Flashcards in Pancreatic Diseases Deck (38)
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1
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
2
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
3
_______ itself can cause pancreatitis
ERCP procedure
4
Acute pancreatitis may also be caused by
Medications, viruses, autoimmune, high cholesterol also are considerations
5
GET SMASHED
(thinks that cause pancreatitis)
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion venom
Hypothermia/Hyperlipidemia
ERCP
Drugs- azathioprine, thiazines, sodium valproate, tetracycline
6
Big blues to think acute pancreatitis
History of gallstones or heavy drinking
Trauma directly to pancreas (insult to gut, kid going over handlebars)
7
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
8
Pancreatitis may also be caused by obstruction of
ampula of vader from stone, etc.
9
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
10
Severity of pancreatitis depends on
Presence of a systemic inflammatory response syndrome (SIRS) or sepsis can independently be associated with a greater mortality rate
11
_______ 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
12
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
13
"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
14
Ultrasound helpful?
Ultrasound can be helpful for identifying gallstones/cholecystitis but generally not helpful for pancreatitis given overlying bowel gas
15
CT helpful?
-CT can help to identify and enlarged or inflamed pancreas
-Can also show necrosis, pseudocyst, or other complications
16
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
17
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
18
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
19
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
20
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
21
______ should follow all severe cases especially with nercocosis/pseudocyst
Surgery
-Some mild cases with stones may need a cholecystectomy or cholecystotomy
22
________ may improve survival but patient must be good candidates
Necrosectomy
-If possible delay until patient is stable and necrosis has organized
23
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%
24
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)
25
Labs with chronic pancreatitis will show
-mild elevation in amylase and lipase
-Serum alkaline phosphatase and bilirubin are slightly elevated
26
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
27
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
28
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
29
Hallmarks of autoimmune pancreatitis
Elevated levels of IgG and certain autoantibodies
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