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16feb 23 Flashcards

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1
Q

What is peripancreatic fistula

A

Disruption of pancreatic ducts causing leakage of pancreatic digestive enzymes.
Most commonly due to acute or chronic pancreatitis.

Acute or chronic pnacreatitis cause formation of internal fistula (comm with hollow viscera or pleural/peritoneal cavities)

Iatrogenic fistulas occur after Percutaneous drainage of pancreatic cysts or abscesses and result in external fistulas (comm with skin)

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2
Q

CF of peripancreatic fistula

A

A/S
Cough
Dyspnea
Dysphagia
Chest pain

Exam: Dec breath sounds and dullness to percussion of affected lung.

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3
Q

PPF and pleural effusion

A

Exudative and amylase rich
Ph 7.3-7.5

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4
Q

Ttt of PPF

A

⏺Recurs after thoracentesis
⏺Bowel rest (to avoid pancreatic stimulation)
⏺ERCP with sphincterotomy
Or stent placemnet to drain pancreatic fluid in ampulla of vater
⏺ refractory cases req PCD or surgery

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5
Q

PPF vs espphageal perforation

A

EP also causes amylase rich exudative pleural Effusion
But
Pleural fluid pH is very low (<6) with undigested food is present
HO severe vomiting.

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6
Q

Exudative effusions causes

A

Infection (TB , Pneumonia )
Malignancy
Rheumatologic dx (RA, SLE)
Pulm embolism
Pancreatitis
Post CABG
Peripancreatic fistula
Boerhaave syndrome.

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7
Q

Cause of exudative effusin

A

Inflammatory disruption of vascular permeability

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8
Q

Cause of transudative effusion

A

Change in hydrostatic or oncotic pressures

Cause :
HF
Cirrhosis (hepatic hydrothorax)
Nephrotic syndrome
Constrictive pericarditis.

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9
Q

Overview of chronic Pancreatitis

A

🐦Alcohol use
🐦Cystic Fibrosis
🐦Ductal obstruction (malignancy , stones
🐦autoimmune

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10
Q

CF of chronic pancreatitis

A

👗Chronic epigastric pain that radiates to back with intermittent pain free intervals but may become constant in adv disease.
Pain may worsen with meals
Partially relieved by sitting upright or leaning forward

👗early CP presents with acute attacks that are continuous as the dx worsens

👗Malabsorption :
Steatorrhea , weight loss

👗Diabetes Mellitus

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11
Q

Lab results /imaging of chrnic pancreatitis

A

🦺amylase and lipase are normal and non diagnostic

🦺 CT scan or MRCP shows calcifications , dilated ducts and enlarged pancreas

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12
Q

Ttt of chronic Pancreatitis

A

👘Pain management

👘Alcohol and smoking cessation

👘Freq small meals

👘Pancreatic enzyme supplements.

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13
Q

Chronic pancreatitis def and RF

A

Progressive inflammatory dx that ultimately leads to pancreatic fibrosis.
As the dx advances destruction if pancreatic islet and acinar cells leads to endocrine (diabetes) and exocrine insufficiency causing protein and fat malabsorption.

RF :
Recurrent episodes of acute panncreatitis
Alcohol abuse
Smoking
Family history (herediatry pancreatitis)

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14
Q

Chronic Pancreatitis DX

A

Exocrine def test
Exocrine enzymes (amylase protease lipase )
🩲Low Fecal elastase (SN and SP fir pancreatic exocrine insuff )
Elastase is produced by oancreatic acinar cells.

🩲Low Serum trypsinogen

Endocrine def test:
Diabetes testing

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15
Q

Pancreatoc exocrine insufficiency mech and ttt

A

👠Pancreatic secretion stimulated by CCK (triggered by protein and fatty meal)

👠Normally pancreatic enzymes break down CCK releasing protein and limit CCk.

👠In pancreatic insuff unchecked CCK release causes pancreatic hyperstimulation.
This causes post prandial abd pain in pts of chronic pancreatitis.

