Pancreatic Diseases

Question 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....

Answer 1

Acute Pancreatitis

Question 2

Most cases of acute pancreatitis are related to

Answer 2

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

Question 3

_______ itself can cause pancreatitis

Answer 3

ERCP procedure

Question 4

Acute pancreatitis may also be caused by

Answer 4

Medications, viruses, autoimmune, high cholesterol also are considerations

Question 5

GET SMASHED
(thinks that cause pancreatitis)

Answer 5

Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion venom
Hypothermia/Hyperlipidemia
ERCP
Drugs- azathioprine, thiazines, sodium valproate, tetracycline

Question 6

Big blues to think acute pancreatitis

Answer 6

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

Question 7

Signs and symptoms of acute pancreatitis

Answer 7

-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

Question 8

Pancreatitis may also be caused by obstruction of

Answer 8

ampula of vader from stone, etc.

Question 9

Lab findings for pancreatitis

Answer 9

**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

Question 10

Severity of pancreatitis depends on

Answer 10

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

Question 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

Answer 11

Ranson’s criteria

Question 12

Ranson's Criteria

Answer 12

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

Question 13

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

Answer 13

-“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

Question 14

Ultrasound helpful?

Answer 14

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

Question 15

CT helpful?

Answer 15

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

Question 16

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

Answer 16

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

-usually present together, correlate high with pancreatic necrosis

Question 17

Treatment for mild pancreatitis

Answer 17

-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

Question 18

Treatment for severe pancreatitis

Answer 18

-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

Question 19

Drug of choice for necrotizing pancreatitis

Answer 19

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

Question 20

Complications of acute pancreatitis

Answer 20

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

Question 21

______ should follow all severe cases especially with nercocosis/pseudocyst

Answer 21

Surgery

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

Question 22

________ may improve survival but patient must be good candidates

Answer 22

Necrosectomy

-If possible delay until patient is stable and necrosis has organized

Question 23

Internal or external drainage of pseudocysts a consideration as well, but risk for _________

Answer 23

infection and fistula formation

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

Question 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.

Answer 24

Think chronic pancreatitis

**Think alcoholics (smoking accelerates process)

Question 25

Labs with chronic pancreatitis will show

Answer 25

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

Question 26

Chronic pancreatitis is characterized by

Answer 26

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

Question 27

Mnemonic for predisposing factors to chronic pancreatitis

Answer 27

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

Question 28

Another preexisting disease that can cause chronic pancreatitis is

Answer 28

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

Question 29

Hallmarks of autoimmune pancreatitis

Answer 29

Elevated levels of IgG and certain autoantibodies

Question 30

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

Answer 30

diabetes

Question 31

S/S of chronic pancreatitis

Answer 31

-Patients generally present with 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
-Pts think they are having GERD

Question 32

Most sensitive test for chronic pancreatitis

Answer 32

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

Question 33

Medical management for chronic pancreatitis

Answer 33

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

Question 34

Steatorrhea is treated with

Answer 34

pancreatic supplements at mealtimes
(Viokace, Creon, Ultresa, Zenpep, Pancreaze, Peptyze- all are capsules filled with pancreatic enzymes)

Question 35

Autoimmune pancreatitis is treated with

Answer 35

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

Question 36

Surgical treatment is advised for chronic pancreatitis when

Answer 36

there is underlying biliary tract disease

-Must reestablish free flow of bile into the duodenum
-Possible endoscopic drainage of pancreatic pseudocysts
-Distal bile duct obstruction can be relieved with stenting

Question 37

In severe cases, _________ is considered as a last resort

Answer 37

subtotal or total pancreatectomy

-Results in diabetes mellitus and pancreatic insufficiency

Question 38

Prognosis is best in patients with

Answer 38

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