Acute Pancreatitis Flashcards
What does the pancreas do?
- neutralizes acidic chyme (secretes 1.5-3L of alkaline fluid daily
- digestion of proteins (trypsin, chymotrypsin) and fats (amylase, lipase)
How does the pancreas manage glucose levels?
releases insulin when blood glucose is too high;
releases glucagon when blood glucose is too low
How does the pancreas manage hormones?
- secretin stimulates ductal cells to secrete bicarb-rich fluid
- cholecystokinin (CCK) stimulates acinar cells to secrete digestive enzymes
What type of neural control does the pancreas have?
autonomic innervation (parasympathetic and sympathetic nerve fibers)
What enzymes are increased with inflammation and have a non-specific pathology?
Amylase
Lipase
Why is an x-ray the initial test for acute pancreatitis?
pancreas looks abnormal in acute and chronic pancreatitis
What can an ultrasound of the pancreas show?
- edema
- inflammation
- calcification
- masses
What can a CT scan with contrast show?
visualizes necrosis and fluid collections
What can an MRCP show?
3-D view of necrosis and fluid collections
(best imaging)
What is the difference between acute and chronic pancreatitis?
acute- inflammation
chronic- fibrosis
What is the cause of acute pancreatitis?
- autodigestion (unregulated activation of trypsin)
- inflammation (activated complement and kinin pathways)
What is the most common cause of acute pancreatitis?
Obstruction
1. Gallstones
2. duodenal obstruction
3. chron’s
What toxins can cause acute pancreatitis?
- alcohol
- medications
- scorpion bite
Why does obstruction cause pancreatitis?
increased ductal pressure leads to the activation of pancreatic enzymes
What antibiotic can cause biliary sludging?
Ceftriaxone
What is the number 1 cause of toxic pancreatitis?
alcohol
What drugs can induce acute pancreatitis?
- statins (rosuvastatin)
- ACE (-)
- oral contraceptives
- Diuretics (loop)
- HIV HAART therapy
- Valproic acid
What are other causes of acute pancreatitis?
- infections
- triglyceridemia >500
- autoimmune
- pregnancy
How does pain present in acute pancreatitis?
constant in the epigastric area and right upper quadrant; can radiate to the back; lasts days
What are the symptoms of acute pancreatitis?
nausea
emesis
fever
tachycardia
leukocytosis
hypocalcemia
hyperglycemia
What is a bruise that shows pancreatic necrosis into the retroperitoneum?
cullen’s sign
What is required for diagnosis?
2/3 required:
1. abdominal pain
2. 3x elevation in serum amylase/ lipase
3. CT scan showing inflammation
When should treatment of infection begin?
If CT scan shows “walled off area”/ puss pocket near necrotic tissue
How is mild acute pancreatitis classified?
- organ failure absent
- local and systemic complications absent
- Hct > 44%
How is moderate acute pancreatitis classified?
- organ failure transient <48 h
- local/ systemic symptoms present
- BUN >22
How is severe acute pancreatitis classified?
- organ failure persistent >48h
- local/systemic symptoms present
- signs of organ failure (BP <90, HR >130, SCr 1.5x baseline)
How are mild and moderate acute pancreatitis managed?
- fluid resuscitation
- NPO until tolerated
- pain management
- anti-emetic therapies
How is severe acute pancreatitis managed?
- fluid resuscitation
- enteral feeding
- management of necrosis
What agent is preferred for fluid resuscitation?
Lactated ringers or normal saline 5-10 ml/kg/hr
What is the goal of fluid resuscitation?
reduce HR <120
What agents are initially used for pain management?
opioids + stimulant laxatives
What issues can occur when a patient is NPO?
- increased intestinal mucosal atrophy
- infectious complications due to bacterial translocation in the gut
How long will someone with severe acute pancreatitis get nutrition through nasoenteric feeding?
24-48 hours
How long should nutrition be withheld in mild pancreatitis?
within 48 hours until patient can tolerate oral intake; restart gradually
Is antibiotic prophylaxis recommended to prevent infectious pancreatitis?
No
What bacteria are potential causes of infection?
GM-: E.coli, Kleb, pneumonia, pseudamonis. proteus mirabilis
GM+: enterococcus, streptococcus
What is the empiric treatment for pancreatic infection?
Imipenem or Meropenem for 14 days
How are future flares prevented?
- avoid alcohol
- maintain triglyceride level
- change to medications with less incidence of pancreatitis
- avoid trigger foods