Ttt :
🧣pancreatic enzyme supplements (lipase , amylase , protease ) reduce pancreatic hyperstimulation and improve nutrient digestion.
Steatorrhea and malabsorptiin also improves.
🧣Ingestion of freq small meals that are low in fat also improve pain.
🧣Ttt of pain with pregablin, nortriptyline, amitriptyline. (Non opiate analgesia prefered)
🧣 treat DM and stop alcohol and tobacco

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16
Q

Post ERCP pancreatitis. Dx

A

Do lipase before CT.
Lipase rises earlier in few hours.
CT remains normal upto 48hrs.

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17
Q

Acute pancreatitis diagnostic criteria

A

🧥Severe Epigastric Pain (radiating to back)
🧥Amylase / lipase >-3 times upper limit of normal.
🧥Characteristic findings of acute pancreatitis on imaging ( CT , MRI, USG)

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18
Q

Post ERCP complications

A

Ascending cholangitis
Perforation
Pancreatitis

Post ERCP pancreatitis is prevalent in SOD pts.

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19
Q

Most common causes of Acute Pancreatitis

A

Gall stones
Alcohol
Hypertrigkyceridemia (TG >1000)

Drug induced (less common)

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20
Q

Severe Acute Pancreatitis def

A

Pancreatitis that causes failure of >-1 organ systems (renal , resp, cardiovascular ) lasting >48hrs.

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21
Q

Predictors of worst prognosis in SAP

A

👘AMS

👘 signs of SIRS

👘 elevated BUN >20mg/dl , Cr >1.8mg/dl and Hct >44%
Reflecting Intravascular volume depletion (with hemoconcentration) due to third spacing of fluid caused by inflammatory response and increased capillary permeability.

👘 radiologic findings of third Spacing of fkuids (pulm infiltrates or pleural effusion)
CT scan : severe pancreatic necrosis

👘old age >55 , obesity BMI >30

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22
Q

Systemic inflammatory Response syndrome criteria

A

2 of the following :

Temperature >100.4 F or <36 (96.8)
Pulse >90/min
Resp >20/min or pCO2 <32 mmhg
WBCs >12,000 or <4000 or >10% bands

23
Q

Infected pancreatic Necrosis etiology

A

Pts with signs of sepsis few days after acute nectrotizing pancreatitis.

pancreatic inflammation (pancreatitis) causes uncontrolled release of pancreatic enzymes causing autodigestion of pancreatic parenchyma and peripancreatic tissue (pancreatic edema and necrosis on CT)
Resulting Necrotic Collection is sterile
Infection with enteric bacteria (Ecoli , Psuedomonas , Enterococcus)
Occurs in a third of patient 7-10days after acute nectrotizing pancreatitis.

24
Q

Dx of infective pancretic necrosis

A

🏣CT scan (even if initial CT was taken)

     Gas within necrotic tissue is diagnostic and prompts IV AB

🏣If CT is equivocal: aspiration and culture

25
Q

Ttt of infected Pancreatic Necrosis

A

🗻IV ab

🗻Debridement if necrotic tissue (after AB so infection is walled off which facilitates debridement )

26
Q

CF of severe pancreatitis

A

🪗Fever, tachycardia , hypotensions
🪗Dyspnea , tachypnea , basilar crackles
🪗Abd tenderness distension
🪗Cullen sign: periumb bluish discoloration (hemoperitoneum)
🪗Grey Turner sign: Reddish brown coloration around flanks (retroperitoneum)

27
Q

RF for severe pancreatitis

A

🚨Age >75
🚨Obesity
🚨Alcoholism
🚨CRP : >150 at 48hrs after presentation
🚨Rising BUN and Cr in first 48hrs
🚨Xray :
Pulm infiltrates /pleural effusion
🚨CT scan/ MRCP :
Pancreatic necrosis and extra pancreatic inf

28
Q

Complications of severe pancreatitis

A

Pseudocyst
Peripancreatic fluid collection
Necrotizing pancreatitis
ARDS
GI bleed

29
Q

Acute pancreatitis complicated by hypotension

A

Activated pancreatic enzymes enter vascular system and inc vascular permeability within and around the pancreas. This causes large volumes of fluid migrating from vascular system to surrounding retroperitoneum.

Systemic inflammation ensues as inflammatory mediators enter vascular system.
Net effect is widespread vasodilation , capillary leak , shock , end organ damage.

