Approach To The Pancreatic Patient - Dr. McGowen Flashcards
Acute Pancreatitis EM : what is it, risks, SX
- autodigestion by self enzymes getting activated
- Biliary tract problems like gallstones, heavy alcohol, hyperglyceridermia, trauma, ERCP, medications
- epigastric pain, radiate to back, cullen or turner sign, ARDS, Chvostek and Trousseau sign = hypocalcemia
Acute Pancreatitis EM : Labs and DX
- Lipase elevated X3*, elevated Hct = pancreatic necrosis, high ALK/ BUN/ Cr/ billirubin, LOW Ca = tetany
- at least 2 of these** (epigastric pain, elevated Lipase 3X upper limit, CT changes consistent with pancreatitis)
Acute Pancreatitis : imaging
- CT no contrast
- CT IV contrast
- ABD XRAY
- Chest XRAY
- US
- CT without contrast : enlarged pancreas
- CT + IV contrast : necrosis, AVOID if cr is over 1.5, can make pancreatitis worse
- ABD X-ray : Sentinel loop (air in LUQ intestines), Colon cutoff sign (gas in colon stoping abruptly at sight on pancreatitis)**
- Chest X-ray : pleural effusion (supinated then prone fluid)
- US not helpful (only gallstones if present)
Acute Pancreatitis : complications
- intravascular volume depletion = fluid leaking out causing pre-renal azotemia (acute tubular necrosis)*
- fluid (plueral effusion), emphysematous pancreatitis)
- ARDS*
Acute Pancreatitis : TX
- fluid resuscitation (LOTS) ** (dont increase fluids it can lead to pain and ARDS)
- Ca gluconate IV : tetany
- give albumin and plasma :
APACHE 2
acute physiology and chronic health evaluation (predicts mortailty) =over 8 is higher mortality
C & HOBBS
score if this happens in the first 48hrs = worsening prognosis 1. Ca < 8 2. Hct >10% DROP 3. O2 <60mmHg 4. Base deficit > 4 5. BUN increase > 5 Sequestering fluid > 6L
BISAP**
Bedside Index for severity in Acute Pancreatitis
- BUN > 25
- Impaired mental status
- SIRS > or = 2 of 4 present
- over 60yo
- pleural effusion
3 organisms causing emphysematous pancreatitis
- Clostridium Perfringens
- Enterobacter aerogenes
- Enterococcus faecalis
Chronic Pancreatitis : what is it, risks
- irreversible damage to pancreas cells (self activating digestion), from a SAPE (sentinel acute pancr. event) —-> inflammatroy process that results in injury and fibrosis (Necrosis/fibrosis)
- TIGAR-O
- Toxic Metabolic (alcohol)
- Idiopathic : smoking
- genetics : CF
- autoimmune : Celiac, hypergammaglobunimia (IgG)
- Recurrent : recurrent AP
- Obstructive : stricture, stone, tumor
Chronic Pancreatitis : SX
constant or intermittent epi pain, CARDINAL SX
= pain hours to weeks, then becomes more constant
= pancreatic exocrine or endocrine insufficiency (steatorrhea –> malabsorption) (DM )
Chronic Pancreatitis : Labs and DX
- high lipase, amylase,
- high Fecal Fat
- LOW fecal chymotrypsin
- LOW fecal elastase
Chronic Pancreatitis : Imaging
- Plain ABD Xray
- CT ABD
- ERCP
- MRCP
- EUS
- Plain ABD X-ray : Calcifications
- CT ABD : (if not seen in xray)calcifications —-> tumefactive chronic pan. = concern for pan cancer
- ERCP : dilated pancr duct, stones, need more
- MRCP : enhance imaging
- EUS : biopsy of pancreas
Chronic Pancreatitis : TX
pain control, pan enzyme supp, low fat diet, X alcohol, Tx DM,
Chronic Pancreatitis : complications + prognosis
- DM**, Pancreatic insufficiency = steatorrhea, Pancreatic cancer
- Eventually pancreatic cancer causes death
Pancreatic Cancer : what type, where, risks
- Adenocarcinoma*,
- pancreatic head (biliary obstr. and jaundice)
