Pancreatitis: Acute and Chronic

Question 1

AP is _____

Answer 1

inflammation of the pancrea

Question 2

the leading cause of ER visits and hospitalizations for GI diseases in the US

Answer 2

pancreatitis

Question 3

3 strategies to increase positive outcomes for AP patients

Answer 3

diagnose rapidly, fluid initiate within 12 hours and nutrition within 24 hours, follow up

Question 4

__% of AP cases are severe

Answer 4

20

Question 5

most common cause of pancreatitis

Answer 5

gallstones

Question 6

second most leading cause of AP

Answer 6

alcohol consumption

Question 7

third most leading cause of AP

Answer 7

hypertriglyceridemia

Question 8

pathogenesis of AP

Answer 8

obstruction of common duct, ampulla of vater–> bile refluxed back into pancreas and damages acini. pancreatic secretions accumulate in the pancreas, proteolytic enzymes are activated= initiate AP.

Question 9

what indicates that gallstones/sludge were the cause of AP

Answer 9

cholecystetomy or removal of gallbadder with subsequent recovery

Question 10

how high are triglycerides to cause AP

Answer 10

> 1000 mg/dL

Question 11

what are some more rare causes of AP

Answer 11

ERCP, some drugs

Question 12

classification: mild AP

Answer 12

inflammation, edema of pancreas. peripancreatic fluid collections, pancreatic fluid collections. no organ failure, no systemic complications. recover in 3-7 days

Question 13

classification: moderately severe AP

Answer 13

necrosis, inflammation, edema, fluid collections, transient organ failure <48 hours

Question 14

classification: severe AP

Answer 14

necrosis, persistent organ failure, 20% mortality

Question 15

_____ increases the severity of AP

Answer 15

infection of the pancreas and peripancreatic collections (fluid and necrotic tissue)

Question 16

______ is death of cells & tissues associated with moderate and severe AP

Answer 16

necrosis

Question 17

what 2 things contribute to organ failure with AP?

Answer 17

the pancreatic enzymes are activated in the pancreas and damage the surrounding tissue, they can leak into the circulation and damage other organs thus leading to organ failure. also: the immune response, systemic inflammatory response syndrome (SIRS)

Question 18

diagnostic marker for severe AP

Answer 18

C reactive protein, CRP > 150 at 48 hours: indicates systemic disease.

Question 19

symptoms of AP

Answer 19

severe pain, acute onset, epigastric, may radiate to the back. nausea, vomiting, fever

Question 20

AP physical exam indications

Answer 20

abdominal distention

Question 21

history to gather for AP

Answer 21

past hx of AP (pt and fam), identify possible cause, gallstone disease, alcohol use, medications, etc

Question 22

if the fluid collection is still there at 4 weeks it is called

Answer 22

pseudocyst

Question 23

when the fluid collections include necrotic tissue at 4 weeks they are called

Answer 23

walled off necrosis

Question 24

if the necrotic collection becomes infected, they are called

Answer 24

infected walled off necrosis

Question 25

there is an increase in mortality associated with infected necrotic collections and ____ are necessary

Answer 25

antibiotics (fluoroquinolones)

Question 26

systemic complications of AP

Answer 26

organ failure (transient or persistent), cardiovascular: hypovolemia, hypotension from fluid loss

Question 27

most important laboratory tests for AP

Answer 27

elevation of serum amylase and lipase 3x ULN or greater

Question 28

longer half life: amylase or lipase?

Answer 28

lipase: so it remains elevated for a longer time 8-14 days. whereas amylase has shorter half life and returns to normal in 3-5 days

Question 29

what findings are suggestive of gallstone disease

Answer 29

liver tests, direct bilirubin, and alkaline phosphatase

Question 30

why is fluid loss such an important problem

Answer 30

it means a loss of blood volume, leads to hypoperfusion or organs--> damages them.

Question 31

symptoms of fluid loss

Answer 31

decreased BP, increased HR, decreased urine output, increased hematocrit and BUN

Question 32

imaging for diagnosis

Answer 32

ultrasound if suspecting gallstones. CT and MRI to detect necrosis after 3 days if patient does not improve/gets worse.

