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pancreatitis Flashcards

1
Q

pancreas

A

Oblong, glandular GI accessory organ measuring ~6 inches
Performs exocrine and endocrine functions

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2
Q
A

Head
Widest part of the pancreas
Found nestled in the curve of the duodenum
Divided into:
Head proper
Uncinate process

Neck
Thin section of the gland between the head and the body of the pancreas

Body
Middle part of the pancreas between the neck and the tail
Superior mesenteric artery and vein run behind this region

Tail
Thin tip of the pancreas in the left side of the abdomen, in close proximity to the hilum of the spleen

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3
Q

Acinar cells

A

exocrine

Cells in clusters located at the terminal ends of pancreatic ducts
Secrete enzyme-rich pancreatic juice into ducts

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4
Q

Major pancreatic ducts:

A

Pancreatic duct joins the common bile duct just before duodenum (ampulla of Vater)
Accessory duct (duct of Santorini) runs from the pancreas directly into the duodenum superior to the pancreatic duct

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5
Q

Islets of Langerhans (endocrine)

A

Small islands of cells scattered throughout the pancreas that produce pancreatic polypeptide, insulin, glucagon, and somatostatin

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6
Q

Pancreatitis

general

A

Inflammation of the pancreas and on occasion, adjacent tissues
Increasing incidence in the United States since 1990
♂>♀
Acute or chronic presentation
Multiple etiologies
Can be life-threatening

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7
Q

pancreatitis

etiology

A

Gallstones (40%)
Heavy alcohol consumption (30%)
Idiopathic (10-15%)

Surgical procedures of the abdomen
Endoscopic retrograde cholangiopancreatography (ERCP) in ~5% of patients – mechanical obstruction

Hypertriglyceridemia
Causes plasma viscosity which may induce ischemia in the pancreatic tissue

Medication-induced
Autoimmune pancreatitis
Infections

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8
Q

pancreas

Normal function of digestive enzymes

A

Pancreatic digestive enzymes are released by the acini cells in an inactive form (zymogen) and travel to the duodenum → activated by trypsin

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9
Q

Pancreatitis

patho

A

Pancreatic enzymes accumulate within the injured acini cells
Intra-acinar activation lead to autodigestive injury of the pancreas itself
Injury leads to activation of the complement system and the inflammatory cascade (cytokines)
Inflammation and edema of the pancreas → necrosis → death

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10
Q

Acute pancreatitis

mild

A

Inflammation confined to the pancreas and its close vicinity
No organ failure
No local or systemic complications

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11
Q

acute pancreatitis

moderate

A

Moderate
Local or systemic complications
No organ failure or only transient organ failure (resolves within 48 hours)

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12
Q

acute pancreatitis

severe

A

One or more local complications
Persistent single or multiorgan failure (>48 hours)
Mortality rate of >30%

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13
Q

pancreatitis

Risk Factors for Severe Disease Course

A

Initial assessment:
Age ≥60 years
Comorbid health problems
Obesity with BMI >30
Long-term, heavy alcohol use
Presence of systemic inflammatory response syndrome (SIRS)
Elevated BUN- number 1 indicator of high mortality
Altered mental status

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14
Q

pancreatitis

S/Sx

A

Upper abdomen/epigastric
Severe, steady, boring pain
Radiation through to the back (50%)

Onset:
Sudden → gallstone pancreatitis
Develops over days → alcoholic pancreatitis

↑ pain with coughing, vigorous movements, or deep breathing

Diminished bowl sounds

Nausea and vomiting
Fever 38.4-39°C
Jaundice
Tachycardia
Hypotensive

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15
Q

pancreatitis

PE findings

A

Patient are ill-appearing; sometimes anxious
Sitting up and/or lean forward to help reduce pain
Scleral icterus/jaundice →choledocholithiasis
Xanthomas→hypertriglyceridemia

Abdomen
Abdominal distension and absent bowel sounds with an associated ileus
Upper abdominal tenderness to palpation
Guarding, rigidity, and rebound tenderness
Hepatomegaly → alcoholic pancreatitis

Palpable mass
Inflamed pancreas
Pseudocyst: collection of leaked pancreatic fluids that forms next to the pancreas

xanthomas
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16
Q

Hemorrhagic pancreatitis

general and PE findings

A

1% of cases
Indicator of poor prognosis

Presentation:
Grey Turner sign
Ecchymosis of the flanks due to blood in the retroperitoneum
Cullen sign
Ecchymosis of the umbilical region due to blood in the peritoneum

17
Q

pancreatitis

Dx criteria (3)

A

Diagnosis is established by the presence of at least 2 of the following:

Abdominal pain consistent with the disease
Serum amylase and/or lipase >3 times the upper limit of normal (within 24 hours of onset)
Characteristic findings on imaging studies (CT or MRI)

NEED CT

18
Q

pancreatitis

labs

A

CBC
Leukocytosis (10,000-30,000 mcL)
Lipase and amylase
>3x upper limit of normal within 24 of onset
Return to normal is dependent on the severity of disease
Other labs that may be elevated:
Bilirubin
Alkaline phosphatase
ALT
Lactate dehydrogenase(LDH): ↑ in severe disease
Fasting triglycerides >1000 mg/dL
BUN & creatinine
Activated pancreatic enzymes and cytokines can enter systemic circulation resulting in acute kidney injury (prerenal azotemia)
Sustained elevated BUN correlates with mortality risk

19
Q

pancreatitis

CT

A

CT scan of the abdomen and pelvis with contrast

Imaging test of choice to establish the diagnosis and to access for local complications
Repeat CT scan should be performed if the patient deteriorates
Necrosis, fluid collection, pseudocyst

