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ACUTE PANCREATITIS Flashcards

1
Q

Inflammation of the pancreas due to activation of enzymes within the pancreas

A

Acute pancreatitis

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2
Q

Pathologic spectrum of acute pancreatitis

A

Interstitial pancreatitis

Necrotizing pancreatitis

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3
Q

Difference between interstitial pancreatitis and necrotizing pancreatitis

A

Interstitial - mild and self limited disorder

Necrotizing pancreatitis - more severe form

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4
Q

Currently accepted pathogenic theory of acute pancreatitis

A 
Autodigestion
Proteolytic ernzymes ( trypsinogen,chymotrypsinogen, proelastase) are activated in the pancreas rather than in the intestinal lumen
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5
Q

Common etiologies of pancreatitis

A

GATED
Gallstones - most common cause
Alcohol- second most common cause
Hypertriglyceridemia (usually with serum triglycerides >1000 mg/dL)
Endoscopic retrograde cholangiopancreatography
Drugs

Trauma
Postoperative
Sphincter of Oddi dysfunction

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6
Q

For recurrent attacks of acute pancreatitis the 2 most common cause are

A

Alcohol and cholelithiasis

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7
Q

Symptoms of acute pancreatitis

A

Abdominal pain
Nausea
Vomiting
Abdominal distention

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8
Q

Character of abdominal pain in acute pancreatitis

A

Quality: steady and boring in character
Location: epigastrium and periumbilical region
Radiation: back, chest, flanks,lower abdomen
Effects of position changes: more intense when supine, relieved upon sitting with the trunk flexed and knees drawn up

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9
Q

General PE of acute pancreatitis

A

Distressed and anxious patient
Low grade fever
Tachycardia
Hypotension

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10
Q

What causes shock in patients with acute pancreatitis

A

Hypovolemia secondary to exudation of blood and plasma proteins into the retroperitoneum
Systemic effects of proteolytic and lipolytic enzymes released into the circulation

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11
Q

What causes disorientation, hallucination, agitation and coma in acute pancreatitis patients

A 
Alcohol withdrawal
Hypotension/ shock
Electrolyte imbalance ( hyponatremia)
Hypoxemia
Fever
Toxic effects of pancreatic enzymes to CNS
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12
Q

Abdominal PE of patient with acute pancreatitis

A

Compared with the intense abdominal pain, there may be unimpressive abdominal tenderness.
Guarding - more marked in the upper abdomen
Decreased or absent bowel sounds

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13
Q

What causes jaundice (although infrequent) in patients with acute pancreatitis

A 
Due to edema of the pancreatic head with compression of the intrapancreatic portion of the CBD 
Possible choledocholithiasis  (gallstone pancreatitis)
Co-existenr liver disease
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14
Q

Pulmonary findings in acute pancreatitis

A

Bnasilar rales, atelectasis, pleural effusion (most frequently left sided) ARDS

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15
Q

Blue discoloration around the umbilicus (results from hemoperitoneum)

A

Cullen’s sign

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16
Q

Blue-red-purple or green-brown discoloration of the flanks reflecting tissue catabolism of hemoglobin

A

Turner’s sign

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17
Q

0.5- 2 cm tender red nodules that commonly appear over the distal extremities but may also occur over the scalp, trunk and buttocks

A

Panniculitis with subcutaneous fat necrosis

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18
Q

Panniculitis with subcutaneous fat necrosis may also be accompanied by

A

Polyarthritis (PPP syndrome) and

Thrombophlebitis in the legs

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19
Q

Morphologic features of acute pancreatitis (revised atlanta definitions)

A 
Intestitial pancreatitis 
Necrotizing pancreatitis
Acute pancreatic fluid collection
Pancreatic pseudocyst 
Acute necrotic collection
Walled- off necrosis (WON)
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20
Q

Acute inflammation of the pancreatic parenchyma and peripancreatic tissues
No recognizable tissue necrosis

A

Interstitial pancreatitis

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21
Q

Inflammation associated with parenchymal and or peripancreatic necrosis

A

Necrotizing pancreatitis

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22
Q

Peripancreatic fluid associated with intestitial edematous pancreatitis
No associated necrosis
Applies only to areas of fluid seen within the first 4 weeks after onset of interstitial edematous pancreatitis and without features of pseudocyst

A

Acute pancreatic fluid collection

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23
Q

Encapsulated collection of fluid with a well-defined inflammatory wall usually outside the pancreas with minimal or no necrosis

A

Pancreatic Pseudocyst

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24
Q

Pancreatic pseudocyst usually occurs

A

> 4 weeks after onset of interstitial edematous pancreatitis

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25
Q

Collection containing variable amounts of both fluid and necrosis associated with necrotizing pancreatitis

A

Acute necrotic collection (ANC)