Ttt: IV fluids.

30
Q

How soon do psudocysts form after Acute pancreatitis episode

A

3-4 weeks

31
Q

Pt with negative CT scan after BAT , persistent upper abd pain , nausea , low grade fever and large upper abd fluid collection

A

Pancreatic duct Injury

32
Q

Pancreatic duct injury after BAT

A

Leakage of inflammatory pancreatic juice causes accumulation of peripancreatic fluid

BAT causes rapid compression of fixed , retroperitoneal pancreas against vertebral column

SS of pancreatic duct injury

🚜 persistent abd discomfort/tenderness
🚜 persistent Nausea/emesis
🚜 increasing Amylase over serial measurements
🚜 Peripancreatic fluid collection (due to ductal injury)

Ttt surgery
Dx : Cholangiopancreatography

33
Q

Dx of Acute pancreatitis

A

Dx requires 2 of the following :

🛞Acute epigastric pain radiating to back
🛞Amylase or lipase >3x normal limit
🛞Abnormalities on imaging consistent with pancreatitis.

Others.
🛞ALT >150 suggests biliary pancreatitis
🛞Severe dx : fever , tachypnea , hypoxemia , hypotension

🥁in pts with typical Abd pain and markedly elevated amylase/lipase levels
CT or imaging is not required. (CT is inaccurate in first 72 hrs as signs of impaired perfusin and necrosis take days to evolve)
Hence CT ismostly done in case of diagnostic uncertainty.

34
Q

Gall stone pancreatitis dx and ttt

A

Pts with pancreatitis (epigastric pain , elevated amylase /lipase) with RF for gall stones and elevated LFTs(high ALT)

Dx : RT upper USG

Ttt: cholecystectomy

35
Q

Pancreatic adenocarcinoma CF

A

🛞Systemic Symptoms (weight loss , anorexia)

🛞Discomfort /subacute pain (abdomen , back)

🛞Jaundice

🛞Unexplained migratory superficial thrombophlebitis

Think about pancreatic CA in pt of chronic pancreatitus with worsenjng abd pain and weight loss

36
Q

Pancreatic CA labs and dx

A

🛞Cholestasis (Inc ALP and direct Bilirubin)

🛞Inc CA19-9

🛞Abd USG (head mass ) or CT scan (ill defined pancreatic mass)

37
Q

Pancreatic CA head dx Ttt

A

P. CA head :
Jaundice due to CBD obstruction
Elevated ALP and bilirubin
Steatorrhea (ductal blockage or exocrine insuff)

Dx : USG
(Also USG rules out other causes of biliary ductal obstruction eg cholidocholithiasis )

38
Q

Pancreatic CA body and tail dx and ttt

A

SS :
Do not present with obstructive jaundice

Dx :

       CT with contrast    Delineate necrosis within pancreas and identify distant mets and helps exclude other conditions.

(USG cannot visualize body and tail due to overlying bowel gas and for small tumors <3cm)

39
Q

Acute pancreatitis first labs to be done

A

Amylase and lipase.
(If pt has typical pain and elevated enzymes no imaging is done)

Early in pancreatitis , pancreas makes enzymes but doesnt secrete them.
These leak out into systemic circulation

Amyalse rises in 6-12hrs. And remains elevated 3-5 days.
Lipase rises within 4-8hrs but remains elevated 8-14 days.
Hence lipase is SN and more. useful

40
Q

Acute Pancreatitis due to Hypertriglyceridemia CF and Dx

A

Eruptive xanthomas
CF of acute pancreatitis

Dx
Fasting Serum TG : >1000
Family History of early MI and hyoertrigkyceridemia

41
Q

Cause of Acute oancreatitis

A

🧘🏻Alcohol
🧘🏻Gall stones
🧘🏻Hypertrigkyceridemia

Less common
Medication: azathioprine , valproic acid , thiazide diuretics

Infection : CMV
ERCP
Trauma

42
Q

Pancreatic ascites cause. And CF

A

Pancreatic ascites results from damage to pancreatic duct with leakage of pancreatic juice in peritoneal space.

CF:
Pt with recurrent pancreatitis now develops abd distension

Chronic pancreatitis pt.

