11c. Clinical Aspects of Acute and Chronic Pancreatitis

Question 1

serum amylase: why is it relevant?
name several tissues that it comes from?
what does it do?

Answer 1

• cornerstone to diagnosis of pancreatitis! leaks from inflamed pancreas, then is reabsorbed.
• comes from pancreas, salivary glands, fallopian tubes, ovaries, prostate, lung
• acts on starch to split alpha 1-4 glucosidic bonds

Question 2

serum amylase lab: what is its sensitivity and specificity for pancreatitis? (relative, not numbers)

Answer 2

sensitivity is high, esp early in course

specificity is low, esp at lower elevations

Question 3

serum lipase: why is it relevant?
how does it change with time?
other conditions that will make it elevated?

Answer 3

• as sensitive for acute pancreatitis as amylase, but more SPECIFIC
• elevated the first day of illness, remains elevated longer than amylase
• other intra-abdominal probs and renal insuff can elevate it (usually only to levels less than 1000 u/L)

Question 4

Atlanta Criteria for acute pancreatitis?

Answer 4

Two of these three:

• abd pain clinically consistent with acute pancreatitis
• elevated amylase/lipase greater than 3x upper limit of normal
• confirmation via abdominal imaging

Question 5

clinical diagnosis of acute pancreatitis?

Answer 5

• symptoms and PE
• lab tests
• other conditions ruled out

Question 6

role of imaging in diagnosing acute pancreatitis?

Answer 6

• not essential
• confirmatory
• stages severity, indicates complications

Question 7

protective mechanisms in the pancreas that prevent activation of zymogens? (this info is also in another deck, but just for repetition)

Answer 7

• enzymes are synthesized/stored in inactive form
• trypsin inhibitor is packaged in zymogen granule just in case
• enzymes are segregated in membrane-bound compartments
• enterokinase exists only in the small intestine
• acidic pH in granules inhibits trypsin

Question 8

serum levels of amylase and lipase over time with acute pancreatitis? what levels might be seen in a case with delayed presentation?

Answer 8

both initially rise quickly, then amylase falls more quickly than lipase.
in a delayed presentation, labs may show elevated lipase but normal amylase (since it returned to nl more quickly)

Question 9

what other conditions may elevate both serum amylase and serum lipase?

Answer 9

• intestinal ulceration, obstruction, ulceration or ischemia. intraluminal pancreatic enzymes are re-absorbed from gut back into bloodstream due to damaged intestinal mucosa.
• elevated amylase and slightly elevated lipase are seen in biliary tract disease and renal failure

Question 10

two types of acute pancreatitis? what does Benson think about these two types?

Answer 10

mild and severe acute pancreatitis

Bensen thinks they are very distinct from each other (apples/oranges)

Question 11

what are a few ways to assess the severity of acute pancreatitis?

Answer 11

• BISAP > 2
• BUN > 22
• CRP > 150 at 48h
• SIRS persisting at 48h

Question 12

what is BISAP?

Answer 12

5 elements, 2+ = severe acute pancreatitis:

• BUN > 25
• Impaired mental status
• SIRS
• Age > 60
• Pleural effusion

Question 13

what is SIRS?

Answer 13

systematic inflammatory response syndrome. defined by at least 2:

• Tachycardia: pulse > 90
• Pulm: RR > 20 or PCO2 < 32
• Temp: T > 100.4 or < 96.8
• Infection: WBC > 12,000 or < 4,000

Question 14

what are Ranson’s Criteria of Severity (general overview)?

Answer 14

(not on exam, may still be on boards)
eleven criteria taken both at time of admission and after 48h that predict the severity of outcome (mild v severe) in acute pancreatitis.

Question 15

what feature of a patient will worsen the prognosis of acute pancreatitis?

Answer 15

OBESITY.

increases both severity and complications

Question 16

Prognosis of mild (interstitial) v severe (necrotizing) acute pancreatitis?

Answer 16

mild (interstitial): infection and mortality both < 1%

severe (necrotizing): infection 30-50%, mortality 10-30%

Question 17

Causes of death in acute pancreatitis if death occurs early on (< 1 wk)?

Answer 17

*multiorgan failure

SIRS

Question 18

Causes of death in acute pancreatitis if death occurs later on (> 1 wk)?

Answer 18

*pancreatic infections, sepsis, infectious complications

multiorgan failure

Question 19

2 most common causes of acute pancreatitis?

Answer 19

alcohol, gallstones

also idiopathic and ‘other’ causes

Question 20

mechanisms for gallstone causing acute pancreatitis?

Answer 20

• stone obstructing the common opening of the common bile duct and pancreatic duct, allows reflux of bile into the pancreas
• obstructed pancreatic duct, same reflux problem

Question 21

what are a few things included in the ‘other’ category of causes of acute pancreatitis?

