rises within 24 hrs; longer half life

18

What is the most important imaging technique for diagnosis/complication identification in acute pancreatitis?

CT

- Not always necessary (mild cases)

19

What is expected in CT of acute pancreatitis?

- Peri-pancreatic inflammatory changes

- Peri-pancreatic fluid collections

- Pancreatic necrosis

20

What is the benefit of using abdominal x-ray for suspected acute pancreatitis?

- Evaluate for other causes of abdominal pain

- Sentinel loop: localized ileus of a segment of small intestine

21

What are the benefits/uses of abdominal ultrasound in the evaluation of acute pancreatitis?

Visualize:

- Gallstones

- Dilated bile duct (choledocholithiasis)

22

What is choledocholithiasis?

Dilated bile duct

23

What will be helpful in determining the cause of acute pancreatitis?

History:

- Alcohol

- Medications

Labs:

- Liver tests

- Calcium

- TG 

- IgG4

Ultrasound:

- Gallstones

- Dilated bile duct

CT

- Pancreatic mass of cyst

24

What are predictors/methodsof assessing severity in cases of acute pancreatitis?

Severe Acute Pancreatitis:

SIRS: 2+ of the following:

- P > 90, R > 20, or PaCO2 < 32

- T < 36 or T > 38

- WBC < 4,000 or WBC > 12,000

Organ failure (pulmonary, renal, cardiovascular)

Pancreatic necrosis

Scoring systems

25

What is Ranson's Criteria?

- At admission

- During initial 48 hrs

At admission:

-  Age > 55 yo

- WBC > 16,000/mm3

- Blood glucose > 200 mg/dL

- Serum LDH > 350 IU/L

- Serum AST > 250 IU/L

Initial 48 hrs:

- Hematocrit decrease > 10%

- BUN increase > 5 mg/dL

- Serum Ca < 8 mg/dL

- Arterial pO2 < 60 mmHg

- Serum base deficit (24 - HCO3) > 4 mEq/L

- Fluid sequestration > 6 L

26

How is Ranson's criteria scored?

- Mortality

- Shortcomings

Scoring:

- 1 pt for each positive

- Severe pancreatitis is 3+ points

- Mortality:

  • 0-2: 2%
  • 3-4: 15%
  • 5-6: 40%
  • 7-8: 100%

- Cumbersome and requires 48 hrs to calculate...

27

What is the CT scoring index for acute pancreatitis?

Balthazar grades (A-E) associated with certain CT findings:

Grade A: Normal pancreas

Grade B:

- Enlargement of pancreas

- Irregular contour

- Inhomogenous attenuation

Grade C: peripancreatic inflammation + B

Grade D: associated single fluid collection + C

Grade E: 2+ peripancreatic fluid collections or gas in pancrease + C

28

What is seen here?

Grade A (normal pancreas)

29

What is seen here? 

CT of acute pancreatitis: Grade B

- Enlargement of pancreas

- Irregular contour

- Inhomogeneous attenuation

30

What is seen here?

CT of acute pancreatitis: grade C

- Peripancreatic inflammation in addition to Grade B:

- Enlargement of pancreas

- Irregular contour

- Inhomogenous attenuation

31

What is seen here?

CT of acute pancreatitis: Grade D

- Associated single fluid collection in addition to Grade C criteria:

- Peripancreatic inflammation

- Enlargement of pancreas

- Irregular contour

- Inhomogenous attenuation

32

What is seen here?

CT of acute pancreatitis: Grade E

- 2+ peripancreatic fluid collections or gas in pancreas in addition to Grade C:

- Peripancreatic inflammation

- Enlargement of pancreas

- Irregular contour

- Inhomogenous attenuation

33

What is the BISAP score?

1 point for each: 

- BUN > 25 mg/dL

- Impaired mental status

- SIRS
- Age > 60 yo

- Pleural effusion

34

35

What are the two main scoring systems in predicting SAP (Severe Acute Pancreatitis)?

1. Ranson's

2. BISAP

36

How do you manage acute pancreatitis?

- Aggressive IVF resuscitation (first 24 hours most important)

- Pain control with opiates

- Close monitoring

- Prophylactic antibiotics not typically indicated (controversial topic with necrotizing pancreatitis)

- "Pancreatic rest"

  • Historical management strategy that patients with pancreatitis should be kept NPO with slow advancement of diet after improvement in pain
  • No longer considered standard of care

- Nutritional support

  • Increased metabolism and protein catabolism with severe acute pancreatitis

  • Enteral nutrition better than parenteral nutrition (TPN) – reduced infections & mortality

  • No TPN!!!

