Acute Pancreatitis B&B

Question 1

what kind of necrosis occurs in acute pancreatitis?

Answer 1

liquefactive necrosis + hemorrhage - rarely cause bleeding around umbilicus (Cullen’s sign) or flank (Grey Turner’s sign)

—> epigastric pain, radiates to back, N/V

Question 2

what are the 2 most common causes of acute pancreatitis?

Answer 2

gallstones (obstruct pancreatic duct) and alcohol

Question 3

what are 2 physical exam signs of acute pancreatitis?

Answer 3

though rare, periumbilical (Cullen’s sign) or flank (Grey Turner’s sign) hemorrhage may occur due to spread of liquefactive necrosis form enzyme-induced damage

[these signs are also seen in ruptured ectopic pregnancy]

Question 4

what pancreatic enzyme is particularly important in the pathology of acute pancreatitis?

Answer 4

trypsin - can activate more trypsin + phospholipase, chymotrypsin, elastase (all other protein enzymes)

this causes auto-digestion of pancreas by its own enzymes !

[all stems from blocked flow of enzymes while synthesis is ongoing]

Question 5

trypsin is secreted as inactive trypsinogen and activated at brush border by _____

Answer 5

trypsin is secreted as inactive trypsinogen and activated at brush border by enterokinase

Question 6

elevation of which pancreatic enzyme is more specific for acute pancreatitis than other conditions?

Answer 6

lipase - will be very high

other pancreatic enzymes will be increased as well (amylase), but these are not as specific

Question 7

what is the classic traumatic cause of acute pancreatitis?

Answer 7

children restrained by seatbelts

[but usually rare due to retroperitoneal location of pancreas]

Question 8

what is the classic infectious cause of acute pancreatitis? (although rare)

Answer 8

mumps

Question 9

which 3 classes of drugs may cause acute pancreatitis?

Answer 9

1. GLP-1 agonists - exenatide, liraglutide
2. sulfa drugs
3. 6-mercaptopurine (6-MP) - chemo drug

Question 10

what is the biochemical marker for autoimmune pancreatitis?

Answer 10

rare, causes chronic abdominal pain and recurrent attacks of acute pancreatitis + diffusely enlarged pancreas

labs show IgG4+ plasma cells and serum IgG4 levels are elevated

responds well to steroids

Question 11

IgG4 positive plasma cells =

Answer 11

autoimmune pancreatitis

Question 12

how can hypercalcemia cause acute pancreatitis?

Answer 12

calcium may deposit in pancreatic ducts and activate trypsinogen

trypsin then goes on to activate other pancreatic enzymes —> autodigestion of pancreatic tissue

Question 13

what is the mechanism by which hypertriglyceridemia causes acute pancreatitis?

Answer 13

high triglycerides (>1000) cause elevation in chylomicrons in plasma - these obstruct capillaries (ischemia) and get broken down to free fatty acids by exposed pancreatic lipase… FFA cause tissue injury and subsequent pancreatitis

Question 14

what are the 3 components of treatment for acute pancreatitis?

Answer 14

1. NPO - no food/liquid allows pancreas to “rest”
2. IV fluids - pancreatic edema causes fluid loss
3. pain control

most patients with mild disease improve in 2-3 days

Question 15

what are the 4 criteria of SIRS (KNOW THIS FOR ROUNDS)

Answer 15

SIRS = systemic inflammatory response syndrome; clinical syndrome of dysregulated inflammation

1. temperature <36C (hypothermia) or >38.3C (hyperthermia)
2. heart rate >90bpm
3. respiratory rate >20/min
4. WBC >12,000

Question 16

what is the clinical use of Ranson’s Criteria?

Answer 16

assesses severity of pancreatitis

considers at admission age, WBC, glucose, lactate, AST

considers at 48h HCT, BUN, Ca2+, pO2

Question 17

CXR looks like pulmonary edema but PCWP is normal =

Answer 17

ARDS (acute respiratory distress syndrome): damage to capillary endothelium and alveolar epithelium —> protein escapes from vascular space and fluid pours into interstitium

Question 18

what are the most common culprits of pancreatic abscess caused by infection of a pancreatic pseudocyst? (4)

Answer 18

1. E. coli

also Pseudomonas, Klebsiella, Enterococcus (intestinal bacteria)

presents as fever and failure to improve clinically ~10 days following acute pancreatitis

Question 19

how does pancreatic fat necrosis affect electrolyte levels? (2)

Answer 19

inflammation involving fat surrounding pancreas can cause release of FFA via lipases

FFA bind Ca2+/Mg2+ —> hypocalcemia, hypomagnesemia (“saponification”)