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Flashcards in pancreatic diseases Deck (39):

case 1: hx gallstones 1 day hx of sev. epigastric pain radiates to mid-upper back
N/V, diaphoretic, have a fever
T=100.7F P=108 RR=18

GERD, ulcers, taking PPIs? better/worse with food?
peritoneal signs (radiation to back) MI

ask if similar presentation to past gallstone attacks


Acute Pancreatitis

Most cases are related to the *biliary tract (often a passed gallstone) or heavy alcohol intake*
Generally there is some insult to the ampulla of Vater causing obstruction and reflux of bile into the pancreatic ducts causing damage and inflammation to the cells of the pancreas


other considerations for acute pancreatitis

ERCP procedure itself can cause pancreatitis
Medications, viruses, autoimmune, high cholesterol also are considerations


acute pancreatitis acronym



scorpion venom
hypothermia hyperlipidemia
drugs: azathioprine, thiazides, na valproate, tetracycline


pancreatitis clinical findings

Most pts have epigastric abdominal pain
Often abrupt onset, radiates to the back, worse when laying flat
Better when laying in the fetal position or leaning forward

N/V, often fever, may have mild jaundice, tender abdomen
Possible history of a heavy meal or heavy alcohol consumption prior to the attack


pancreatitis labs

Elevations in amylase and *lipase* (more specific)
Generally 3x the upper limits of normal within 24 hours of symptoms
Return to normal is variable
Lipase remains elevated longer than amylase and is slightly more accurate for the diagnosis of acute pancreatitis

Elevated WBC count (can be pure inflammation)
Hyperglycemia (pancreas isn’t functioning properly) (may become DM)
Hyperbilirubinemia and/or elevated LFTs may be present as well
High crea is associated with progression to pancreatic necrosis


?? can independently be associated with a greater mortality rate

Presence of a systemic inflammatory response syndrome (SIRS) or sepsis


?? is widely used to determine the severity of acute alcoholic pancreatitis

Ranson’s criteria

Sensitivity of predicting a severe course as accurate as 60-80% based on these criteria

each factor worth a point
more than 3 positives: pancreatitis is likely
less than 3: pancreatitis unlikely
the greater, higher mortality: 4-6: 50% mortality
close to all positive: almost 100% mortality


Ranson's criteria

Blood glucose > 200 mg/dL
Age in years > 55 years
Serum LDH > 350 IU/L
Serum AST > 250 IU/L
White blood cell count > 16000 cells/mm3
Within 48 hours:
Serum calcium less than 8.0 mg/dL
Hematocrit fall > 10%
Oxygen: PaO2 below 60mmHg
BUN rise more than 5 mg/dL
base deficit more than 4 mEq/L
Sequestration of fluids > 6 L

mnemonic GALAW AND CHOBBS: Glucose, Age, LDH, AST and Whites; Calcium, Hematocrit, Oxygen, BUN, Base, Sequestration.
-the more risk factors you have to more severe of a case it is
if increase in score: increase in morbidity/mortality


pancreatitis imaging

Plain radiographs may show calcified gallstones
A “sentinel loop”
Segment of air-filled small intestine usually in the LUQ
“Colon cutoff sign”:
Gas-filled segment of transverse colon abruptly ending at the area of pancreatic inflammation


pancreatitis U/S

can be helpful for identifying gallstones/cholecystitis but generally *not helpful* for pancreatitis given overlying bowel gas


CT can help to identify an ??

enlarged or inflamed pancreas
Can also show necrosis, pseudocyst, or other complications


Pancreatitis EponymsPresent in 1-2% of cases…

Cullen's sign
Grey Turner's sign

may present together
imply pancreatic necrosis, higher risk of death
need volume resuscitation


Mild pancreatitis tx

most will subside over a few days
Bowel rest, bed rest, pain control
Fluid resuscitation
Classically meperidine has been given for pain preferentially over morphine due to risk of?
(Now thought to be an acceptable alternative and is often preferred)

Slowly resume p.o. diet when pain free (after "gut rest"), bowel sounds are present, and labs are improving
can go home when eating again


Severe pancreatitis tx

Large amounts of IVF resuscitation due to volume loss in necrotizing disease
Treatment of sepsis and evolving multi-organ dysfunction
Calcium replacement if hypocalcemic
Enteral feeding via nasojejunostomy preferred
Parenteral nutrition (TPN) in those with ileus