20
Q

pancreatitis

Ultrasound

A

Performed if gallstone pancreatitis is suspected (if CT cant find it and suspecting small stone)

21
Q

pancreatitis

Chest radiograph

and potential findings

A

Forpatientswith pulmonary symptoms (dyspnea, tachypnea, hypoxia)

Potential findings
Pleural effusions
Diffuse, patchy infiltrates indicatingacute respiratory distress syndrome(ARDS)

22
Q

pancreatitis

ERCP (endoscopic retrograde cholangiopancreatography)

A

Diagnostics and therapeutic
Performed to relieve bile duct obstruction

23
Q

pancreatitis

Treatment – Mild to Moderate Disease

support and meds

A

Admission to a step-down bed
Supportive measures

Fluid resuscitation
Early, aggressive IV fluids of lactated Ringer’s 250-500 mL/hour for the first 12-24 hours
Modifications will need to be made based on underlying renal or cardiovascular comorbidities
How to measure fluid adequacy?
Improvement of BUN levels, improvement of vital signs, maintaining adequate urine output

Analgesics
IV opioids (hydromorphone 1.0mg or fentanyl 70mcg)

Antiemetics
Given as needed for nausea and vomiting

Nutritional support
Early enteral nutrition as soon as it can be tolerated
Clear liquids → oral low-residue, low-fat, soft diet
Prophylactic antibiotics are not recommended in patients with acute pancreatitis, regardless of disease severity

24
Q

pancreatitis

Treatment – Moderate to Severe Disease

A

ICU admission
Same supportive measures on the previous slide
IV antibiotics
Used for the development of extrapancreatic infection (pneumonia, cholangitis, UTI)

25
Q

pancreatitis

Sign of deterioration

A

Fever
↑ WBC count
Failure to improve after 7-10 days of hospitalization

Most common organisms are gram-negative bacteria

26
Q

pancreatitis

Surgery

A

All cases of severe acute pancreatitis should receive a surgical consult
Necrosectomy
Removal of infected tissue

Cholecystectomy
Performed prior to discharge for patients with gallstone pancreatitis who spontaneously improve

Percutaneous, surgical, or endoscopic ultrasound-guided cystogastrostomy
Performed for a pseudocyst that is expanding, infected, bleeding, or at risk for rupture

27
Q

KEY POINTS of acute pancreatits

There are many causes of acute pancreatitis, but the most common are gallstones and alcohol intake

Inflammation is confined to the pancreas in mild cases, but, with increasing severity, a severe systemic inflammatory response may develop, resulting in single or multiorgan failure

Once pancreatitis is diagnosed, assess risk using clinical criteria and scoring systems to triage appropriate patients to more intensive care and aggressive therapy and to help estimate prognosis

Treatment includes IV fluid resuscitation, pain control, and nutritional support

Complications, including pseudocyst and infected pancreatic necrosis, need to be identified and treated appropriately (drainage of pseudocyst, necrosectomy)

A
28
Q

Chronic Pancreatitis

general

A

Persistent inflammation of the pancreas
Results
Permanent structural damage with fibrosis and ductal strictures
Decline in exocrine and endocrine function (pancreatic insufficiency)–> diabetes

29
Q

chronic pancreatitis

Etiology

A

Heavy alcohol consumption (50%)
Pancreatic duct obstruction
Cigarette smoking
Dose-dependent risk factor
Additive risk when combined with alcohol consumption

30
Q

chronic pancreatitis

Complications

A

Malabsorption
Occurs when lipase and protease secretions are reduced to 10% of normal

Fat malabsorption
Vitamin A, D, E, and K deficiencies

Glucose intolerance → overt diabetes mellitus (type 3c diabetes)

Formation of pseudocysts
Development of pancreatic adenocarcinoma

31
Q

pancreatitis

A
32
Q

chronic pancreatitis

S/Sx

A

Abdominal pain:
Epigastric region
Postprandial
Initially episodic (after meals) → continuous

Nausea and vomiting
Malabsorption without pain (10-15%)
Abdominal distention
Steatorrhea: oily, foul-smelling stools
Flatulence
Weight loss
Fatigue

33
Q

Chronic pancreatitis

Dx and labs

A

Diagnosis is highly dependent on clinical assessment, imaging studies, and
pancreatic function tests

Lipase and amylase
Slightly elevated or normal…Why?- due to ongoing damage

Pancreatic function tests
Can detect early disease, but are expensive and invasive

high ETOH use

34
Q

chronic pancreatitis

imaging studies

A

CT scan of the abdomen and pelvis with contrast
Exclude pancreatic cancer as a cause of pain
Detect pancreatic abnormalities

Magnetic resonance imaging with cholangiopancreatography (MRCP)
Indicated when CT findings are equivocal

35
Q

chronic pancreatitis

lifestyle changes and management

A

Directed by a multidisciplinary team that includesgastroenterologists, surgeons (pseudocysts), endocrinologists, dieticians, and pain management specialists

Includes:
Smoking cessation
Avoidance of alcohol
Low-fat diet
Pain control – most challenging
Pancreatic enzyme supplements
Management of diabetes - insulin
Management of other complications

36
Q

pancreatitis

A
37
Q

Which of the following is the most common cause of acute pancreatitis?

A. Viral infection
B. Gallstones
C. Alcoholism
D. Smoking

A

B

38
Q

High-pitched peristalsis or borborygmiin a patient with acute abdominal pain and distention suggests which of the following?

A. Peritonitis
B. Biliary colic
C. Bowel obstruction
D. Acute pancreatitis

A

C

39
Q

Which of the follow elevated labs correlates most closely with increased mortality in acute pancreatitis?

A. Alkaline phosphatase
B. Lipase
C. Creatinine
D. BUN

A

D

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