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26
Q

Mature encapsulated collection of pancreatic and or peripancreatic necrosis that haas developed a well-defined inflammatory wall
Usually occurs after >4 weeks after onset of necrotizing pancreatitis

A

Walled- off necrosis (WON)

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27
Q

Phases of acute pancreatitis

A

Early < 2weeks

Late > 2weeks

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28
Q

In early acute pancreatitis what is expected

A

Most exhibit SIRS and are predisposed to organ failure

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29
Q

What organs should be assessed to define organ failure in early pancreatitis

A

3 organs : respiratory, cardiovascular, renal

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30
Q

Most important clinical finding with regard to severity of acute pancreatitis episode

A

Persistent organ failure > 48 hours

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31
Q

Late acute pancreatitis is characterized by a protracted course of illness and may require ___ to evaluate for local complications

A

Imaging

32
Q

Supportive measures for late acute pancreatitis

A

Dialysis
Ventilator support
TPN

33
Q

What is mild acute pancreatitis

A

Without local complications or organ failure

Self-limited disease and subsides within 3-7 days after tx is instituted

34
Q

What characterizes moderately severe acute pancreatitis

A

Transient organ failure (resolves < 48 hours) or

Local or systemic complications in the absence of persistent organ failure

35
Q

What characterizes severe acute pancreatitis

A

Persistent organ failure > 48 hours

36
Q

When can oral intake be resumed in mild acute pancreatitis patients

A

If patient is hungry
Normal bowel function
No nausea or vomiting

37
Q

What diagnostic modality is employed for severe acute pancreatitis

A

CT scan or MRI- to assess for necrosis and or complications

38
Q

2 types of pancreatitis are recognized on imaging

A

Interstitial

Necrotizing

39
Q

CT imaging in acute pancreatitis is best evaluated when

A

3-5 days into hospitalization when patients are not responding to supportive care to look for local complications such as necrosis

40
Q

When will perfusion defects after IV contrast may not appear until

A

48-72 hours after onset of acute pancreatitis

41
Q

Diagnostics employed in acute pancreatitis.

A

Amylase inc more than 3 fold
Lipase - inc more than 3 fold
CBC - leukocytosis (15000 -20000 - uL)
-hemoconcentration with hematocrit 44% and a failure to decrease levels in 24 hours from admission -predictors of necrotizing pancreatitis
Renal function - azotemia with BUN >22 mg /dL (associated with inc mortality) due to loss of plasma into retroperitoneal space and peritoneal cavity

serum chemistry -
hyperglycemia
hypocalcemia
hyperbilirubinemia
serum ALP and AST elevated - acute biliary obstruction
ALT conc 150 IU/L (3 fold elevation)- gallstone pancreatitis
Markedly elevated serum LDH levels - poor prognosis
Hypertriglyceridemia >1000 mg/dL

ABG - hypoxemia (aterial PO2 <60 mmHg)- herald onset of ARDS

Abdominal CT scan - indicating the severity of acute pancreatitis and risk of morbidity and mortality; evaluates for complications of acute pancreatitis

sonography- evaluate gallbladder if gallstone disease is suspected

42
Q

amylase returns to normal after

A

3-7 days

43
Q

differentials for elevated amylase

A 
macroamylasemia
papillarycystadenocarcinoma of the ovary
benign ovarian cyst
carcinoma of the lung
intestinal infarction
perforated viscus
44
Q

more specific test for acute pancreatitis

a. amylase
b. lipase

A

b. lipase

45
Q

lipase is elevated when

A

for 7 - 14 days

46
Q

diagnostic that is predictive of necrotizing pancreatitis

A

hemoconcentration with HCT value of >44%

and failure to decrease in 24 hours from admission

47
Q

what causes azotemia in acute pancreatitis

A

due to loss of plasma into the retroperitoneal space and peritoneal cavity

48
Q

what causes hyperglycemia in acute pancreatitis

A

due to decreased insulin release
increased glucagon release
increased output of adrenal glucocorticoids and cathecholamines

49
Q

what causes hypocalcemia in acute pancreatitis ?

A

due to decreased albumin (calcium is normally bound to albumin ) which is lost into the peritoneum as albumin-rich intravascular fluid that extravasates intro he peritoneum or retroperitoneum

50
Q

Hyperbilirubinemia, serum ALP and AST levels are transiently elevated in Acute pancreatitis particularly in

A

acute biliary obstruction from choledocholithiasis

51
Q

which diagnostic tests for acute pancreatitis are associated with gallstone pancreatitis

A

hyperbilirubinemia, elevated serum ALP and AST levels, ALT conc 3 fold elevation

52
Q

what is indicated by elevated serum LDH levels in acute pancreatitis

A

poor prognosis

53
Q

hypertriglyceridemia >1000 mg/dL secondary to acute pancreatitis is also increased with concomitant

