Pancreatic Diseases Flashcards Preview

CSI- Winter > Pancreatic Diseases > Flashcards

Flashcards in Pancreatic Diseases Deck (38)
Loading flashcards...

Case: A 46yo man with a h/o gallstones presents to the ER with a 1 day history of severe epigastric pain which radiates to his mid-upper back
Patient reports nausea and vomited en route to the hospital
He is diaphoretic and believes he has a fever but has not taken his temp.
**Epigastric pain, mid-upper back**
History of GRED, ulcers, taking PPIs, peritoneal signs....

Acute Pancreatitis


Most cases of acute pancreatitis 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


_______ itself can cause pancreatitis

ERCP procedure


Acute pancreatitis may also be caused by

Medications, viruses, autoimmune, high cholesterol also are considerations


(thinks that cause pancreatitis)

Scorpion venom
Drugs- azathioprine, thiazines, sodium valproate, tetracycline


Big blues to think acute pancreatitis

History of gallstones or heavy drinking
Trauma directly to pancreas (insult to gut, kid going over handlebars)


Signs and symptoms of acute pancreatitis

-Most patients 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)
**Nausea and vomiting are usually present**
-Possible history of a heavy meal or heavy alcohol consumption prior to the attack
-Abdomen is generally tender on exam
-Fever is often present
-Mild jaundice may be seen


Pancreatitis may also be caused by obstruction of

ampula of vader from stone, etc.


Lab findings for pancreatitis

**LIPASE is most specific and stays high for longer**
-Elevations in amylase and lipase
-Generally 3x the upper limits of normal within 24 hours of symptoms
-Return to normal is variable
-Elevated WBC count- not always infection, can be inflammation
-Hyperglycemia (pancreas isn’t functioning properly- isn’t producing insulin properly)
-Hyperbilirubinemia and/or elevated LFTs may be present as well
-High creat is associated with progression to pancreatic necrosis


Severity of pancreatitis depends on

Presence of a systemic inflammatory response syndrome (SIRS) or sepsis can independently be associated with a greater mortality rate


_______ is widely used to determine the severity of acute alcoholic pancreatitis
Sensitivity of predicting a severe course as accurate as 60-80% based on these criteria

Ranson’s criteria


Ranson's Criteria

At admission or diagnosis:
-Age over 55
-WBC count over 16,000
-Blood glucose over 200
-Serum lactic dehydrogenase (LDH) over 350
-Serum AST over 250

During initial 48 hrs
-Hematocrit fall greater 10% points
-Blood urea nitrogen rise over 5 mg/dl
-Arterial PO2 below 60mmHg
-Serum calcium below 8 mg/dl
-Base deficit > 4
-Estimated fluid sequestration over 6000 ml

*more you have=higher risk of mortality


"Sentinel Loop" and "Colon cutoff Sign" seen in xray

-“sentinel loop” is a segment of air-filled small intestine usually in the LUQ (Air filled small bowel; air filled loops towards stomach- google image)

-“Colon cutoff sign” is a gas-filled segment of transverse colon abruptly ending at the area of pancreatic inflammation
(cutoff right where pancreas is, showing potential acute inflam- google image)
-Plain radiographs may show calcified gallstones


Ultrasound helpful?

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


CT helpful?

-CT can help to identify and enlarged or inflamed pancreas
-Can also show necrosis, pseudocyst, or other complications


Physical signs that present in 1-2% of pancreatitis cases

Cullen sign (bruising around umbilicus)
Grey Turner's sign (bruising along side, flank)

-usually present together, correlate high with pancreatic necrosis


Treatment for mild pancreatitis

-Most cases are mild and 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--> Morphine may cause spasm of sphincter of odi (now people don’t think this but may still be test answer- older way of thinking)
Now thought to be an acceptable alternative and is often preferred
-Slowly resume p.o. diet when pain free, bowel sounds are present, and labs are improving
-Even eating a little food/drinking/hard candy will cause pancreas to think your eating and it will start contracting causing severe pain
-Must do FULL gut rest


Treatment for severe pancreatitis

-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


Drug of choice for necrotizing pancreatitis

Carbapenems (imipenem) considered the drug of choice for necrotizing pancreatitis involving >30% of the pancreas (more than 1/3)
-Antifungals a consideration as well, if sick for longer, higher blood glucose (pancreas isn’t working), want to prevent yeast/candida


Complications of acute pancreatitis

1. 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)

2. 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

3. Fistula formation, erosion into a blood vessel, chronic pancreatic insufficiency and permanent diabetes may also occur


______ should follow all severe cases especially with nercocosis/pseudocyst


-Some mild cases with stones may need a cholecystectomy or cholecystotomy


________ 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, but risk for _________

infection and fistula formation

-Mortality rates in the most severe cases are 25% and if there is multiorgan failure present, 50%


Case: A 65yo man with a h/o chronic alcohol use presents to the ER with a c/o intermittent epigastric pain, weight loss, and diarrhea. Frequent, watery diarrhea, green-yellow color, prefers to drink liquids, not much solid food; no recent travel. "Oily stools" seen and CT scan demonstrated diffuse pancreatic calcifications (chronic irritation) and some ductal dilation.

Think chronic pancreatitis

**Think alcoholics (smoking accelerates process)


Labs with chronic pancreatitis will show

-mild elevation in amylase and lipase
-Serum alkaline phosphatase and bilirubin are slightly elevated


Chronic pancreatitis is characterized by

1. persistent or intermittent epigastric pain
2. steatorrhea
3. weight loss
4. up to 30% of affected patients have calcifications of their pancreas on CT
5. Nearly 80% of cases due to chronic alcoholism


Mnemonic for predisposing factors to chronic pancreatitis

T – toxic metabolic
I – idiopathic (10-30% of cases)
G – genetic
A – autoimmune
R – recurrent and severe acute pancreatitis
O - obstructive


Another preexisting disease that can cause chronic pancreatitis is

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


Hallmarks of autoimmune pancreatitis

Elevated levels of IgG and certain autoantibodies


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