Question 33

2/3 things for diagnosis of AP

Answer 33

characteristic pain, elevated amylase/lipase 3x ULN, positive imagine results

Question 34

3 treatment goals for AP

Answer 34

early fluid resuscitation, early initiation of nutrition (lowers mortality, prevents progression), relieve pain

Question 35

guidelines for fluid resuscitation

Answer 35

initiate within 12 hrs: lactated ringers or normal saline. monitor vitals, BUN elevated at 24 hours is a sign of increased mortality

Question 36

how does early nutrition help

Answer 36

counteracts the catabolic state, prevents damage to organs such as mucosal lining of intestines, reduces morbidity and mortality

Question 37

nutrition for mild AP

Answer 37

low fat soft/solid oral diet as early as 12h after diagnosis if it does not exacerbate pain.

Question 38

removal of the gallbladder is carried out as early as _____ if this is the cause

Answer 38

24-48h after diagnosis (before they leave the hospital)

Question 39

nutrition for moderately severe or severe AP

Answer 39

initiated about 24h after diagnosis and admission. oral if tolerated, enteral thru nasogastric or nasojejunal if not.

Question 40

what if there are contraindications for enteral feeding

Answer 40

parenteral can be initiated

Question 41

drugs for pain

Answer 41

opioids: IV LD, continuous IV, PCA. fentanyl is more potent and given in mcg (others are mg)

Question 42

why is meperidine not first line

Answer 42

because possible accumulation of its metabolite normeperidine has CNS effects/seizures

Question 43

prophylactic antibiotics?

Answer 43

not usually. can be initiated if infection is suspected. if infection is not confirmed then drug would be discontinued.

Question 44

what is chronic pancreatitis

Answer 44

progressive inflammation with structural and functional loss (permanent) of both endocrine and exocrine functions

Question 45

major cause of chronic pancreatitis

Answer 45

alcohol abuse

Question 46

other factors that increase the risk of CP

Answer 46

cigarette smoking, hereditary, obstruction of pancreatic ducts, previous AP episodes

Question 47

pathogenesis of chronic pancreatitis

Answer 47

chronic inflammation and damage to acinar cells, islets, duct cells--> permanent structural/functional losses. lost cells replaced by fibrous material. calcified pancreatic proteins block or damage ducts, inflammation, activation of enzymes

Question 48

CP increases the risk of _____

Answer 48

pancreatic cancer

Question 49

diagnosis of CP: pain?

Answer 49

usually not as severe as AP. in epigastric area, can be intermittent or chronic episodic flare-ups. can radiate to the back. nausea and vomiting common

Question 50

diagnosis of CP: malnutrition?

Answer 50

loss of exocrine function= malabsorption of nutrients leading to malnutrition and weight loss (because loss of enzymes for digestion of the 3 major foods, digestion must occur before absorption of nutrients). loss of lipase: malabsorption of fats, fat soluble vitamins

Question 51

diagnosis of CP: endocrine function?

Answer 51

loss of endocrine function results in insulin-dependent diabetes mellitus

Question 52

diagnosis of CP: steatorrhea?

Answer 52

lack of lipase: dietary fat eliminated in the feces= steatorrhea

Question 53

how can you determine steatorrhea

Answer 53

evaluate 72 hour collection for fecal fat or measure elastase in feces (elastase not degraded in intestines)

Question 54

diagnosis of CP: serum amylase and lipase?

Answer 54

usually normal or below normal: loss of gland tissue is gradual, acinar cells no longer synthesizing and releasing the enzymes

Question 55

diagnosis of CP?

Answer 55

test of choice is MRCP. may be useful for observing calcified protein deposits that block pancreatic ducts and alcoholic CP

Question 56

guidelines for selection of a pancreatic enzyme supplement

Answer 56

administered to correct malabsorption (because of insufficient digestion). dosing/choice: focus on achieving nutritional goals.

Question 57

administration of the enzymes depends on

Answer 57

amount of food, rate of consumption. entire dose may be taken with first bite, or half at the beginning and other half in the middle of the meal

Question 58

the number associated with the name of the pancreatic enzyme preparation is the amount of _____ units in the preparation

Answer 58

lipase

Question 59

how to take pancreatic enzyme capsules

Answer 59

can be swallowed whole or opened/sprinkle contents on acidic food such as applesauce. follow consumption with a beverage. do not chew or crush capsules or their contents.