Acute and chronic pancreatitis

Question 1

Overview of pancreatitis

Answer 1

• Chain reaction of digestive nz activation, due to premature trypsin activation in acing cells
• Both intrapancreatic and extra pancreatic inflammation
• Intrapancreatic: fluid collection and abscess formation
• Extrapancreatic: SIRS (systemic inflammatory response syndrome), ARDS, DIC

Question 2

Diagnosis criterion of pancreatitis

Answer 2

• Requires 2 out of the 3
• Epigastric pain radiating to back (DDx: biliary colic, ulcer, dissecting aortic aneurysm, inferior MI, bowel obstruction)
• Amylase (elevates earlier) and lipase (more specific) ≥3x ULN
• Characteristic imaging: edema in pancreas, heterogenous parenchyma, peripancreatic fluid collection

Question 3

Severe vs mild pancreatitis

Answer 3

• Mild much more common, usually no complications
• Severe can lead to necrosis, local and systemic inflammatory responses
• Cytokine storm (IL1, TNFa) may occur
• Persistent elevation of amylase and lipase can lead to pseudocyst, abscess, duct obstruction (severe)

Question 4

Etiology of acute pancreatitis 1

Answer 4

• 80% of cases are either gallstones or etoh
• Other causes: very high TAGs (>1000), autoimmune pancreatitis (IgG4 high, responds to steroids), hypercalcemia (high Ca leads to auto activation of trypsin), genetic mutations (PRSS1, CFTR), drugs via direct effect (valproic acid) or hypertriglyceridemia (thiazides, vit A, estrogen)

Question 5

Etiology of acute pancreatitis 2

Answer 5

• Structural: pancreas divisum (failed fusion of ventral and dorsal pancreas, small duct not large enough to drain pancreas)
• Malignancy (if >50): ampullary, pancreatic, IPMN (inarticulate papillary mutinous tumor)
• Trauma, idiopathic
• Rarer causes: mumps, scorpion sting, ascaris parasitic worm
• ERCP: scope up ampulla of vater

Question 6

I GET SMASHED

Answer 6

• Idiopathic
• Gallstones
• ETOH
• Trauma
• Steroids/structural
• Malignancy/mumps (infections)/mutations
• Autoimmune
• Scropion/spider
• Hyperlipidemia/hypercalcemia/hypothermia
• ERCP
• Drugs (azathioprine, valproic acid, thiazides)

Question 7

Workup

Answer 7

• H&P
• Labs: amylase/lipase, LFTs, TAGs, Ca, IgG4
• Ultrasound for gallstones, CT for malignancy if >50

Question 8

Staging: ranson’s criterion

Answer 8

• If pt is positive for >3 criterion @admission it’s severe pancreatitis
• GA LAW @admission
• Glucose > 200
• Age >55
• LDH >350
• AST >250
• WBC >16k
• C HOBBS @48hrs
• Ca low
• Hematocrit
• O2
• BUN
• Base deficit
• sequestration of fluid

Question 9

Rx of acute pancreatitis

Answer 9

• Fluids: aggressive hydration
• Antibios only in severe acute
• Nutrition thru gut better than IV

Question 10

Complications of acute pancreatitis

Answer 10

• Systemic: ARDS, cytokine storm and organ failure, DIC, hypoCa
• Local: pancreatic pseudocyst, pancreatic necrosis
• Pseudocyst: peri-pancreatic juice surrounded by non-epithelialized wall (granulation and fibrous tissue), can lead to abscess when infected
• Pseudocyst must be drained if symptomatic or infected
• Progression to chronic pancreatitis

Question 11

Chronic pancreatitis

Answer 11

• Duct fibrosis due to recurrent or severe pancreas injury
• Exocrine dysfunction can lead to malabsorption (fat first)
• Dx via fecal fat measurement, fecal pancreatic elastase
• Endocrine dysfunction can lead to diabetes
• Requires most of pancreas to be destroyed
• Dx w/ imaging: dilation of pancreatic ducts, pancreatic stones/calcification, gland atrophy
• Do not use amylase/lipase levels

Question 12

Chronic pancreatitis Rx

Answer 12

• Diet low in fat, pancreatic nz replacement, insulin if necessary (but glucagon production also limited, more susceptible to hypoglycemia)
• Pain management: analgesics, small duct pain responds to uncoated pancreatic nz (inhibits CCK releasing hormone, thus rests pancreas), large duct pain responds to decompression