Ascitic fluid high in protein >-2.5 g/dl

High in amylase >1000U/L

Low SAAG ratio (<1.1 indicating non portal HTN)

43
Q

Abdominal Compartment syndrome def

A

Rise in intraabd pressure reduces organ perfusion to the point of causing organ dysfunction.

RF :
Massive fluid resuscitation (as in acute oancreatitis )
Major intraabd surgery

44
Q

Cardiovascular consequences of Abd Compartment syndrome ACS

A

🥇 inc IAP and intrathoracic pressure causes venous compression ➡️ Inc CVP
(Despite reduce preload due to Extrinsic compression- uncoupled CVP and Cardiac preload. As Normally dec preload has reduced CVP )

🥇 the extrinsic compression ➡️ dec VR to heart ➡️ dec Cardiac PRELOAD

🥇 diaphragmatic elevation compresses heart and decreases ventricukar filling.

🥇 dec Cardiac Preload and Ventricukar filling ➡️ Dec CO , hypotension , compensatory tachycardia

45
Q

Management of Abdominal compartment syndrome

A

Temporizing measures :
🗻Avoid over resuscitation
🗻Dec intraabd vol (NG tube)
🗻Inc Abd wall compliance (sedation)

Definitive ttt: Surgical decompression

46
Q

Why doesnt abdomen accomodate fluids in ACS as it does in ascites

A

Abd wall compliance doesnt increase in acute setting so small volume of rapidly accumulating intraabd fluid can markedly increase IAP and cause ACS.

In ascites progressive abd wall stretching over time (weeks) greatly increase abd wall compliance allowing large fluid volumes (>15L) to accumulate without ACS.

47
Q

Pancreatic pseudocyst Pathophys and dx

A

Mature walled off pancreatic fluid collection (no necrosis or solid material ) surrounded by thick fibrous capsule and contains enzyme rich fluid , tissue and debris.
Can leak amylase rich fluid into circulation and inc serum amylase.

Dx: CT with contrast

48
Q

Complications of pseudocyst

A

Spontaneous infection
Duodenal /biliary obs
Pseudoaneurysm (digestion of adj vessels)
Pancreatic ascites
Pleural effusion

49
Q

Ttt of Pseudocyst

A

Minimal to no symtoms no complications;
NPO , conservative ttt

Sig symptoms/infection:
Endoscopic drainage

Psudoaneurysm:
Embolization then endoscopic drainage

50
Q

Acute pancreatitis after cardiac catheterization/vascular procedure

A

Consequences of cholesterol emboli

🦷Skin : Livedo reticularis (reticulate , mottled , discolored skin ) blue toe syndrome

🦷Kidney : Acute kidney injury

🦷GIT : Pancreatitis , mesenteric ischemia

51
Q

Ttt of acute pancreatitis due to ischemia/atherosclerosis (cholesterol emboli after cardiac cath)

A

Analgesics and IV fluids

52
Q

How to manage gall stone pancreatitis

A

👗If patient has ascending cholangitis or
Confirm Biliary obs(CBD dilation plus stone)
⬇️
Urgent ERCP
⬇️
Once pancretitis has resolved do Cholecystectomy

👗If no ascending Cholangitis
Possible biliary Obstruction (persistent Inc LFTs , CBD dilation)
⬇️
EUS/MRCP followed by ERCP
If bile stone visualized
⬇️
Cholecystectomy once Pancreatitis has resolved

👗No ascending cholangitis
No biliary obs
⬇️
Supportive Care
(IV fluids , analgesics)
⬇️
Chole when pancreatitis has resolved

53
Q

Indication of ERCP in pancreatitis

A

CBDobstruction. (Dilated CBD containing stone on USG)

Evidence of acute cholangitis
(Fever RUQ abd pain , jaundice , hypotension , confusion)

54
Q

Common drugs to cause Acute pancreatitis

A

🐦Diuretics (furosemide , thiazides)
🐦IBD drugs (sulfasalazine , 5-ASA)
🐦Immunosuppressive (azathioprine)
🐦HIV related medications (didanosine, pentamidine)
🐦Antibiotics (metronidazole , tetracycline)

🥾Drug induced pancreatitis is mild

GIT (20 decks)

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