Acute Pancreatitis

Question 1

protection from pancreatitis

Answer 1

• lysosomal and digestive enzymes are packaged separately
• trypsin inhibitor is packaged into each vesicle
• ## alpha-1 anti-trypsin protects against autodigestion in the bloodstream

Question 2

cascade of pancreatitis

Answer 2

• trypsin is activated by cathepsin B from lysozymes or other trypsin
• trypsin then activates other pro-enzymes into active form
• active enzyme then affect other targets in the body
• AMYLASE AND LIPASE ARE THE ONLY ENZYMES WITHOUT A PRO-ENZYME

Question 3

activation of chymotrypsin and kallikrein by trypsin

Answer 3

• leaky vessels

Question 4

activation of elastase by trypsin

Answer 4

• weakens artery walls and leads to aneurysms and hemorrhage

Question 5

activation of thrombin by trypsin

Answer 5

• DIC

Question 6

activation of complement by trypsin

Answer 6

• WBC chemotaxis

Question 7

release of lipase

Answer 7

• fat necrosis

Question 8

activation of phospholipase A2 by trypsin

Answer 8

• ARDS

Question 9

macroamylassemia

Answer 9

• hereditary condition in which macromolecules of amylase exist
• creatinine nearly zero

Question 10

creatine levels in acute pancreatitis

Answer 10

• elevated

- nearly zero in macroamylassemia

Question 11

etiologies of high amylase

Answer 11

• if its salivary amylase - diabetic ketoacidosis

- if its pancreatic amylase - pancreatitis

Question 12

factors predictive of gallstone pancreatitis

Answer 12

• the more the risk factors the more likely gallstones are the cause and not alcohol
• age > 50
• female
• amylase > 400
• AST > 100
• ALP > 300

Question 13

etiologies of high lipase

Answer 13

• lipase is only elevated in pancreatitis

Question 14

Ranson’s criteria, at admission

Answer 14

• age > 55
• WBC > 16,000
• glucose > 200
• LDH > 350
• AST > 250

Question 15

Ranson’s criteria, during initial 48 hours

Answer 15

• Hct decrease of > 10
• BUN increase of > 5
• Ca < 8
• PaO2 < 60
• Base deficit > 4
• fluid sequestration > 6

Question 16

Ranson’s criteria

Answer 16

• if over the levels, the more likely to develop severe pancreatitis
• if 3-5 criteria met, about 20% mortality
• 6-8, 60% mortality
• 9-11, 80% mortality

Question 17

rapid IV bolus contrast CT scan

Answer 17

• used to indicate viable vs necrotic pancreas and delineates pancreas from extrapancreatic fluid
• if whole pancreas takes up dye there is no necrosis
• if necrotic it will look black on CT

Question 18

necrosis with infection

Answer 18

• bad prognosis

- about 30% mortality

Question 19

3 sequelae of pancreatitis

Answer 19

• pseudocyst
• phelgmon
• necrosis

Question 20

Grey-Turner sign

Answer 20

• bruising on flank from bleeding and rupture of splenic artery
• if bruising is by umbilicus its called Cullen’s sign and is a sign of retroperitoneal hemorrhage

Question 21

treatment of acute pancreatis

Answer 21

• hemodynamic and renal monitoring
• FLUID, FLUID, FLUID
• NPO
• antibiotics with pancreas penetration
• O2 as needed for ARDS
• ERCP for biliary pancreatitis IF STABLE, especially in severe cases WITHIN 24 HOURS of presentation to relieve obstruction by stone

Question 22

calcium and albumin levels

Answer 22

• normally decrease together
• if calcium drops by itself by binding to free fatty acids it can lead to cardiac problems and neuromuscular irritability

Question 23

indications for intervention of pseudocysts

Answer 23

• larger than 5 cm, lasts > 4-6 weeks, severe pain, rapid expansion, complications

Question 24

ERCP

Answer 24

• scope passed into 2nd part of duodenum where papilla is located, catheter is passed via scope into pancreatic or bile ducts and dye injected
• X-rays then obtained to see if filling defects of either duct
• spincterotomy can be performed with stone removal or stent placement
• drainage of pseudocyst can be accomplished through stomach or duodenum

Question 25

2 common causes of drug induced pancreatiits

Answer 25

• azathioprine and 6-MP

Question 26

pancreas divisum

Answer 26

• 2 ducts drain the pancreas instead of 1