10/8- Pancreatitis Flashcards
Familiarize yourself with this picture
Vasculature:
- Splenic a down body/tail of pancreas
- Hepatic a
- Portal v
- Superior/inferior pancreatico-duodenal a
- Superior mesenteric a/v
What is acute pancreatitis?
- Mild vs. severe
- Mortality rates
Acute inflammatory process of the pancreas
- 80% mild, 20% severe
Mortality
- 25-33% mortality with severe pancreatitis
- Two peaks of morality:
- Half within 1-2 wks from multiorgan failure
- Late peak from infection
What is the pathophysiology of acute pancreatitis?
- Conversion of trypsinogen to trypsin in acinar cells in sufficient quantity
- Trypsin catalyzes conversion of proenzymes to active enzymes
- Active enzymes autodigest the pancreas
- Cycle of releasing more enzymes
- Microcirculatory injury with resulting edema and ischemia
- Disruption of pancreatic ducts
- Cytokine release from PMNs and macrophages
- Systemic inflammatory response and systemic effects
70% of US cases of acute pancreatitis are related to either _____ or _______
70% of US cases of acute pancreatitis are related to either gallstones or chronic alcohol abuse
Gallstones are related to __% of acute pancreatitis cases but only __% of pts with gallstones will get pancreatitis
- More common with ____
- Process/pathogenesis
Gallstones are related to 40% of acute pancreatitis cases but only 3-7% of pts with gallstones will get pancreatitis
- More common with stones < 5mm
Process/pathogenesis:
- Stone obstructs pancreatic duct
- Stone passage -> edema
- Reflux of bile
What is seen here?
Gallstone throwing shadow
Describe the anatomy of the gallbladder
- Fundus (most distal)
- Body
- Hartmann’s pouch (proximal)
- Neck
Describe the outflow path from the gallbladder
- Cystic duct (with spiral valves), which joins with the common hepatic duct
- > Bile duct, which combines with the pancreatic duct
- > Ampulla of Vater
Dumps into duodenum (2nd stage)
Ethanol is related to __% of cases of acute pancreatitis; it affects a ____ (small/large) percentage of alcoholics
- Often occurs in the setting of _____
- Possible mechanisms
Ethanol is related to 30% of cases of acute pancreatitis; it only affects a small percentage of alcoholics
- Often occurs in the setting of chronic alcoholic pancreatitis
Possible mechanisms:
- Relaxatin or spasm of sphincter of Oddi
- Higher protein concentration in pancreatic juice
- Direct toxic injury
What are other predisposing factors of acute pancreatitis? (not alcohol or gallstones)
- Hypertriglyceridemia (> 100 mg/dL)
- Microlithiasis and biliary sludge
- Drugs:
- Azathioprine
- Valproate
- Tetracycline
- Furosemide..
- Hypercalcemia
- Post-ERCP pancreatitis (5-25% of ERCPs)
- Trauma (blunt or penetrating)
- Infections:
- Mumps
- CMV
- VZV
- Mycoplasma
- Aspergillus
- Toxoplasma
- Hereditary (trypsinogen gene)
- Autoimmune pancreatitis (IgG4 elevated)
What is necessary to establish acute pancreatitis diagnosis?
Combo of at least 2 of the 3:
- Typical symptoms
- Elevated amylase/lipase
- CT findings of pancreatitis
What are typical symptoms of acute pancreatitis?
Abdominal pain
- Steady and moderate to severe
- Upper abdomen, epigastric
Nausea and vomiting
What are physical exam findings in acute pancreatitis?
- Abdominal tenderness
- Estravasation fo hemorrhagic exudate (rare)
- Grey Turner’s sign: ecchymoses in flanks
- Cullen’s sign: periumbilical ecchymoses
- Tachycardia, fever
- Respiratory distress, altered mental status in severe pancreatitis
What is Grey Turner’s sign?
Ecchymoses in flanks
- (rare) finding in acute pancreatitis
What is Cullen’s sign?
Periumbilical ecchymosis
- (rare) finding in acute pancreatitis
What is seen here?
Acute pancreatitis: Cullen’s sign?
– periumbilical ecchymosis
What are lab values expected in acute pancreatitis?
Amylase
- 3x serum elevation
- Rises within 6-12 hrs; half life 10 hrs
Lipase
- 3x serum elevation
- Rises within 24 hrs; longer half life
What is the most important imaging technique for diagnosis/complication identification in acute pancreatitis?