?? considered the drug of choice for necrotizing pancreatitis involving more than 30% of the pancreas

Carbapenems (imipenem)

Antifungals a consideration as well (yeast is in gut, higher risk for candida if on TPN, higher blood glucose)


pancreatitis complications: Intravascular volume depletion due to leakage of fluids in the pancreatic bed and ileus can cause ??

acute renal insufficiency/ATN

Could last 1-2 weeks and in some cases patients require hemodialysis


pancreatitis complications: Pancreatic necrosis and fluid collections (pseudocysts)

can be acute or chronic and can be sterile or infected
This complication occurs in 5-10% of cases and is a frequent predictor of mortality
An infected pseudocyst can form a pancreatic abscess
Often associated with splenic vein thrombosis and L sided pleural effusions as well

about 50% mortality, not good candidate for sx, can only effectively drain thru tubes


other possible pancreatitis complications

Fistula formation, erosion into a blood vessel, chronic pancreatic insufficiency and permanent diabetes


slide 18

pseudocyst on right


tx of pancreatitis complications

Surgery should follow all severe cases especially with nercocosis/pseudocyst:
Some mild cases with stones may need a cholecystectomy or cholecystotomy
Necrosectomy may improve survival but patient must be good candidates:
If possible delay until patient is stable and necrosis has organized
Internal or external drainage of pseudocysts a consideration as well:
Risk for infection, fistula formation

Mortality: 25% and if there is multiorgan failure present, 50%


case 2: chronic alcohol use presents to the ER with a c/o intermittent epigastric pain, weight loss, and diarrhea

Patient has mild elevation in amylase and lipase
Serum alkaline phosphatase and bilirubin are slightly elevated
Patient uses the restroom and returns to tell you his stool looked “oily”
CT scan demonstrated diffuse pancreatic calcifications (chronic!) and some ductal dilation


slide 23

chronic pancreatitis: calcifications


chronic pancreatitis Characterized by ??

persistent or intermittent epigastric pain, steatorrhea, weight loss, and up to 30% of affected patients have calcifications of their pancreas on CT


nearly 80% chronic pancreatitis due to

chronic alcoholism

BUT The risk of pancreatitis in heavy drinkers is only 5-10%
Smoking can accelerate this risk


Mnemonic for predisposing factors of chronic pancreatitis:

T – toxic metabolic
I – idiopathic
G – genetic
A – autoimmune
R – recurrent and severe acute pancreatitis
O - obstructive


?? which increases levels of serum calcium can lead to increased calcium deposition in the pancreas and be a cause



Elevated levels of IgG and certain autoantibodies can be the hallmarks of autoimmune pancreatitis

autoimmune pancreatitis


Between 10-30% of all cases of chronic pancreatitis are ??

80% of adults develop ?? within 25 years after the onset of chronic pancreatitis




CP presentation

epigastric and LUQ pain
Anorexia N/V, constipation acutely (steatorrhea is a later finding)
Abdominal exam may reveal LUQ tenderness over the pancreas
Attacks can last a few hours or possibly 2+ weeks


?? is the most sensitive test and can show dilated ducts, intraductal stones, strictures, pseudocyst development



medical management of chronic pancreatitis

Low fat diet
Abstinence from all alcohol
Use NSAIDs, tramadol, acetaminophen (avoid opioids)


Steatorrhea is treated with pancreatic supplements at mealtimes:

Viokace, Creon, Ultresa, Zenpep, Pancreaze, Peptyze


Autoimmune pancreatitis is treated with ??

Prednisone 40mg/d for 1-2mo followed by a taper


CP Surgical Treatment

If there is underlying biliary tract disease, surgical treatment is advised
Must reestablish free flow of bile into the duodenum
Possible endoscopic drainage of pancreatic pseudocysts
Distal bile duct obstruction can be relieved with stenting


considered as a last resort ??

In severe cases, subtotal or total pancreatectomy is considered as a last resort

Results in diabetes mellitus and pancreatic insufficiency


Prognosis is best in patients with ??

recurrent acute pancreatitis caused by stones or sphincter of Oddi stenosis which can be remedied


Endoscopic Pseudocyst Drainage

listen 28 min
slide 29
creating a fistula to drain into the gut


ramsey criteria

each factor worth 1 pt (look up)