PANCREATITIS

Question 1

DDx

Answer 1

Peptic Ulcer Disease
Gastritis
Acute Cholecystitis

*Mesenteric Ischemia
*Perforated Viscus
*SBO

*Thoracic Aortic Dissection

*Acute Coronary Syndrome

*AAA

Question 2

Clinical Features

Answer 2

Epigastric Abdominal Pain (90%)

Nausea and Vomiting (90%)

Anorexia

Question 3

Common Etiology

Answer 3

Cholelithiasis (MC)
EtOH
Hyper triglycerides
Idiopathic

Question 4

Risk Factors

Answer 4

gallstones
alcohol use
prior pancreatitis

Question 5

Red Flags for complicated pacreatitis

Answer 5

Fever
Tachycardia Hypotension

Question 6

Diagnostic Criteria

Answer 6

2/3 of Atalanta Criteria:

1) Classic midepigastric abdominal pain

2) Serum Lipase levels >/3 times the UL (100% sn, 99% sp)

3) Imaging consistent with pancreatic inflammation (IV-contrast CT or Transabdominal US)

Question 7

Labs / Imaging

Answer 7

CBC
Lytes
Cr
LFT’s
LDH
Lipase
Lactate
Calcium
Triglycerides

Ultrasound

CT scan with IV contrast

CXR r/e pleural effusion for BISAP

Question 8

U/S Abdomen Findings

Answer 8

To document the presence/absence of gallstones or biliary involvement (small stones/sludge are more likely to cause pancreatitis than large stones).

Often obstructed by gas

Question 9

CT Abdomen with IV Contrast Findings

False Negative Rates

Answer 9

‘pancreatic protocol’:
1) Pancreatic parenchymal inflammation +/- peripancreatic fat inflammation
2) Pancreatic parenchymal necrosis or peripancreatic necrosis
3) Peripancreatic fluid collection
4) Pancreatic pseudocyts

27% FN rate if done too early

Question 10

Findings a/w Chronic Pancreatitis

Answer 10

Labs may be normal

Pancreatic Calcifications

Question 11

Initial Management

Answer 11

Fluid resuscitation is important (crystalloid or colloid)
2.5 - 4L

Pressors if indicated

NPO

Analgesia - Hydromorphone 0.2-0.4 mg IV q 15 min

Morphine 0.05-0.1 mg/kg intravenous push or 4-6 mg

Zofran 4 mg IV

CIWA protocol
prophylaxis if indicated.

Prophylactic antibiotics for severe pancreatitis with necrosis on the CT

Correct hypocalcemia, hypomagnesemia

Calculate BISAP

Question 12

Antibiotics Indicated and dose

Answer 12

Meropenem 1 g IV q 8 hr

Pip-Tazo 3.375 g IV q 6 hr

Cipro 500 mg IV + Metro 500 mg IV

Question 13

Complications: local and systemic

Answer 13

Acute pancreatic fluid collections
Pancreatic pseudocyst
Acute pancreatic / peripancreatic necrosis
Walled off necrosis
Splenic or portal vein thrombosis
Colonic inflammation / necrosis
Organ failure: cardiovascular, respiratory, renal

Question 14

Disposition

Answer 14

Bedside Index of Severity in Acute Pancreatitis (BISAP):

Obtain a surgical consultation if the patient has gallstones or biliary pancreatitis

Consult Medicine if EtOH or Triglyceride Induced