CT
- Not always necessary (mild cases)
What is expected in CT of acute pancreatitis?
- Peri-pancreatic inflammatory changes
- Peri-pancreatic fluid collections
- Pancreatic necrosis
What is the benefit of using abdominal x-ray for suspected acute pancreatitis?
- Evaluate for other causes of abdominal pain
- Sentinel loop: localized ileus of a segment of small intestine
What are the benefits/uses of abdominal ultrasound in the evaluation of acute pancreatitis?
Visualize:
- Gallstones
- Dilated bile duct (choledocholithiasis)
What is choledocholithiasis?
Dilated bile duct
What will be helpful in determining the cause of acute pancreatitis?
History:
- Alcohol
- Medications
Labs:
- Liver tests
- Calcium
- TG
- IgG4
Ultrasound:
- Gallstones
- Dilated bile duct
CT
- Pancreatic mass of cyst
What are predictors/methodsof assessing severity in cases of acute pancreatitis?
Severe Acute Pancreatitis:
SIRS: 2+ of the following:
- P > 90, R > 20, or PaCO2 < 32
- T < 36 or T > 38
- WBC < 4,000 or WBC > 12,000
Organ failure (pulmonary, renal, cardiovascular)
Pancreatic necrosis
Scoring systems
What is Ranson’s Criteria?
- At admission
- During initial 48 hrs
At admission:
- Age > 55 yo
- WBC > 16,000/mm3
- Blood glucose > 200 mg/dL
- Serum LDH > 350 IU/L
- Serum AST > 250 IU/L
Initial 48 hrs:
- Hematocrit decrease > 10%
- BUN increase > 5 mg/dL
- Serum Ca < 8 mg/dL
- Arterial pO2 < 60 mmHg
- Serum base deficit (24 - HCO3) > 4 mEq/L
- Fluid sequestration > 6 L
How is Ranson’s criteria scored?
- Mortality
- Shortcomings
Scoring:
- 1 pt for each positive
- Severe pancreatitis is 3+ points
- Mortality:
- 0-2: 2%
- 3-4: 15%
- 5-6: 40%
- 7-8: 100%
- Cumbersome and requires 48 hrs to calculate…
What is the CT scoring index for acute pancreatitis?
Balthazar grades (A-E) associated with certain CT findings:
Grade A: Normal pancreas
Grade B:
- Enlargement of pancreas
- Irregular contour
- Inhomogenous attenuation
Grade C: peripancreatic inflammation + B
Grade D: associated single fluid collection + C
Grade E: 2+ peripancreatic fluid collections or gas in pancrease + C
What is seen here?
Grade A (normal pancreas)
What is seen here?
CT of acute pancreatitis: Grade B
- Enlargement of pancreas
- Irregular contour
- Inhomogeneous attenuation
What is seen here?
CT of acute pancreatitis: grade C
- Peripancreatic inflammation in addition to Grade B:
- Enlargement of pancreas
- Irregular contour
- Inhomogenous attenuation
What is seen here?
CT of acute pancreatitis: Grade D
- Associated single fluid collection in addition to Grade C criteria:
- Peripancreatic inflammation
- Enlargement of pancreas
- Irregular contour
- Inhomogenous attenuation
What is seen here?
CT of acute pancreatitis: Grade E
- 2+ peripancreatic fluid collections or gas in pancreas in addition to Grade C:
- Peripancreatic inflammation
- Enlargement of pancreas
- Irregular contour
- Inhomogenous attenuation
What is the BISAP score?
1 point for each:
- BUN > 25 mg/dL
- Impaired mental status
- SIRS
- Age > 60 yo
- Pleural effusion
What are the two main scoring systems in predicting SAP (Severe Acute Pancreatitis)?
- Ranson’s
- BISAP
How do you manage acute pancreatitis?
- Aggressive IVF resuscitation (first 24 hours most important)
- Pain control with opiates
- Close monitoring
- Prophylactic antibiotics not typically indicated (controversial topic with necrotizing pancreatitis)
- “Pancreatic rest”
- Historical management strategy that patients with pancreatitis should be kept NPO with slow advancement of diet after improvement in pain
- No longer considered standard of care
- Nutritional support
- Increased metabolism and protein catabolism with severe acute pancreatitis
- Enteral nutrition better than parenteral nutrition (TPN) – reduced infections & mortality
- No TPN!!!
- Early initiation of enteral feeding
- Nasogastric feeding may be ~ to nasojejunal feeding
- If gallstone cause, treat it (later slide)
How do you manage acute pancreatitis associated with gallstones?