- smoking, obese, AA, over 65yo, DM, chronic pancr., cirrhosis, FH
Pancreatic Cancer : SX
= painless jaundice ** (if pain usuaully epi and at night when laying back, relived by bending forward)
= New onset DM in elderly **
= Trousseau sign of Malignancy (many venous thrombosis = migratory thrombophlebitis)
= Courvoisers sign : nontender enlarged palpable gallbladder (mass)
Pancreatic Cancer :DX and TX
- CT ABD and CA 19-9 (mutation in KRAS)
2. whipple procedure surgery (10% curabe)
which lab thing is most important when assessing pancreas function
Lipase more then amylase (elevated in other conditions also)
AST/ALT, Alk Phasphate, bilirubun levels show what
if there is damage to the liver (nothing to do with the function of the liver)
true liver function enzymes to be measured
- PT/INR
- Albumin
- Cholesterol
- Ammonia
Hepatocellular disease
= primary injury to hepatocytes
= elevated AST/ ALT (most specific is ALT unless alcohol injury)
Cholestatic Disease
= primary injury to bile ducts
= primarly Alk phosphatase and bilirumbin elevated
= bile does not get to SI, pruritus ** + jaundice, no hepatocellular necrosis)
elevated alk phosphatase is also seen when
childhood, preg, bone disease
Coagulation factors measurement
best mesure for hepatic synthetic function (all clotting factors except F8 is made in liver) = common to use INR
clinical signs of jaundice happens at what level
> 2mg/dL
Jaundice figure out what first and DX
- unconjugated or conjugated
= fractionated bilirubin = indirect vs direct
= Fractionate ALP : ordering GGT (gamma-glutamyl transferase) - elevated GGT = liver source
- normal GGT= bone or other source (placenta)
high ALP in children
growing bones
conjugated jaundice
below liver problem DIRECT , hepatitis, FE problem, lipase, biliary obstruction
= image with US
unconjugated jaundice
prehepatic problem INDIRECT
= CBC anemia or thrombocytopenia, hemolysis**, sickle cells, mishaped RBCs , fasting **
= image peripheral smear
= LOW haptoglobin, HIGH retic count, HIGH LDH
Gilbert syndrome
fasting (sick / post exercise / on purpose) —-> indirect high bilirubin
Cholelithiasis is what 2 types , and what and SX
- cholesterol (80%) + Pigment stones calcium bilirubinate (20%)
- gallstones
- asymp, RUQ pain, can radiate upper right scapula -> biliary colic
Cholelithiasis DX
US ** = stones show acoustic shadow
Cholelithiasis Risks
- fair, fat, FH, F, Fertile, Forty (males only more if they have cirrhosis and hep C)
- prolonged fasting = biliary sludge
acute cholecystitis : what 2 types and how
- Calculous : gallstones impacting cystic duct , inflammation in gallbladder
- Acalculous : true cholecystitis = no stones , from burns trauma, infections of gallbladder
acute cholecytitis SX
large fatty meal gives acute attack, N,V,
RUQ and epi pain, MURPHY,
(jaundice, pale color stools, dark urine)
acute cholecytitis labs and imaging
- elevated bilirubin, ALP, GGT
2. RUQ abd US show stones, wall thickening, pericholecystic fluid, acoustic shadows)
acute cholecytitis tx
complications
- surgery, ABs
2. Gangrene of gallbladder —-> perforation, Emphysematous cholecystitis (gas forming infection)
Emphysematous cholecystitis risk and what to do
DM = urgent cholecystectomy
air in lumen and wall of gallbladder
Chronic Cholecystitis : what, how, SX
- chronic inflammation of GB, usually from gallstones = repeated acute subacute cholecystitis