Answer 21

(impt because some of these causes are reversible)

• drugs, toxins
• metabolic and structural issues
• autoimmune
• infectious
• neoplastic
• trauma

Question 22

how does a gallstone look on ultrasound?

Answer 22

white round/oval mass with characteristic acoustic ‘shadow’ – darkened area where US was blocked by stone

Question 23

how does microlithiasis/biliary sludge look on ultrasound?

Answer 23

dense layer of material in dependent area of gallbladder. does not cause an acoustic shadow like a gallstone will.

Question 24

what anatomical anomaly puts pts at higher risk for acute pancreatitis?

Answer 24

pancreas divisum

Question 25

inherited causes of acute pancreatitis?

Answer 25

- altered enzyme activity: trypsinogen mutation - Cystic Fibrosis (may not be a mutation severe enough to cause CF, but can still cause reduction in CFTR function -> pancreatitis) - familial hypertriglyceridemia

Question 26

familial hypertriglyceridemia: what are serum triglyceride levels? mechanism of causing pancreatitis?

Answer 26

- serum TG levels > 1000 - reversible, can also be drug-induced - mechanism (theoretical): lipase continuously released from pancreas, TG hydrolysis generates short chain FAs that are toxic to the pancreas

Question 27

mechanism by which trauma can cause acute pancreatitis?

Answer 27

- midline injury, panc compressed against spine - may sever pancreatic duct - may cause ductal leak - may cause a gradual obstructing stenosis of duct at site of trauma

Question 28

a cause of pancreatitis in south america?

Answer 28

scorpion bite! toxin can cause pancreatitis. | found in central and south america and the caribbean

Question 29

strategies for altering the severity of acute pancreatitis?

Answer 29

unfortunately there is very little data to show that interventions exist. in severe gallstone pancreatitis ERCP seems to help (removal of the stone)

Question 30

supportive care for acute pancreatitis?

Answer 30

aggressive fluid and electrolyte replacement monitoring analgesia

Question 31

systemic complications of acute pancreatitis?

Answer 31

``` shock/multiorgan failure coagulopathy resp failure renal failure hyperglycemia hypocalcemia ```

Question 32

a local complication of acute pancreatitis that may self-resolve?

Answer 32

acute fluid collection, around the pancreas. usually resolve spontaneously but may require drainage (if infected or symptomatic)

Question 33

what is a pancreatic pseudocyst?

Answer 33

localized pancreatic fluid collection with a well-defined, fibrous wall. not lined by epithelium (hence PSEUDOcyst).

Question 34

why is someone with acute pancreatitis at incr risk for infection?

Answer 34

in the critically ill pt there is a breakdown in the fut barrier function, allows translocation of gut bacteria

Question 35

nutrition issues in pancreatitis: what should I do in mild acute pancreatitis? severe acute pancreatitis? TPN vs enteral? composition of diet?

Answer 35

- nutritional support not as impt in mild acute pancreatitis: early recovery is expected - severe acute pancreatitis: nutritional support will speed recovery, prevent nutritional depletion. - enteral is beneficial and safe for severe acute panc. - give low fat elemental diet into the jejunum

Question 36

cardinal clinical features of chronic pancreatitis?

Answer 36

- pain - calcification (intraductal) - panc insufficiency (endo and exocrine) - eventually: malabsorption, diabetes

Question 37

western countries; most common cause of chronic pancreatitis? other causes?

Answer 37

alcoholism | other causes include CF, hereditary, hypertriglyceridemia, autoimmune

Question 38

causes of pain in chronic pancreatitis?

Answer 38

- acute pancreatitis superimposed on chronic (inf, pseudocysts) - obstruction -> incr pressure - nerve inflammation

Question 39

how diminished does a person's lipase reserve have to get before the pt will show signs of steatorrhea?

Answer 39

- capacity of panc to secrete lipase must decr to 10% of normal level before excess fecal fat excretion (steatorrhea) - so, we have impressive reserves of lipase - also, when a pt with chronic pancreatitis presents with steatorrhea, it implies that 90% of their pancreas is destroyed

Question 40

what's the best way to detect pancreatic calcifications?

Answer 40

CT: more sensitive than abd Xray, often used if the xray is negative

Question 41

in patients with fat malabsorption due to severe pancreatic insufficiency, what is a possible treatment?

Answer 41

pancreatic enzyme supplements. decreased fecal fat excretion by greater than 50%

Question 42

pain management for chronic pancreatitis? what is the role of narcotics, TCAs, anti-inflammatories, decreasing pancreatic stimulation?

Answer 42

- narcotics are first line. AE = addiction, pain from narcotic bowel syndrome - TCAs help some patients (neuromodulation) - anti-inf not shown to be helpful - somatostatin analogs (octreotide) not very helpful

Question 43

what is a lateral pancreaticojejunostomy?

Answer 43

- aka Puestow procedure. - reduces pain in chronic pancreatitis - main pancreatic duct is opened, jejunum anastomosed so that pancreatic duct drains directly into the jejunum.