pancreatitis

Question 1

pancreas

Answer 1

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

Question 2

Answer 2

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

Question 3

Acinar cells

Answer 3

exocrine

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

Question 4

Major pancreatic ducts:

Answer 4

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

Question 5

Islets of Langerhans (endocrine)

Answer 5

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

Question 6

Pancreatitis

general

Answer 6

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

Question 7

pancreatitis

etiology

Answer 7

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

Question 8

pancreas

Normal function of digestive enzymes

Answer 8

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

Question 9

Pancreatitis

patho

Answer 9

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

Question 10

Acute pancreatitis

mild

Answer 10

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

Question 11

acute pancreatitis

moderate

Answer 11

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

Question 12

acute pancreatitis

severe

Answer 12

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

Question 13

pancreatitis

Risk Factors for Severe Disease Course

Answer 13

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

Question 14

pancreatitis

S/Sx

Answer 14

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

Question 15

pancreatitis

PE findings

Answer 15

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

Question 16

Hemorrhagic pancreatitis

general and PE findings

Answer 16

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

Question 17

pancreatitis

Dx criteria (3)

Answer 17

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

Question 18

pancreatitis

labs

Answer 18

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

Question 19

pancreatitis

CT

Answer 19

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

Question 20

pancreatitis

Ultrasound

Answer 20

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

Question 21

pancreatitis

Chest radiograph

and potential findings

Answer 21

Forpatientswith pulmonary symptoms (dyspnea, tachypnea, hypoxia)

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

Question 22

pancreatitis

ERCP (endoscopic retrograde cholangiopancreatography)

Answer 22

Diagnostics and therapeutic
Performed to relieve bile duct obstruction

Question 23

pancreatitis

Treatment – Mild to Moderate Disease

support and meds

Answer 23

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

Question 24

pancreatitis

Treatment – Moderate to Severe Disease

Answer 24

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

Question 25

# pancreatitis Sign of deterioration

Answer 25

Fever ↑ WBC count Failure to improve after 7-10 days of hospitalization Most common organisms are gram-negative bacteria

Question 26

# pancreatitis Surgery

Answer 26

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

Question 27

# 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)

Question 28

# Chronic Pancreatitis general

Answer 28

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

Question 29

# chronic pancreatitis Etiology

Answer 29

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

Question 30

# chronic pancreatitis Complications

Answer 30

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**

Question 31

# pancreatitis

Question 32

# chronic pancreatitis S/Sx

Answer 32

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

Question 33

# Chronic pancreatitis Dx and labs

Answer 33

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

Question 34

# chronic pancreatitis imaging studies

Answer 34

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

Question 35

# chronic pancreatitis lifestyle changes and management

Answer 35

Directed by a multidisciplinary team that includes gastroenterologists, 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

Question 36

# pancreatitis

Question 37

Which of the following is the most common cause of acute pancreatitis? A. Viral infection B. Gallstones C. Alcoholism D. Smoking

Answer 37

B

Question 38

High-pitched peristalsis or borborygmi in a patient with acute abdominal pain and distention suggests which of the following? A. Peritonitis B. Biliary colic C. Bowel obstruction D. Acute pancreatitis

Answer 38

C

Question 39

Which of the follow elevated labs correlates most closely with increased mortality in acute pancreatitis? A. Alkaline phosphatase B. Lipase C. Creatinine D. BUN

Answer 39

D