Pancreatitis Flashcards
1
Q
- leading cause of acute pancreatitis
- second most common
A
- Gallstones
- alcohol
2
Q
- pancreas blood supply maintained
- which is generally self-limited
A
nterstitial pancreatitis
3
Q
- pancreas blood supply interrupted
- the extent of necrosis may correlate with the severity of the
attack and its systemic complications
A
Necrotizing pancreatitis
4
Q
- accepted pathogenic
- proteolytic enzymes (e.g., trypsinogen, chymotrypsinogen,
proelastase, and lipolytic enzymes such as phospholipase A2) are activated in the pancreas acinar cell rather than in the intestinal lumen
A
Autodigestion
5
Q
Factors that facilitate premature
activation of trypsin
A
- Endotoxins
- Exotoxins
- viral infection
- Ischemia
- oxidative stress
- lysosomal calcium
- direct trauma
6
Q
- characterized by intrapancreatic digestive enzyme activation and acinar cell injury
- Trypsin activation
A
Initial phase
7
Q
activation, chemoattraction, and sequestration of leukocytes
and macrophages in the pancreasenhanced intrapancreatic inflammatory reaction
A
Second phase
8
Q
due to the effects of activated proteolytic enzymes and
cytokines, released by the inflamed pancreas, on distant
organs
A
Third phase
9
Q
Genetic variants associated with susceptibility to pancreatitis
A
- cationic trypsinogen gene (PRSS1)
- pancreatic secretory trypsin inhibitor (SP/NKz)
- the cystic fibrosis transmembrane conductance regulator
gene (CFTR) - the chymotrypsin C gene (CTRC)
- the calcium-sensing receptor (CASR)
10
Q
- major symptom
- mild discomfort to severe, constant, and incapacitating distress
- steady and boring in character, is located in the epigastrium and periumbilical region, and may radiate to the back, chest, flanks, and lower abdomen
A
Abdominal pain
11
Q
- A faint blue discoloration around the umbilicus
- Due to hemoperitoneum
A
Cullen’s sign
12
Q
Symptoms of Pnacreatitis
A
- Abdominal pain
- Nausea/ vomiting
- Abdominal distention
- distressed and anxious
- Low-grade fever, tachycardia, and hypotension
- hypovolemic Shock
- Jaundice (rare)
- Erythematous skin nodules
- basilar rales, atelectasis, and pleural effusion (left sided)
- Abdominal tenderness and muscle rigidity
- Diminished or absent bowel sounds
13
Q
- a blue-red-purple or green-brown discoloration of the
flanks - tissue catabolism of hemoglobin from severe necrotizing pancreatitis with hemorrhage
A
Turner’s sign
14
Q
- Return to normal after 3-7 days
- acidemia (arterial pH $7.32)
A
Serum amylase
15
Q
- Preferred test
- nocorrelation between the severity of pancreatitis and the degree of serum lipase and amylase elevations
- remain elevated for 7-14 days
A
Serum Lipase
16
Q
LABORATORY DATA OF PANCREATITIS
- Leukocytosis
- Hemoconcentration- Hematocrit
- BUN
- glycemia
- calcemia
- bilirubinemia
- Serum alkaline phosphatase and aspartate aminotransferase levels
- triglyceridemia
- Hypoxemia
- ECG -
A
- Leukocytosis -15,000—20,000 leukocytes/uUL)
- Hemoconcentration- Hematocrit of >44%
- BUN >22mq/dl
- Hypoglycemia
- Hypocalcemia
- Hyperbilirubinemia (serum bilirubin >4.0 mg/dL)
- Serum alkaline phosphatase and aspartate aminotransferase levels are also transiently elevated
- Hypertriglyceridemia
- Hypoxemia (arterial PO2 <60 mm Hg
- ECG - ST-segment and T-wave abnormalities
17
Q
- initial diagnostic imaging modality
- most useful to evaluate for gallstone disease and the
pancreatic head
A
Abdominal ultrasound
18
Q
CT scan
Revised Atlanta Criteria of pancreatitis
A
1) necrotizing pancreatitis
2) acute pancreatic fluid collection
3) pancreatic pseudocyst
4) acute necrotic collection (ANC)
C) walled-off necrosis (WON)
19
Q
DIAGNOSIS Criteria of pancreatitis
A
two of the three criteria
- (1) typical abdominal pain in the epigastrium that may
radiate to the back - (2) threefold or greater elevation in serum lipase and/or
amylase, an - (3) confirmatory findings of acute pancreatitis on crosssectional abdominal imaging
20
Q
- lasts 1-2 weeks
- severity is defined by clinical parameters rather than morphologic findings.
- Organ failure is defined as a score of 2 or more for one of these three organ systems using the modified Marshall scoring system.
