77. Pancreas Flashcards by Tegan Turner

Is the pancreas intra or retroperitoneal

retro!

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What are the three segments of the pancreas

head
body
trail

*epigastrium, LUQ direction

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Why is damage to the pancreas concerning from an “enzyme leaking perspective”

Inciting event –> cellular injury can trigger inappropriate activation of trypsinogen to trypsin –> further injury and activation other enzymes = autodigestion
- further cytokine release increases vascular permeability, causing complications such as edema, hemorrhage, necrosis

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List 5 ddx overall “types”/categogies of acute pancreatitis causes

toxic/metabolic
mechanical - obstructive
infectious
vascular
other

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Name 2 ind RF for development of pancreatitis

smoking
diabetes

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Name two types of acute pancreatitis

interstitial edematous
necrotizing *worse, can become infected

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List 5 causes of toxic-metabolic pancreatitis

etoh
drugs
hyperlipidemia
hypercalcemia
uremia
scorpion venom

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List 5 causes of mechanical-obstructive pancreatitis

biliary stones
congenital - dividsum, annular pancreas
tumor - ampulla, neuroendocrine, pancreatic carcinoma
post ercp
ampullary dysfunc/steonosis
duodenoal diverticulum
trauma

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List 4 causes of infectious pancreatitis

viral - mumps, coxsackie, HIV, cmv, ebv, varicella
bacterial: tb, salmonella, campy, legionella, mycoplasma
parasitic: ascaris

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Name 4 types of vascular cause of acute pancreatitis

vasculitis
embolism
hypoperfusion, ischemia
hypercoagulbility

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Name 4 “other” causes of acute pancreatitis

idiopathic
hereditary
diabetes mellitus
dka
autoimmune

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What are 2 local complications of interstitial edematous pancreatitis?

Acute peripancreatic fluid collection—homogeneous fluid collection adja- cent to pancreas; seen within 4 weeks of symptom onset
Pancreatic pseudocyst—homogeneous fluid collection with well-defined wall; seen >4 weeks from symptom onset

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What are 2 local complications of necrotizing pancreatitis?

Acute necrotic collection—heterogeneous collection of fluid and necrosis; intrapancreatic and/or extrapancreatic
Walled-off necrosis—heterogeneous collection of fluid and necrosis with well-defined wall; intrapancreatic and/or extrapancreatic; seen >4 weeks from symptom onset

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List 10 ddx of acute appendicitis

Abdominal Disorders
Peptic ulcer disease Gastritis
Gastroenteritis Cholelithiasis
Cholecystitis Choledocholithiasis Cholangitis
Nephrolithiasis
Bowel obstruction Perforated viscus Mesenteric ischemia Abdominal aortic aneurysm Ectopic pregnancy

Cardiopulmonary Disorders
Myocardial infarction Pneumonia Pericarditis
Pleural effusion

Systemic Disorders
Sickle cell crisis Diabetic ketoacidosis

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What are the three criteria for acute pancreatitis diagnosis?

(1) abdominal pain characteristic of acute pancreatitis,
(2) serum lipase or amylase levels greater than three times the upper limit of normal
(3) characteristic findings seen on abdominal imaging.

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Name 5 things other than acute pancreatitis that can raise the amylase?

renal failure, salivary gland disease, liver disease, appendicitis, cholecystitis, intestinal obstruction, intestinal ischemia, peptic ulcer disease, and gynecologic diseases.

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When should you order a CT in acute pancreatitis?

(1) in cases of diagnostic uncertainty (e.g., atypical abdominal pain) or normal pancreatic enzyme levels in the setting of high clinical suspicion;
(2) to rule out other suspected intra-abdominal pathology (e.g., bowel obstruction or aortic aneurysm)
(3) to assess for complications in patients who fail to respond to appropriate therapy after at least 48 to 72 hours.

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Definition of mild acute pancreatitis based on revised 2012 Atlanta Classification of Acute Pancreatitis

No organ failure
No local or systemic complications

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Definition of mod severe acute pancreatitis based on revised 2012 Atlanta Classification of Acute Pancreatitis

transient organ failure <48h
local or systemic complications

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Definition of severe acute pancreatitis based on revised 2012 Atlanta Classification of Acute Pancreatitis

persistent organ failure >48h
local complications: acute peripancreatic fluid collection, pancreatic
pseudocyst, acute necrotic collection, walled-off necrosis

Systemic complications—exacerbation of a preexisting comorbidity
Organ failure—defined as a modified Marshall score of 2 or more for the
respiratory, cardiovascular, or renal system.

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What is the Acute physiology and chronic health evaluation II score?

15 variables designed for use in the intensive care unit (ICU) to predict mortality

What is included in the BISAP score for pancreatitis?

bun
impaired mental status
sirs
age
pleural effusions

Treatment of acute pancreatitis

fluid resus 5-10ml/kg/hour based on getting HR <120, MAP 65-85, urine output >0.5-1ml/kg/h

Ranson criteria at admission: contains?

