Pancreatitis

Question 1

Acute pancreatitis Tx requires

Answer 1

early and aggressive IVF resuscitation, management similar to sepsis

Question 2

Sx of acute pancreatitis are related to

Answer 2

activation of enzymes in the pancreas 2/2 pain, n/v, and intestinal ileus

Question 3

Etiology of acute pancreatitis is

Answer 3

Alcohol 
gall stones 
trauma, surgery 
acute d/c of diabetes or HLD drugs 
s/p endoscopic retrograde cholangiopancreatography

Question 4

MC meds that cause pancreatitis are

Answer 4

ACE, ARB, Thiazide diuretics, Furosemide 
Azathioprine 
Corticosteroids
Glyburide
Mesalamine 
Bactrim 
Valproic acid 
Statins (esp. Simvastatin)

Question 5

The meds that cause acute pancreatitis do so 2/2

Answer 5

direct toxic effects of the drug or it’s metabolites
hypersensitivity
drug induced hypertriglyceridemia
alterations of cellular function in pancreas/pancreatic duct

Question 6

Analgesics used to Tx acute pancreatitis are

Answer 6

Hydromorphone
Fentanyl
Morphine (but can increase pressure in sphincter of oddi)
AVOID: demerol! normeperidine (metabolite) can accumulate and become toxic

Question 7

Does acute pancreatitis require antibiotics and if so, which

Answer 7

Prophylaxis no longer recommended
Ascending cholangitis or necrotizing pancreatitis: Piperacillin-Tazobactam
Cholangitis allergic to penicillin: Levofloxacin

Question 8

Does acute pancreatitis require fluids

Answer 8

Yes! Isotonic crystalloid solution, NS or LR to reduce risk of persistent SIRS and organ failure

Question 9

Other acute pancreatitis Tx are

Answer 9

Enteral or parenteral nutrition
Can start oral alimentation after pain subsides and ileus has resolved (small amounts of high carb, low fat/protein)
NPO or NG if vomiting persists
Dc w/: diet modification (reduce fat, alcohol, added sugar)

Question 10

Algorithm for acute pancreatitis says start with

Answer 10

screen for SIRS 
Fluid replacement w/ LR 
correct lytes 
treat metabolic abn 
pain control 
assess meds and contributing factors 
consider ERCP if cholangitis or biliary pancreatitis

Question 11

Algorithm for acute pancreatitis says step 2 based on severity is

Answer 11

Mild: PO food when pain decreases and labs improve
mod: +/- ICU, Tx systemic complications, Gradual diet advance
Severe: ICU. Tx systemis Sx, Enteral tube feed. If no improvement and you r/o pancreatic necrosis, Tx w/ abx

Question 12

Hallmark complications of chronic pancreatitis are

Answer 12

Chronic pain
malabsorption w/ steatorrhea
DM
Pancreatic cancer

Question 13

Primary treatments for malabsorption 2/2 chronic pancreatitis are

Answer 13

Pancreatic enzyme supplement (enteric coated)

Reduce dietary fat intake

Question 14

What can be added to pancreatic enzyme supplement for choronic pancreatitis

Answer 14

Antisecretory agent to increase effect on malabsorption and steatorrhea
H2 blocker or PPI

Question 15

What analgesics can be used in treating chronic pancreatitis

Answer 15

Tramadol (first line)
Chronic opioid (morphine, fentanyl)
Gabapentin, pregabalin, SNRI, TCA (adjunct)
(pancreatic enzymes can also be used to Tx pain form the diseasE)

Question 16

Should you take coated or non-coated enzymes

Answer 16

Uncoated (Viokase) are more effective in pain control when given w/ a PPI, but are controversial

Question 17

What IV drug is beneficial therapy for pancreatic ductal fistulae

Answer 17

Octreotide

Question 18

What can you take for autoimmune pancreatitis

Answer 18

Individualized dose of corticosteroids

Question 19

In order to treat malabsorption and steatorrhea, how should you take pancreatic enzymes

Answer 19

Start at 25-40K USP Lipase with each meal
Admin dose during or just after meal
Max dose is 75K
Enteric coated microsphere products may be more effective

Question 20

Why do pancreatic enzymes provide pain relief

Answer 20

They can break down CCK

normally, CCK causes an increase in pancreatic secretion but can be inhibited by Trypsin

Question 21

Patients with chronic pancreatitis show a decrease in

Answer 21

Trypsin production- which normally inhibits the release of CCK
When CCK is released, pain increases 2/2 unabated pancreatic secretion

Question 22

Proteases in pancreatic supplements act as

Answer 22

substitutes for endogenous trypsin= decrease in CCK

Question 23

Available pancreatic enzymes are

Answer 23

Creon (enteric coated minimicrospheres)

Pancreaze and Ultresa (enteric coated minitabs/microtabs)

Question 24

What is celiac disease

Answer 24

AI immune mediated response to gluten
Sensitivity to Gliadin fraction in glutens
Tissue transglutaminase modified proteins (not sure what she is saying about these)
Immunologic cross reactivity, inflammation, and tissue damage cause malabsorption

Question 25

Mnemonic for celiac disease Tx is (CELIAC)

Answer 25

Consultation w/ dietician 
Education about dz 
Lifelong gluten free adherence 
Identify and treat ntr deficiency 
Access to advocacy group 
Continuous long term f/u

Question 26

Overlooked sources of gluten are

Answer 26

Oral Rx drugs
Non-Rx drugs
vitamins and minerals
health and beauty aids

Question 27

What are safe foods to eat

Answer 27

Rice 
Corn 
Soybean flour 
Uncontaminated oats 
Tapioca 
Quinoa 
Amaranth 
Sorghum

Question 28

What Ig normalizes when you remove gluten

Answer 28

IgA!

Question 29

In refractory celiac reports, treat with

Answer 29

Steroids 
Azathioprine (caution, leads to lymphoma) 
Cyclosporine 
Tacrolimus 
Infliximab, Alemtuzumab

Question 30

What nutrients do you need to sub in celiac

Answer 30

A, D, E, B12 
Calcium 
Carotene
copper
zinc
folic acid
ferritin
iron

Question 31

Celiac disease is associated with

Answer 31

hyposplenism; give pneumovac!!