August 27, 2015 - Pancreatitis Flashcards
Endocrine or Exocrine
Both! The pancreas is the only organ that is both. It secretes products through ducts, and also secretes insulin.
Major Functional Units
Acinus and Duct.
Acinus secretes proenzymes and enzymes. Proenzymes are zymogens which are an inactive enzyme precursor.
Duct secretes water, electrolytes, and other secretory products.
Pancreatic Protection Mechanisms
Synthesis of enzymes as inactive zymogens
Trypsin inhibitor packaged in zymogen granule
Segregation of enzymes in membrane-bound compartments
When these mechanisms break down, bad things happen. Enzymes may attack the pancreas and digest it, causing big inflammation.
Acute Pancreatitis
Alcohol and stones are the main causes. Zymogen activation causes autodigestion which results in massive inflammation of the pancreas as well as a systemic inflammatory response.
Ethanol may cause this by creating toxic metabolites, and gallstones may cause this by potentially causing a bile reflux. Small stones are more likely to cause pancreatitis than large stones.
Acute Pancreatitis and Drugs
Some drugs may cause pancreatitis and there is good evidence for about 20 of them. Drugs account for approximately 1.5% of the cases of pancreatitis.
Azathioprine is a bad culprit.
Azathioprine
Azathioprine is an immunosuppressive drug that is often used in organ transplantation and autoimmune diseases.
Iatrogenic
We did it.
For pancreatitis, this can be induced by performing an ERCP which is the fancy endoscope to look into the bile duct. Unfortunately, this has approximately a 1-10% chance of causing acute pancreatitis.
Surgery can also cause this when done in the upper abdomen. If pancreatitis develops post-surgery, the morality rate can be up to 35%.
Traumatic Pancreatitis
May be caused by handle-bar injuries. Under the microscope, you can observe leakage.
Immune Pancreatitis
Autoantibodies (ANA, ASMA) that target the pancreas. Fortunately, this condition responds well to steroids and is the only case where you want to put the patient on anti-inflammatory drugs.
Always be aware, that autoimmune pancreatitis is a good mimicker of malignancy. You must be aware that it may not be cancer, but may instead be autoimmune pancreatitis.
Acute Pancreatitis Presenting Features
Abdominal pain
Nausea / vomiting
Tachycardia
Grey Turner’s Sign
Bruises that appear on the flanks of an individual. This indicates a retroperitoneal hemorrhage. This is bad and is a huge indication for acute pancreatitis or a pancreatic hemorrhage.
Acute Pancreatitis Diagnosis
Patient must have two out of the following
- Typical upper abdominal pain
- Serum levels of amylase or lipase >3x ULN
- Confirmatory findings from cross-sectional imaging
Every patient with potential pancreatitis needs an abominal ultrasound to rule out gallstones as a cause.
Treatment for Acute Pancreatitis
Supportive care
- Aggressive fluid and electrolyte replacement
- Monitoring
- Analgesia, anti-emetics
Nutrition for Pancreatitis
Nasogastric (NG) or Nasojujunal (NJ) is far superior to Total Parenteral Nutrition (TPN)
NG/NJ >> TPN
Antibiotics and Pancreatitis
Routine antibiotics are not recommended unless for specific indications such as infected necrosis or cholangitis.
