Clinical Presentation of Pancreatitis (Necrotizing, Acute and Chronic) Flashcards Preview

Gastrointestinal 1 > Clinical Presentation of Pancreatitis (Necrotizing, Acute and Chronic) > Flashcards

Flashcards in Clinical Presentation of Pancreatitis (Necrotizing, Acute and Chronic) Deck (20)
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1
Q

What are the 3 types of pancreatitis?

A
  1. acute, which can become:
  2. chronic -OR-
  3. necrotizing
2
Q

How does acute pancreatitis present, clinically?

A
  • epigastric pain= dull, boring, steady, usually suden onset, and gradually becomes a constant intense ache (pain improves when sitting forward).
  • pain radiation to back
  • nausea and vomiting
  • diarrhea
3
Q

What key histories should we seek on H&P, if suspicious of acute pancreatitis?

A
  • PSHx (past surgical Hx) of recent operative or invasive procedures (especially ERCP) -OR-
  • FMHx of hypertriglyceridemia -OR-
  • PMHx of BILIARY DISEASE (those with gallstones), CHRONIC ALCOHOL ABUSE, cystic fibrosis, inflammatory bowel disease -OR-
  • recent Hx of BINGE DRINKING, trauma, use of certain prescription meds (furosemide, sulfa drugs…).
4
Q

Why can high triglyceride levels cause pancreatitis?

A

bc when they are transported on large chylomicrons, they can become wedged in the pancreatic capillaries, which will activate LIPASE, causing self-digestion of the pancreas.

5
Q

What are the physical exam findings on H&P for acute pancreatitis (in order of likelihood)?

A
  • FEVER (remember this is a marker of inflammation)
  • abdominal tenderness/guarding
  • TACHYCARDIA
  • HYPOTENSION (due to pancreatic enzymes entering the blood causing damage to vascualr walls, allowing fluid to leak into the extravascular space).
  • ABDOMINAL DISTENSION
  • DECREASED OR ABSENT BOWEL SOUNDS
  • PALLOR
  • DIAPHORESIS
6
Q

What causes abdominal distention in acute pancreatitis?

A

edema of Pancreas +/- gaseous distention of colon, secondary to narrowing of colonic splenic flexure from inflammation +/- sympathetically-induced ileus

7
Q

What is a sentinel loop?

A
  • sign seen on a radiograph that indicates localized ileus (painful obstruction) from nearby inflammation. Aka, it is the dilatation of a segment of small intestine, and an inability to move things forward.
8
Q

What are some less likely findings you will find with acute pancreatitis?

A
  • jaundice (due to possible blocking of bile duct).
  • dyspnea (due to enzymes released into the blood stream affecting the lungs).
  • hemodynamic instability
  • hematemesis or melena
  • Purtscher retinopathy= delivery of fat emboli with destroyed tissue of the pancreas to the retinal vessels causing loss of vission.
  • muscle spasms of extremities= due to lowering of serum calcium levels. As lipase is digesting fats to 3 fatty acids and glycerol, the fatty acids are amphipathic, and will avidly bind calcium with one end bc it is charged. This is essentially soap!
9
Q

What are some diagnostic tests for acute pancreatitis?

A

LABS are a must!
- amylase and lipase (bc they are made by the pancreas).
- alkaline phsphatase, AST, ALT, total bilirubin (to see if there is an effect on the liver).
- BUN, creatinine, and electrolytes (to see effects on kidney).
- glucose (bc pancreatic islet cells make insulin, and if these are affected, you will have hyperglycemia).
- cholesterol and triglycerides (bc if these are high it will make the situation worse)
- CBC (for WBC count; this is almost always elevated bc this is a marker for inflammation) and hematocrit (to show how volume depleted the patient is; if it is high then you have more RBCs relative to water, since you are losing plasma).
- CRP (marker for inflammation)
- +/- ABG (to see if lungs are effected)
LDH (shows anaerobic respiration) and bicarb (drops since we see a metabolic acidosis).
- +/- IgG4 (elevation will indicate autoimmune pancreatitis).

10
Q

Is imaging necessary?

A

only if Dx in doubt

11
Q

What are some imaging considerations?

A
  • abdominal ultrasound= test of choice for suspected biliary disease; not a test to test “for” pancreatitis
  • MRCP (Magnetic Resonance Cholangiopancreatography)= provides non-invasive image of biliary and pancreatic ducts; done if choledocholithisasis is suspected.
  • Abdominal CT= ALWAYS done if disease is severe.
12
Q

What are the 2 classifications of acute pancreatitis?

A
  1. Mild= interstitial edema + inflammatory infiltrate (admitted to med-surg floor, lower mortality).
  2. sever= sever inflammatory infiltrate, necrosis, +/- severe gland dysfunction, +/- multi-organ failure (admitted to ICU, higher mortality rate, complications).
13
Q

How do we stage acute pancreatitis? (aka what is their risk for death)

A
  • RANSON criteria= only able to provide assessment for 1st 48 hours, but easier; thresholds are only met with EtOH or gallstone induced pancreatitis.
  • APACHE (acute physiology and chronic health evaluation) II= able to assess pt at any time of illness, but very cumbersome; provides a better mortality predictions, and is useful despite the cause of the pancreatitis.
14
Q

*** What are the RANSON criteria? (She said to memorize)

A

On admission:
- Pt > 55
- WBC > 16,000
- Blood glucose > 200 gm/dL
- serum LDH >350 IU/L
- AST > 250 IU/L
Within 48 hours:
-Hct drops >10% (bc this could mean hemolysis of RBCs is occurring due to excessive pancreatic enzymes).
- BUN increases by 5 mg/dL
- serum Ca2+ 4 mEqu/L (this means metabolic acidosis).
- Estimated fluid sequestration > 6 L (fluid that is not in the vessels).
*You get one point for each of these that is met.
0-2= minimal mortality
3-4= 15% mortality rate
> 5 mortality rate > 40%

15
Q

How does chronic pancreatitis present?

A
  • epigastric pain= constant/chronic OR recurring severe attacks that last for hours.
  • weight loss
  • +/- diarrhea, steatorrhea (fatty stools)
  • insulin-dependent DM (late)
16
Q

** What will KUT and CT ALWAYS show in chronic pancreatitis? (TEST QUESTION)

A

Ca2+ deposits (pathognomonic) in the pancreas due to saponification! These are really easy to see.
*YOU WILL SEE WHITE SPOTS ON CT!!! KNOW THIS IMAGE

17
Q

What is necrotizing pancreatitis?

A
  • a complication of acute pancreatitis
  • cases develop within 4 weeks of acute pancreatitis.
  • features necrosis (tissue death) of peri-pancreatic fat +/- pancreatic parenchyma
18
Q

What will you see on CT and MRI in necrotizing pancreatitis?

A

devitalized tissues will have decreased IV contrast (black amorphous area).

19
Q

What is Cullen sign in necrotizing pancreatitis?

A

bluish discoloration around umbilicus secondary to hemoperitoneum (remember the pancreas is mostly retroperitoneal, and if it bleeds, it can track around the umbilicus).

20
Q

What is Grey-Turner sign?

A

reddish-brown/purplish discoloration of flank secondary to retroperitoneal blood dissecting along tissue planes.