A

alcohol use

uncontrolled diabetes

54
Q

this elevated diagnostic serum chemistry may precipitate attacks of acute pancreatitis

A

hypertriglyceridemia

55
Q

helpful in indicating the severity of acute pancreatitis and the risk of morbidity and mortality

A

abdominal CT scan

56
Q

aids in evaluating for complications of acute pancreatitis

A

abdominal CT scan

57
Q

useful in acute pancreatitis to evaluate the gallbladder if gallstone disease is suspected

A

sonography

58
Q

risk factors for severity of acute pancreatitis

A

age >60 years old
Obesity, BMI >30
Comorbid disease ( Charlson comorbidity index)

59
Q

markers of severity on admission or within 24 hours of acute pancreatitis

A

SIRS
APACHE II
hemoconcentration >44% Hct
Admission BUN >22 mg/dL

BISAP >/= 3 - inc risk of in-hospital mortality
BUN >25 mg/dL
Impaired mental status GCS <15
SIRS >/=2 of 4 present
Age >60 years old
pleural effusion

Organ failure - modified marshall score
Cardiovascular SBP <90 mmHg, HR 130 bpm
pulmonary PaO2 <60 mmHg
Renal: serum creatinine >2 mg/dL

60
Q

Markers of severity of acute pancreatitis during hospitalization

A

persistent organ failure > 48 hours

pancreatic necrosis `

61
Q

is acute pancreatitis self limited?

A

Usually self-limited

62
Q

when does acute pancreatitis resolve after treatment

A

3-7 days after tx

63
Q

conventional measures for acute pancreatitis

A

analgesics for pain
no oral alimentation
oxygen via nasal canula

64
Q

the most important intervention for acute pancreatitis

A

safe and aggressive IV fluid resuscitation

65
Q

how to do fluid resuscitation for acute pancreatitis

A

initial IVF - LR or PNSS 15-20 cc/kg bolus followed by 3 mg/kg /hr infusion to maintain urine output >0.5 cc/kg/hr

66
Q

how to monitor adequacy of fluid resuscitation for acute pancreatitis

A

measure Hct and BUN every 8-12 hours and serum electrolytes daily to ensure adequacy of fluid resuscitation

67
Q

does antibiotics have a role in interstitial or necrotizing pancreatitis

A

None

68
Q

role of CT scan in acute pancreatitis

A

to evaluate for necrosis and other local complications if the patient still exhibits evidence of severe disease and or organ failure > 72 hours despite adequate resuscitation

69
Q

when is ERCP indicated for management of acute pancreatitis

A

for SEVERE ACUTE BILIARY PANCREATITIS with

ORGAN FAILURE and or cholangitis within 24-72 hours

70
Q

when is resumption of diet allowed in acute pancreatitis

A

early refeeding -> improve outcome and allow early discharge

mild acute pancreatitis - oral feedings can be started immediately (low fat solid diet or clear liquids) - if there is NO NAUSEA & VOMITING, ABDOMINAL PAIN RESOLVED
severe acute pancreatitis - enteral nutrition- prevent infectious complications

71
Q

when is parenteral nutrition advised for acute pancreatitis

A

unless the enteral route is NOT tolerated, NOT available, or NOT meeting caloric requirements

72
Q

what is indicated if the conventional measures for management for acute pancreatitis if no improvement in 7-28 days

A

FNA (fine needle aspiration) of pancreas for culture

73
Q

role of surgery in acute pancreatitis

A

GALLSTONE PANCREATITIS - cholecystectomy should be done prior to discharge to prevent recurrence
ASYMPTOMATIC PSEUDOCYSTS and PANCREATIC and or EXTRAPANCREATIC NECROSIS - do not warrant intervention

74
Q

local complications of acute pancreatitis

A

necrosis (sterile or infected)
Pancreatic fluid collections (Pseudocyst and abscess)
Pancreatic ascites
Obstructive jaundice
Bowel compression or fistulization (usually to the left colon)

75
Q

which part of bowel is most probably affected (bowel compression or fistulization) by acute pancreatitis

A

usually to the left colon

76
Q

systemic complications of acute pancreatitis

A

pulmonary - ARDS, effusion, pneumonitis
cardiovascular - hypotension, sudden death
hematologic - DIC
gastrointestinal - ulcer formation, gastritis, mallory-weiss, rupture of splenic artery/ vein leading to gastric varices, hemosuccus pancreaticus (bleeding into pancreatic duct from pseudoaneurysm)
renal- oligura, azotemia, acute tubular necrosis
Metabolic - hyperglycemia, hypocalcemia
others: pancreatic encephalopathy (agitation, hallucination, confusion, disorientation, coma)
Putscher’s retinopathy (flame-shaped hemorrhages with cotton wool spots)

IM (25 decks)

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