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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
Collection containing variable amounts of both fluid and necrosis associated with necrotizing pancreatitis
Acute necrotic collection (ANC)
26
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
Walled- off necrosis (WON)
27
Phases of acute pancreatitis
Early < 2weeks | Late > 2weeks
28
In early acute pancreatitis what is expected
Most exhibit SIRS and are predisposed to organ failure
29
What organs should be assessed to define organ failure in early pancreatitis
3 organs : respiratory, cardiovascular, renal
30
Most important clinical finding with regard to severity of acute pancreatitis episode
Persistent organ failure > 48 hours
31
Late acute pancreatitis is characterized by a protracted course of illness and may require ___ to evaluate for local complications
Imaging
32
Supportive measures for late acute pancreatitis
Dialysis Ventilator support TPN
33
What is mild acute pancreatitis
Without local complications or organ failure | Self-limited disease and subsides within 3-7 days after tx is instituted
34
What characterizes moderately severe acute pancreatitis
Transient organ failure (resolves < 48 hours) or | Local or systemic complications in the absence of persistent organ failure
35
What characterizes severe acute pancreatitis
Persistent organ failure > 48 hours
36
When can oral intake be resumed in mild acute pancreatitis patients
If patient is hungry Normal bowel function No nausea or vomiting
37
What diagnostic modality is employed for severe acute pancreatitis
CT scan or MRI- to assess for necrosis and or complications
38
2 types of pancreatitis are recognized on imaging
Interstitial | Necrotizing
39
CT imaging in acute pancreatitis is best evaluated when
3-5 days into hospitalization when patients are not responding to supportive care to look for local complications such as necrosis
40
When will perfusion defects after IV contrast may not appear until
48-72 hours after onset of acute pancreatitis
41
Diagnostics employed in acute pancreatitis.
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
amylase returns to normal after
3-7 days
43
differentials for elevated amylase
``` macroamylasemia papillarycystadenocarcinoma of the ovary benign ovarian cyst carcinoma of the lung intestinal infarction perforated viscus ```
44
more specific test for acute pancreatitis a. amylase b. lipase
b. lipase
45
lipase is elevated when
for 7 - 14 days
46
diagnostic that is predictive of necrotizing pancreatitis
hemoconcentration with HCT value of >44% | and failure to decrease in 24 hours from admission
47
what causes azotemia in acute pancreatitis
due to loss of plasma into the retroperitoneal space and peritoneal cavity
48
what causes hyperglycemia in acute pancreatitis
due to decreased insulin release increased glucagon release increased output of adrenal glucocorticoids and cathecholamines
49
what causes hypocalcemia in acute pancreatitis ?
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
Hyperbilirubinemia, serum ALP and AST levels are transiently elevated in Acute pancreatitis particularly in
acute biliary obstruction from choledocholithiasis
51
which diagnostic tests for acute pancreatitis are associated with gallstone pancreatitis
hyperbilirubinemia, elevated serum ALP and AST levels, ALT conc 3 fold elevation
52
what is indicated by elevated serum LDH levels in acute pancreatitis
poor prognosis
53
hypertriglyceridemia >1000 mg/dL secondary to acute pancreatitis is also increased with concomitant
alcohol use | uncontrolled diabetes
54
this elevated diagnostic serum chemistry may precipitate attacks of acute pancreatitis
hypertriglyceridemia
55
helpful in indicating the severity of acute pancreatitis and the risk of morbidity and mortality
abdominal CT scan
56
aids in evaluating for complications of acute pancreatitis
abdominal CT scan
57
useful in acute pancreatitis to evaluate the gallbladder if gallstone disease is suspected
sonography
58
risk factors for severity of acute pancreatitis
age >60 years old Obesity, BMI >30 Comorbid disease ( Charlson comorbidity index)
59
markers of severity on admission or within 24 hours of acute pancreatitis
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
Markers of severity of acute pancreatitis during hospitalization
persistent organ failure > 48 hours | pancreatic necrosis `
61
is acute pancreatitis self limited?
Usually self-limited
62
when does acute pancreatitis resolve after treatment
3-7 days after tx
63
conventional measures for acute pancreatitis
analgesics for pain no oral alimentation oxygen via nasal canula
64
the most important intervention for acute pancreatitis
safe and aggressive IV fluid resuscitation
65
how to do fluid resuscitation for acute pancreatitis
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
how to monitor adequacy of fluid resuscitation for acute pancreatitis
measure Hct and BUN every 8-12 hours and serum electrolytes daily to ensure adequacy of fluid resuscitation
67
does antibiotics have a role in interstitial or necrotizing pancreatitis
None
68
role of CT scan in acute pancreatitis
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
when is ERCP indicated for management of acute pancreatitis
for SEVERE ACUTE BILIARY PANCREATITIS with | ORGAN FAILURE and or cholangitis within 24-72 hours
70
when is resumption of diet allowed in acute pancreatitis
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
when is parenteral nutrition advised for acute pancreatitis
unless the enteral route is NOT tolerated, NOT available, or NOT meeting caloric requirements
72
what is indicated if the conventional measures for management for acute pancreatitis if no improvement in 7-28 days
FNA (fine needle aspiration) of pancreas for culture
73
role of surgery in acute pancreatitis
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
local complications of acute pancreatitis
necrosis (sterile or infected) Pancreatic fluid collections (Pseudocyst and abscess) Pancreatic ascites Obstructive jaundice Bowel compression or fistulization (usually to the left colon)
75
which part of bowel is most probably affected (bowel compression or fistulization) by acute pancreatitis
usually to the left colon
76
systemic complications of acute pancreatitis
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)

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