- asymp for years, chronic or post-prandial RUQ or epi pain
Chronic Cholecystitis : tx and complications
- surgery,
2. Porcelain gallbladder : XRAY —-> incidental calcified lesions
calcified gallbladder means
high risk of gallbladder cancer (poor prognosis)
courvoisier gallbladder
enlarged palpable nontender gallbladder with jaundice
= associated with cancer of the head of the pancreas
porcelain gallbladder
chronic cholithiasis causes calcified scarring
= associated with GB carcinoma
choledocholithiasis : is what, sx
- stones in common bile duct
2. severe RUQ pain , fever, jaundice
choledocholithiasis : DX and labs
- high AST, ALT, direct hyperbilirubin, hihg lipase and amylase (secondary pancreatitis**)
choledocholithiasis : imaging
INR then ERCP
choledocholithiasis : TX
= ERCP with sphincteromy and stone extraction /stent placement **
= do preg test, INR, kidney function before ERCP
= cholecystectomy is another option
choledocholithiasis complications
acute pancreatitis = from ERCP
= acute ascending cholangitis
Ascending cholangitis : is what and risk
- infection in biliary tract from an obstruction
2. choledocholithiasis
Ascending cholangitis SX
= Charcot TRIAD : 1. RUQ pain 2. fever 3. jaundice = Reynold PENTAT : 1. altered mental status 2. hypotension 3. RUQ pain 4. fever 5. jaundice
acute suppurative cholangitits
pus in biliary duct from infection
= reynolds pentat
Ascending cholangitis : DX and imaging
- high WBC
- blood culture
- high AST/ALT, lipase, direct biilirubin
= ERCP, INR
Ascending cholangitis complications
and tx
- acute pancreatitis from ERCP (monitor lipase)
2. ERCP + sphincterotomy and stone extraction + stent placement *****, or cholecystectomy
Biliary Dyskinesia is what and sx
- functional disorder of GB, unknown reason
2. frustrated pt, RUQ pain episodes, severe limiting daily activities, N when pain
Biliary Dyskinesia DX
= normal US, labs
= RUQ pain like biliary colic
= normal in HIDA scan, you can see GB ejection fraction
Biliary Dyskinesia tx
low fat
surgery (cholecystectomy
Primary Sclerosing Cholangitis (PSC) : risk, and sx
- male, IBD (esp UC), lowered risk with smoking onset, still don’t advice it
- pruritis* , fatigue, jaundice, RUQ pain
Primary Sclerosing Cholangitis (PSC) : DX and labs
- high Alk phosphatase, high direct bilirubin
= cholestasis - IMAGING :
= MRCP / ERCP —-> “beads on string” in duct wall , segmental fibrosis of bile duct with saccular dilations b/w strictures
= Liver bx —-> “onion - skinning” in the biopsy
Primary Sclerosing Cholangitis (PSC) : tx and complications
- none, liver transplant or support sxs
2. high risk of getting cholangiocarcinoma, colon cancer (from UC), ascending cholangitits
Primary Biliary cholangitis (PBC) : is what and how, risks
PB Cirrhosis
- chronic disease of liver and biliary tree, destructive intrahepatic cholagitis
- autoimmune destruction of small intrahepatic bile duct and cholestasis
- F, over 50yo, UTI, smoking, hormone therapy, hair dye
Primary Biliary cholangitis (PBC) : SX
- asympt isilated elevation in alk phosphatase
2. pruritus, fatigue, jaundice, xanthelasma*, steatorrhea, hyperpigmentation, portal HTN
Primary Biliary cholangitis (PBC) : DX ,
high serum alk Ph. (GGT elevated)**
= antimitochondrial Abs (AMA) **
= high IgM,
= do liver bx if AMA-
Primary Biliary cholangitis (PBC) : TX and complications
- ursodeoxycholic acid, liver transplant at end stage disease
- cirrhosis –> liver failure