- ERCP
- Urgent: impacted stone; cholangitis, rising/elevated bilirubin
- Delayed: evidence of choledocholithiais by labs or imaging
- Cholecystectomy
What are localized complications (of acute pancreatitis?)
Under 4 wks:
- Acute fluid collection
- Acute necrotic collection
Over 4 wks:
- Pseudocyst
- Walled-off necrosis
What is a pancreatic pseudocyst?
- Characteristics
- Timeline
- Treatment
Most commonly encountered chronic complication (of acute pancreatitis?)
- Develop adjacent to pancreas after 4 weeks
- Fluid filled
- Encapsulated wall
- May require drainage if symptomatic
What is the pathophysiology of chronic pancreatitis?
- Loss of parenchymal cells (acinar first, then islet), chronic inflammation, fibrosis
- Alcoholic chronic pancreatitis
- 10% heavy alcohol users (genetic effect)
- Direct toxic effects of alcohol and metabolites
- Stimulates stellate cells (fibrosis)
- Recurrent acute episodes lead to chronic changes
What is the etiology of chronic pancreatitis?
- Smoking: chronic pancreatitis and cancer
- Alcohol: 70%
- Idiopathic: 10-30%
- Tropical pancreatitis
- Genetic (PRSS1, SPINK1, CFTR)
- Autoimmune pancreatitis
- Ductal obstruction
How does chronic pancreatitis present?
- Abdominal pain – most common symptom
- Exocrine insufficiency
- Steathorrhea (< 10% pancreas function)
- Diarrhea and weight loss
- Endocrine insufficiency
- Diabetes Mellitus
- Reduced glucagon – risk of hypoglycemia with insulin treatment
How is chronic pancreatitis diagnosed?
It’s difficult
- Tests of pancreatic function
- Direct: bicarbonate output in duodenum after dose of secretin; not practical
- Indirect: fecal elastase and fecal fat (72 hr vs. Sudan stain)
- Tests of pancreatic structure
- Abdominal x-ray: diffuse calcifications
- CT:
- Dilated, irregular pancreatic duct
- Intraductal filling defects
- Calcifications
- Irregular contour, heterogeneous parenchyma
- MRI/MRCP
- Endoscopic ultrasound (EUS)
- ERCP
- Exocrine/endocrine deficiency
- Abdominal pain alone…
All tests are most useful in advanced chronic pancreatitis
What is seen here?
Calcification in pancreas on abdominal x-ray
- Indicative of chronic pancreatitis
What is seen here?
Calcifications in pancreas??
What is the gold standard for diagnosing chronic pancreatitis?
- What does it show?
ERCP
- Dilated pancreatic duct, filling defects, dilated side branches
- Invasive
What does MRI/MRCP do for the diagnosis of chronic pancreatitis?
- Provides imaging of the pancreatic parenchyma and the pancreatic duct
- Non-invasive
What does endoscopic ultrasound (EUS) do for the diagnosis of chronic pancreatitis?
- Some questions about specificity
- Completely normal EUS -> chronic pancreatitis unlikely
Look at this pic
Normal?
No idea what this is…
When can exocrine/endocrine deficiency be used to help diagnose chronic pancreatitis?
Advanced disease
- CT or other tests are likely positive
When can abdominal pain alone be used to help diagnose chronic pancreatitis?
- Not advanced disease -> challenging diagnosis
- Pancreatic protocol CT or MRI/MRCP
- EUS
How should chronic pancreatitis be managed from an abdominal pain standpoint?
What if:
- ERCP
- Steatorrhea
- Diabetes mellitus
- Most common and bothersome symptom
- Pain medication – risk of addiction
- Stop ETOH
- Pancreatic enzymes (non-enteric coated)
Also if:
- ERCP: pancreatic duct strictures or stones
- EUS: celiac plexus block (transient, rarely used)
- Surgery – Puestow, pancreatectomy w/ islet cell transplant
- Steatorrhea: pancreatic enzyme supplementation
- Diabetes mellitus: insulin often needed; risk of hypoglycemia
- Malignancy: pancreatic adenocarcinoma (later cad)
What malignancy is associated with chronic pancreatitis?
- Lifetime risk
- Increased risk factors
Pancreatic adenocarcinoma
- 4% lifetime risk
- Smoking increases risk
Difficult to diagnose in setting of chronic pancreatitis
- Similar symptoms (abdominal pain, weight loss)
- Clinical suspsicion