Age > 55 years
WBC > 16,000/mm3
Glucose > 200 mg/dL
AST > 250 IU/L
LDH > 350 IU/L

Ranson criteria at admission if biliary cause includes

Age > 70 years WBC > 18,000/mm3 Glucose > 220 mg/dL AST > 250 IU/L LDH > 400 IU/L

Ranson score at 48h includes (nonbiliary vs biliary cause)

Hematocrit drop > 10% BUN rise > 5 mg/dL Calcium < 8 mg/dL PaO2 < 60 mm Hg Base deficit > 4 mEq/L Fluid needs > 6 L vs biliary cause Hematocrit drop > 10% BUN rise > 2 mg/dL Calcium < 8 mg/dL Base deficit > 5 mEq/L Fluid needs > 4 L

List 10 APACHE II variables

Age Temperature Mean Arterial Pressure Heart Rate Respiratory Rate PaO2 pH or HCO3 Serum sodium Serum potassium Serum creatinine Hematocrit WBC count Glasgow Coma Scale Chronic health problems: * Cirrhosis of the liver confirmed by biopsy * New York Heart Association Class IV * Severe COPD * Hypercapnia, home O2 use, or pulmonary hypertension * On regular dialysis * Immunocompromised

Acute pancreatitis scoring sytem: compute tomography severity index (CTSI): includes?

Pancreatic inflammation 0: normal pancreas 2: intrinsic pancreatic abnormalities ± inflammatory changes in peripancreatic fat 4: pancreatic or peripancreatic fluid collection or peripancreatic fat necrosis Pancreatic necrosis 0: none 2: 30% or less 4: more than 30% Extrapancreatic complications 2: one or more of pleural effusion, ascites, vascular complications, parenchymal complications and/or gastrointestinal involvement

Why is Ca often low in pancreatitis?

low albumin

when does ca need to be replaced in acute pancreatiits?

ionized calcium level is low, in cases of QT prolongation or cardiac dysrhythmias, or when neuromuscular effects of hypocalcemia, such as Chvostek or Trous- seau sign, are present. ****When concurrent hypomagnesemia is present, magnesium repletion should be done prior to correction of hypocal- cemia.

Who gets abx in pancreatitis?

toxic appearing pt infected necrotizing pancreatitis extrapancreatic infections - cholangitis, pneumonia, bacteremia

What abx would be used in necrotic pancreatititis?

In cases of known infected pancreatic necrosis, the chosen antibiotic regimen should penetrate pancreatic tissue and cover gram- negative and gram-positive bacteria as well as anaerobes; carbapenems (meropenem 1 g, ertapenem 1 g, or imipenem-cilastin 500 mg) and quinolones with metronidazole (ciprofloxacin 400 mg with metronida- zole 500 mg)

Who needs at early ERCP?

cholangitis or bile duct obstruction within 24-48h

who gets a perc transhepatic gallbladder drainage tube?

unstable patients with cholangitis or bile duct obstruction

If there is a dilated biliary tree on CT, without evidence of cholangitis or clear biliary obstruction (jaundice, hyperbili, signs of sepis), what test is recommended?

MRCP or EUS is preferred over ERCP because ERCP is a more invasive study and can itself trigger pancreatitis. No benefit of ERCP has been shown in patients with nonobstructive causes of pan- creatitis regardless of severity.

When do infected/symptomatic necrotizing pancreatitis patients get surgery/endoscopy/radiologic intervention?

after 3 to 4 weeks to allow better demarcation of the viable pancreatic tissue and area of necrosis.

What is the defn of chronic pancreatits?

rogressive fibroinflammatory syndrome of the exocrine pancreas. It is thought that pancreatitis is a continuum which is initiated with the inflammation of acute pancreatitis and pro- gresses to chronic pancreatitis by repeated pancreatic injury due to recurrent episodes of acute pancreatitis

What is the mneumonic often used to describe chronic pancreatitis causes?

"TIGAR- O" toxic-metabolic idiopathic genetic autosomal recessive/modifier genes autoimune recurrent and severe acute pancreatitis obstructive

Name 4 causes of chronic pancreatitis - toxic metabolic category

etoh tobacco hyperca hypertrig ckd meds

Name 3 causes of chronic pancreatitis - idiopathic category

tropical chronic pancreatitis early onset late onset

Name 2 causes of chronic pancreatitis - genetic category

auto dom: hereditary pancreatitis PRSS1 mutations

Name 4 causes of chronic pancreatitis - auto rececessive, modifier genes category

GFTR muyt SPINK1 mut CTRC mut other

Name 1 cause of chronic pancreatitis - autoimm category

type I IgG4related and type 2

Name 2 causes of chronic pancreatitis - recurrent and severe acute pancreatitis

postnecrotic (after severe nec) vascular disease/ischemia

Name 4 causes of chronic pancreatitis - obstructive cateogry

Pancreas divisum Sphincter of Oddi disorders Malignant pancreatic duct obstruction Posttraumatic pancreatic duct scars and strictures

What is the best way to define chronic pancreatitis?

ct - intraductal pancreatic calcifications, pancr enlargment, dilated pancreatic ducts, atrophy, biliary duct dilatation, fluid collections, changes in panpancreatic fat

Pancreatic ca: survival

median survival of patients with locally advanced disease is 6 to 9 months and only 3 months for those with metastatic progression.

Pancreatic ca RF

disease include tobacco use, alcohol abuse, obesity, type 2 diabetes mellitus, chronic pancreatitis, and a family history of pancreatic cancer

MC type pancreatic ca

adenocarcinoma neuroendocrine tumor - gastrinoma (ZE syndrome), insulinomas, glucagonomas

Name 4 complications of pancreatic ca

GIB bowel obstruction acute cholangitis venous thrombosis

Surgical management of pancreatic head tumor

partial pancreaticoduodenectomy (also known as the Whipple proce- dure) with or without partial resection of the distal stomach