Abdominal Pain and Pancreatic Disease (Darrow) Flashcards
A 62 year old morbidly obese diabetic female presents with acute epigastric pain and mental confusion. She takes thiazides for hypertension. Pulse is 110 bpm with respirations of 30. She drinks alcohol occasionally. Result of ultrasound are equivocal related to the obesity. Serum triglycerides are 600 mg/dL. Amylase is 1500 U/dL (50-150) with lipase of 1200 U/L (10-140). WBC is 19,000 with elevated LDH and AST. ALT is 175 IU/L (8-32). Glucose is 350 mg/dL. BUN is 25 mg/dL with creatinine of 1.8 mg/dL. Most likely cause of pancreatitis in this patient would be:
CMV. autoimmune. lipids. thiazide. alcohol. gallstones. pancreas divisum. obesity.
The next day the BUN has increased from 25 to 35 mg/dL, the C-RP is 250 mg/dL*, creatinine is 2.2 mg/dL, and the hemoglobin has dropped from 12 to 8 grams. The abdomen is shown. The patient now has:
A. heparin induced thrombocytopenia B. Cullen’s and Grey Turner’s sign (may be erythema only) C. paniculitis D. ruptured aortic aneurysm E. Nikolsky’s sign
What facts and markers of this case point to a poor prognosis?
obesity adds a large complication to pancreatitis and also produces hypoxia by limiting respiration (BMI >30 = poor prognosis)
The patient now has B. Cullen’s and Grey Turner’s sign (may be erythema only)
What facts and markers of this case point to a poor prognosis?
If you have to pick one test to follow pancreatitis –> BUN- if this keeps increasing then you have a problem
patients are hemoconcentrated when they come in
What is the definition of acute Pancreatitis?
need 2 of 3 criteria
Characteristic Abdominal pain- epigastric going to the back, relieved my maintaing a supine position or leaning forward and not moving
Amylase or lipase > 3 times normal
Characteristic findings on CT
What is the significance of obesity in pancreatic disease?
Central obesity is a metabolically active organ associated with Barret’s epithelium, adenocarcinoma of the esophagus and, especially in diabetics, pancreatic cancer.
Obesity also makes acute pancreatitis worse by causing local circulatory changes in peripancreatic fat and produces hypoxia by limiting respiration.
So BMI > 30 kg/m2 = poor prognosis
What else can elevate the amylase?
Amylase: Bowel problems (obstruction, perforation or infarction)
Ectopic production Lung, fallopian tube and salivary gland secretion(mumps) Macroamylasemia (low urinary amylase b/c its too big to get through the kidneys) (normal serum lipase) Renal insufficiency Trauma (ERCP)
what are the labs used to diagnose acute pancreatitis
lipase- this is the best to use!
amylase
ALT
urine for trypsinogen activation peptide (TAP)
What causes acute pancreatitis?
Obesity
Obstructive cause- gallstones
Drugs and toxins- alcohol (raises AST >ALT) , sulfa drugs, tetracycline, metronidazole
Metabolic - hyperlipidemia, hypercalcemia
Infectious- EBV, CMV, MAC mumps
Genetic
- hereditary pancreatitis (PRSS1) (SPINK1)
- CF
Vascular- shock
Autoimmune - IgG4***, PSC, ANA, Celiac
what is the PRSS1 gene pancreatitis pathophysiology
Activating mutations in PRSS1 or inactivating mutations in CASR may result in elevated trypsin levels, and ethanol may act as a trigger to pancreatitis by elevating calcium levels.
The cystic fibrosis transmembrane conductance regulator (encoded by the gene CFTR) eliminates trypsin
by flushing the pancreatic duct. Inflammation caused by excess trypsin leads to up-regulation of the serine protease inhibitor Kazal type 1
(encoded by the gene SPINK1), which blocks trypsin, prevents further activation of trypsinogen, and limits further tissue injury
see slide 8
increased calcium drives the system- leading to pancreatitis
Ranson Criteria
what is a bad criteria
(score of 3 or more = bad!) and predicts a severe course complicated by pancreatic necrosis
At admission - Age (over 55) WBC (>16x10^3) Glucose (>200) LDH (>350) AST (>250)
At 48 hours, development of other findings indicates a worsening prognosis
- BUN >5 (among other things)
- arterial PO2 <60
APACHE II
- (score of 8 or more = bad!) used to access severity;
Rectal temp, mean arterial pressure, HR, RR, FiO2, arterial pH, Na, K, Cr, Hct, WBC.
Score of 8 = necrosis.
BISAP***
BUN > 25 mg/dL
Impaired mental status *disorientation, lethargy, somnolence, coma or stupor
> 2 SIRS criteria- how do we know a pt has this? Pulse is over 110, resp over 30, WBC 19,000
Age > 60
Pleural effusion present or not
score of 3 or more = bad sign. (Obesity should also be considered as a point - BISOAP.)
Dr. darrow likes this one
it is a criteria used for pancreatitis
CRP in pancreatitis
Other markers
C-reactive protein (at 48 hrs) > 150 mg/dL – marker for pancreatic necrosis. (PMN elastase peaks at day 1).
Creatinine in pancreatitis
Creatinine > 1.8 mg/dL at 48 hours – marker for necrosis.
hematocrit in pancreatitis
Hemacrit > 44% at admission and 24 hours – necrosis.
HAPS score
the Harmless Acute Pancreatitis Score score
absence of rebound tenderness
normal hemacrit
normal creatinine
*** predicts a nonsevere course.
calcium in pancreatitis
Calcium - decreased with albumin extravasation or saponification.
hypercalcemia CAUSES pancreatitis
AMYLASE - what does this stand for in terms of clinical presentation of acute pancreatitis
Acute abdominal pain to the back
Mid-abdominal staining (Cullen’s and Grey Turner signs)
Yellow (jaundice –stones or cancer)
Lipase, Left sided pleural effusion or atelectasis (left side b/c the pancreas is on the left)
Amylase (>1000) (poor test compared to lipase)
Sentinel loop and colon cut off signs
Emesis and nausea
what needs to be done by the 4th day of acute pancreatitis
CT!
On the 4th day, after adequate hydration, CT scan reports gallstones in the GB along with pancreatic necrosis
wait to do CT by 3rd or 4th day (at least in a mild case)
*The first test for suspected gall stone pancreatitis should be US