  • Early initiation of enteral feeding

  • Nasogastric feeding may be ~ to nasojejunal feeding

- If gallstone cause, treat it (later slide)

 

37

How do you manage acute pancreatitis associated with gallstones?

- ERCP

- Urgent: impacted stone;  cholangitis, rising/elevated bilirubin

- Delayed: evidence of choledocholithiais by labs or imaging

- Cholecystectomy

38

What are localized complications (of acute pancreatitis?)

Under 4 wks:

- Acute fluid collection

- Acute necrotic collection

Over 4 wks:

- Pseudocyst

- Walled-off necrosis

39

What is a pancreatic pseudocyst?

- Characteristics

- Timeline

- Treatment

Most commonly encountered chronic complication (of acute pancreatitis?)

- Develop adjacent to pancreas after 4 weeks

- Fluid filled

- Encapsulated wall

- May require drainage if symptomatic

40

What is the pathophysiology of chronic pancreatitis?

- Loss of parenchymal cells (acinar first, then islet), chronic inflammation, fibrosis

- Alcoholic chronic pancreatitis

  • 10% heavy alcohol users (genetic effect)
  • Direct toxic effects of alcohol and metabolites
  • Stimulates stellate cells (fibrosis)
  • Recurrent acute episodes lead to chronic changes

41

What is the etiology of chronic pancreatitis?

Smoking: chronic pancreatitis and cancer

- Alcohol: 70%

- Idiopathic: 10-30%

- Tropical pancreatitis

- Genetic (PRSS1, SPINK1, CFTR)

- Autoimmune pancreatitis

- Ductal obstruction

42

How does chronic pancreatitis present?

- Abdominal pain – most common symptom

- Exocrine insufficiency

  • Steathorrhea (< 10% pancreas function)
  • Diarrhea and weight loss

- Endocrine insufficiency

  • Diabetes Mellitus
  • Reduced glucagon – risk of hypoglycemia with insulin treatment

43

How is chronic pancreatitis diagnosed?

It's difficult

- Tests of pancreatic function

  • Direct: bicarbonate output in duodenum after dose of secretin; not practical
  • Indirect: fecal elastase and fecal fat (72 hr vs. Sudan stain)

- Tests of pancreatic structure

  • Abdominal x-ray: diffuse calcifications
  • CT:
    • Dilated, irregular pancreatic duct
    • Intraductal filling defects
    • Calcifications
    • Irregular contour, heterogeneous parenchyma
  • MRI/MRCP
  • Endoscopic ultrasound (EUS)

- ERCP

- Exocrine/endocrine deficiency

- Abdominal pain alone...

All tests are most useful in advanced chronic pancreatitis

44

What is seen here?

Calcification in pancreas on abdominal x-ray

- Indicative of chronic pancreatitis

45

What is seen here? 

Calcifications in pancreas??

46

What is the gold standard for diagnosing chronic pancreatitis?

- What does it show?

ERCP

- Dilated pancreatic duct, filling defects, dilated side branches

- Invasive

47

What does MRI/MRCP do for the diagnosis of chronic pancreatitis?

- Provides imaging of the pancreatic parenchyma and the pancreatic duct

- Non-invasive

48

What does endoscopic ultrasound (EUS) do for the diagnosis of chronic pancreatitis?

- Some questions about specificity

- Completely normal EUS -> chronic pancreatitis unlikely

49

Look at this pic

50

Normal?

No idea what this is...

 

51

When can exocrine/endocrine deficiency be used to help diagnose chronic pancreatitis?

Advanced disease

- CT or other tests are likely positive

52

When can abdominal pain alone be used to help diagnose chronic pancreatitis?

- Not advanced disease -> challenging diagnosis

- Pancreatic protocol CT or MRI/MRCP

- EUS

53

How should chronic pancreatitis be managed from an abdominal pain standpoint?

What if:

- ERCP

- Steatorrhea

- Diabetes mellitus

- Most common and bothersome symptom

- Pain medication – risk of addiction

- Stop ETOH

- Pancreatic enzymes (non-enteric coated)

Also if:

ERCP:  pancreatic duct strictures or stones

- EUS:  celiac plexus block (transient, rarely used)

- Surgery – Puestow, pancreatectomy w/ islet cell transplant

Steatorrhea: pancreatic enzyme supplementation

Diabetes mellitus: insulin often needed; risk of hypoglycemia

- Malignancy: pancreatic adenocarcinoma (later cad)

54

What malignancy is associated with chronic pancreatitis?

- Lifetime risk

- Increased risk factors

Pancreatic adenocarcinoma

- 4% lifetime risk

- Smoking increases risk

Difficult to diagnose in setting of chronic pancreatitis

- Similar symptoms (abdominal pain, weight loss)

- Clinical suspsicion