- respiratory, cardiovascular, and renal
- Persistent organ failure (>48 h) is the most important clinical finding in regard to severity of the acute pancreatitis episode
A
Early phase of acute pancreatitis
21
Q
- > 2 weeks
- characterized by a protracted course of illness
- require imaging to evaluate for local complications
- persistent organ failure- important clinical parameter of severity
- may require supportive measures- renal dialysis, ventilator support, supplemental nutrition via the nasojejunal or parenteral route
- necrotizing pancreatitis- radiographic feature of greatest importance
A
Late phase
22
Q
Severity Classifications
- without local complications or organ failure
- self-limited and subsides spontaneously
- within 3-7 days after treatment is instituted
- Oralintake resumed ifthe patient is hungry, has normal
bowel function, and is without nausea and vomiting - aclear or full liquid diet has been recommended for the initial meal
- a low-fat solid diet
A
Mild acute pancreatitis
23
Q
Severity Classifications
- characterized by transient organ failure
- (resolves in <48h
- local or systemic complications in the absence of persistent organ failure
- may develop a local complication such as a fluid collection that requires a prolonged hospitalization >1 week
A
Moderately severe acute pancreatitis
24
Q
Severity Classifications
- is characterized by persistent organ failure (>48 h)
- Organ failure can be single or multiple
- CT scan or MRI should be obtained to assess for necrosis
and/or complications - management is dictated by clinical symptoms, evidence
of infection, maturity of fluid collection, and clinical stability of the patient - Prophylactic antibiotics are not recommended
A
Severe acute pancreatitis
25
Types of Pancreatitis
- 90-95% of admissions for acute pancreatitis
- characterized by diffuse gland enlargement, homogenous contrast enhancement, and mild inflammatory changes or peripancreatic stranding
- Symptoms resolve with a week of hospitalization
Interstitial pancreatitis
26
Types of Pancreatitis
- 5-10% of acute pancreatitis admissions
- does not evolve until several days of hospitalization
- characterized by lack of pancreatic parenchymal enhancement by intravenous contrast agent and/or presence of findings of peripancreatic necrosis.
Necrotizing pancreatitis
27
ACUTE PANCREATITIS MANAGEMENT
- Fluid Resuscitation
- lactated Ringer’s or normal saline
- initially bolused at 15-20 mL/kg (1050-1400 mL),
- followed by 2-3 mL/kg per hour (200-250 mL/h), to maintain urine output >0.5 mL/kg per hour.
- targeted resuscitation strategy with measurement of hematocrit and BUN every 8-12 h
- A rise in hematocrit or BUN- repeat volume challenge with a 2-L crystalloid bolus followed by increasing the fluid rate by 1.5 mg/kg per hour
- The patient is made NPO to rest the pancreas and is
given intravenous narcotic analgesics to control abdominal pain and supplemental oxygen (2 L) via nasal cannula
28
Markers of Severity At Admission or within 24hr
SIRS—defined by presence of 2 or more criteria:
- Core temperature <
- Heart rate
- Respirations: or Pco2
- White blood cell count
- APACHE
- Hemoconcentration ()
- Admission BUN
- BISAP Score
- (B) BUN
- (I) mental status
- (s) sirs:
- (A) Age
- (P) Pleural
- Organ (Modified Marshall Score)
- Cardiovascular: systolic BP: , heart rate:
- Pulmonary: Pao2
- Renal: serum creatinine
SIRS—defined by presence of 2 or more criteria:
- Core temperature <36° or >38°C
- Heart rate >90 beats/min
- Respirations >20/min or Peo, <32 mmHg
- White blood cell count >12,000/pL, <4000/yL, or 10% bands
- APACHE II
- Hemoconcentration (hematocrit >44%)
- Admission BUN (>22 mg/dL)
- BISAP Score
- (B) BUN >25 mg/dL
- (I) Impaired mental status
- (s) sirs: >/=2 of 4 present
- (A) Age >60 years
- (P) Pleural effusion
- Organ failure (Modified Marshall Score)
- Cardiovascular: systolic BP <90 mmHg, heart rate >130 BPM
- Pulmonary: Pao2 <60 mm Hg
- Renal: serum creatinine >2.0 mg
29
- ascending cholangitis (rising white blood cell count, increasing liver enzymes) should undergo ERCP within
24-48 h of admission
- increased risk of recurrence
- cholecystectomy during the same admission or within 4—
6 weeks of discharge.
- non surgical candidates — endoscopic biliary sphincterotomy before discharge
GALLSTONE PANCREATITIS
30
- Serum triglycerides >1000 mg/dL
- insulin, heparin, or plasmapheresis
- Outpatient therapies: control of diabetes if present, lipidlowering agents, weight loss, and avoidance of drugs that elevate lipid levels.
HYPERTRIGLYCERIDEMIA
31
Nutritional Therapy for Pancreatitis
- low-fat solid diet after the abdominal pain has resolved
- Enteral nutrition should be considered 2-3 days after
admission in subjects with more severe pancreatitis
instead of total parenteral nutrition (TPN)
- Enteral feeding
+ maintains gut barrier integrity
+ limits bacterial translocation
+ less expensive
+ has fewer complications than TPN
32
Complications of Acute Pancreatitis
- Local Necrosis (Sterile, Infected)
- Walled-off necrosis
- Pancreatic fluid collections
- Pancreatic pseudocyst
- Disruption of main pancreatic duct
- Thrombosis of blood vessels (splenic vein, portal vein)
- Pancreatic enteric fistula
- Bowel infarction
- Obstructive jaundice
