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MS2 GI > 10/8- Pancreatitis > Flashcards

10/8- Pancreatitis Flashcards

(54 cards)

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1
Q

Familiarize yourself with this picture

A

Vasculature:

  • Splenic a down body/tail of pancreas
  • Hepatic a
  • Portal v
  • Superior/inferior pancreatico-duodenal a
  • Superior mesenteric a/v
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2
Q

What is acute pancreatitis?

  • Mild vs. severe
  • Mortality rates
A

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
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3
Q

What is the pathophysiology of acute pancreatitis?

A
  • 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
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4
Q

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

A

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

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5
Q

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

  • More common with ____
  • Process/pathogenesis
A

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
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6
Q

What is seen here?

A

Gallstone throwing shadow

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7
Q

Describe the anatomy of the gallbladder

A
  • Fundus (most distal)
  • Body
  • Hartmann’s pouch (proximal)
  • Neck
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8
Q

Describe the outflow path from the gallbladder

A
  • 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)

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9
Q

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
A

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
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10
Q

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

A
  • 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)
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11
Q

What is necessary to establish acute pancreatitis diagnosis?

A

Combo of at least 2 of the 3:

  • Typical symptoms
  • Elevated amylase/lipase
  • CT findings of pancreatitis
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12
Q

What are typical symptoms of acute pancreatitis?

A

Abdominal pain

  • Steady and moderate to severe
  • Upper abdomen, epigastric

Nausea and vomiting

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13
Q

What are physical exam findings in acute pancreatitis?

A
  • 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
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14
Q

What is Grey Turner’s sign?

A

Ecchymoses in flanks

  • (rare) finding in acute pancreatitis
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15
Q

What is Cullen’s sign?

A

Periumbilical ecchymosis

  • (rare) finding in acute pancreatitis
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16
Q

What is seen here?

A

Acute pancreatitis: Cullen’s sign?

– periumbilical ecchymosis

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17
Q

What are lab values expected in acute pancreatitis?

A

Amylase

  • 3x serum elevation
  • Rises within 6-12 hrs; half life 10 hrs

Lipase

  • 3x serum elevation
  • Rises within 24 hrs; longer half life
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18
Q

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

A

CT

  • Not always necessary (mild cases)
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19
Q

What is expected in CT of acute pancreatitis?

A
  • Peri-pancreatic inflammatory changes
  • Peri-pancreatic fluid collections
  • Pancreatic necrosis
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20
Q

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

A
  • Evaluate for other causes of abdominal pain
  • Sentinel loop: localized ileus of a segment of small intestine
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21
Q

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

A

Visualize:

  • Gallstones
  • Dilated bile duct (choledocholithiasis)
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22
Q

What is choledocholithiasis?

Study These Flashcards
A

Dilated bile duct

23
Q

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

Study These Flashcards
A

History:

  • Alcohol
  • Medications

Labs:

  • Liver tests
  • Calcium
  • TG
  • IgG4

Ultrasound:

  • Gallstones
  • Dilated bile duct

CT

  • Pancreatic mass of cyst
24
Q

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

Study These Flashcards
A

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

MS2 GI (26 decks)

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