Pancreatitis

Question 1

Acute Pancreatic H&P

Answer 1

Acute onset
Upper abdominal pain or epigastric pain
Pain may radiate to back
Severe and constant
+ Nausea/Vomiting
Improved with leaning forward
Fever, chills, sweats

Question 2

Chronic Pancreatic H&P

Answer 2

Less abrupt onset
Improved with leaning forward
Upper and chronic abdominal pain
Steatorrhea
Weight loss
Diabetes
Fever, chills, sweats

Question 3

Pancreatic Cancer

Answer 3

Nonspecific
Upper abdominal pain
New onset diabetes
Weight loss and anorexia
Nausea and vomiting
Fever, chills, sweats

If mets to the liver…
Jaundice
Dark urine
Light colored stools

Question 4

Pancreatic PE

Answer 4

+ abdominal distension
- bowel sounds
+ tenderness on examination
Cullen’s sign-periumbilical bruising
Grey Turner’s sign-bruising of the flank
Dyspnea due to diaphragmatic inflammation
Pleural effusions
ARDS
Scleral icterus and/or jaundice
Hepatomegaly

Question 5

Differentials Include:

Answer 5

Peptic ulcer disease
GI Perforation
Cholecystitis, cholangitis, choledocholithiasis
Intestinal obstruction
Mesenteric ischemia
Hepatitis
Cardiac

Question 6

Pancreatic Causes

Answer 6

Alcohol Use – 25-35%
Gallstones – 40-70%
Hypertriglyceridemia 1-14%
Post ERCP
Family History and/or autoimmune diseases
Hypercalcemia
Medication History - < 5%
ACE inhibitors
Diuretics
Azathioprine
Sulfa drugs

Question 7

Etiology of Acute Pancreatitis: Mechanical

Answer 7

-Gallstones
-Biliary sludge
-ascariasis-roundworm
-periampullary diverticulum
-pancreatic or periampullary cancer
-ampullary stenosis
-duodenal stricture or obstruction

Question 8

Etiology of Acute Pancreatitis: Toxic

Answer 8

-Ethonal
-methanol
-scorpion venom
-organophosphate poisoning

Question 9

Etiology of Acute Pancreatitis: Metabolic

Answer 9

-Hyperlipidemia (types I, IV, V)
-Hypercalcemia

Question 10

Etiology of Acute Pancreatitis: Infection

Answer 10

-Viruses-mumps, coxsacks, hep B, CMV, varicella-zoster, HSV, HIV
-Bacteria-mycoplasma, legionella, leptospira, salmonella
-Fungi-aspergillus
-Parasites-toxoplasma, cryptospordium, ascaris

Question 11

Etiology of Acute Pancreatitis: Vascular

Answer 11

-Ischemia
-Atheroembolism
-Vasculitis (polyarteritis nodosa, SLE)

Question 12

Amylase

Answer 12

-Breaks down carbohydrates
-Rises in 6-12 hours after onset of pancreatitis
-Level returns to normal w/in 3-5 days
-Short half life – 10 hours
-May miss acute diagnosis
-Level > 3 times of normal = sensitivity for the diagnosis of acute pancreatitis of 67 to 83 percent and a specificity of 85 to 98 percent
-Rarely use

Can also be elevated in
Renal failure
Renal Stones
Intestinal disease
Parotitis
Salivary disorders

Question 13

Lipase

Answer 13

-Breaks down fats
-More sensitive and specific to pancreas
-Rises 4-8 hours onset of symptoms
-Peaks at 24 hours
-Normalizes 8-14 days
-More sensitive when compared to amylase for pancreatitis secondary to alcohol

Also elevated in
Renal failure
Acute cholecystitis
Bowel obstruction
Duodenal ulcer
Pancreatic tumors
Type II DM, DKA
HIV
Sarcoidosis
Celiac disease

Question 14

Diagnostic Criteria for Acute Pancreatitis

Answer 14

Must meet 2/3 criteria
-Epigastric pain
-Elevation in lipase or amylase to 3x or more upper limit of normal
-Imaging findings of acute pancreatitis

No imaging needed if met criteria of epigastric pain and elevation of lipase/amylase labs

Question 15

Imaging Recommendations for Acute Pancreatitis

Answer 15

Pain not characteristic
Amylase or Lipase < 3x normal
Routine imaging not recommended

Abdominal CT
Abdominal MRI w/ gadolinium if renal failure or contrast allergy

Question 16

Management of AP

Answer 16

-Fluids (1.5 mL/kg/hour with a 10 mL/kg bolus in patients with hypovolemia)
-Limit fluid resuscitation to first 24-48 hours
-Pain control
-glucose
-treat underlying cause
-nutrition
-ppx abx not recommended

Question 17

Pancreatitis from Hypertriglyceridemia

Answer 17

-Triglyceride levels > 1000 mg/dL risk factor
-Blood becomes “milky” and break down of free fatty acids by pancreatic lipases causes inflammatory response and injury
-Risk factors: Diabetes, alcohol, hypothyroidism, estrogen, propofol, olanzapine, thiazide diuretics, beta blockers, pregnancy, obesity

-Gemfibrozil 600 mg BID
-Low fat/cholesterol diet & exercise
-Apheresis/Therapeutic Plasma Exchange (TPE)

Question 18

Pancreatitis from hypercalcemia

Answer 18

Identify and treat underlying causes
-Hyperparathyroidism
-Hyperthyroidism
-Immobility
-Medication induced – lithium, thiazide, theophylline
-CKD
-Multiple myeloma

Question 19

Pancreatic Pseudocyst

Answer 19

Encapsulated and mature fluid collection with minimal or no necrosis
Well defined wall on imaging

Question 20

Walled off pancreatic necrosis (WOPN)

Answer 20

Encapsulated collection of necrosis
Imaging contains thick liquid and debris
Consider drainage if symptomatic or greater than 6 cm in size

Question 21

Pancreatic Insufficiency

Answer 21

Pancreas unable to digest food due to lack of enzymes
–Trypsin and chymotrypsin – digest protein
–Amylase – digest carbohydrates
–Lipase – digest fat
s/s
Steatorrhea
Weight loss
Fatigue
Excessive gas and abdominal distension
Anemia

Question 22

Pancreatic Diabetes

Answer 22

30-50% of patients with chronic pancreatitis
Annual Hemoglobin A1c and fasting blood glucose for monitoring

Question 23

Abdominal Compartment Syndrome: pancreatic complication

Answer 23

Intra-abdominal pressure > 20 mmHg with no organ failure
Tissue edema from aggressive hydration, inflammation, ascites, ileus
Serial urinary bladder pressure measurements
Increased abdominal girth

Supportive care
Surgical decompression and open abdomen
Temporary abdominal wall closure

Question 24

Splenic Vein Thrombosis: Pancreatic Complication

Answer 24

-1-24% in patient with chronic pancreatitis
-Develops secondary to inflammatory process
-May develop gastric varices due to increased portal hypertension
-Asymptomatic presentation is common
-UGI bleed from varices
-+ascites, +splenomeagly
-? anticoagulation