Acute pancreatitis continued

Question 1

most important part of tx for pancreatitis

Answer 1

fluid and electrolyte replacement. volume depletion seen frequently as “third spacing.” exacerbates pancreatic ischemia and may worsen pancreatitis.

Question 2

tx of metabolic abnormalities seen in acute pancreatitis

Answer 2

hyperglycemia: seen frequently; usually considered ok because their bodies have fewer glycongen stores so it can’t respond properly to hypoglycemia. hyperglycemia usually transient and gets better with improvement of pancreatitis.
Low calcium: bad under 7.5 mg/dl; poor prognostic indicator. may be due to sequestration of aclcium by free fatty acids in fat necrosis or in circulating free fatty acids. May also be due to administration of low calcium fluids: calcium gets diluted. Replace slowly
hyperlipidemia: don’t treat this until the acute pancreatitis has cleared

Question 3

nutritional support in acute pancreatitis

Answer 3

controversial. initially put pts NPO. then give TPN if pt has had no food for 7-10 days. monitor Ca2+ and trigylceride levels

Question 4

Role of NG suction in acute pancreatitis

Answer 4

good for pts with severe pancreatitis/ileus that ma be preventing the food from moving through the intestines, or in pts with persistent vomiting. Doesn’t alter the course of the disease.

Question 5

Role of abx in pts with pancreatitis

Answer 5

prophylactic abx decr. infection in cases of necrotic pancreatitis

Question 6

ERCP in acute pancreatitis

Answer 6

good for gallstone pancreatitis
urgent ERCP recommended in pts with jaundice and prediced severe pancreatitis and no improvement in the first 12-24 hrs
elective ERCP good for ppl with ultrasound-confirmed bile duct stone or persistent jaundice. Also good for ppl with dilated duct on ultrasound or elevated pre-operative serum liver tests.

Question 7

complications of pancreatitis

Answer 7

fluid collections, pseudocysts, ascites, pancreatic necrosis, GI bleeds, pancreatic infection, pleural effusion, pleuropancreatitc fistula

Question 8

general thoughts on fluid collections in pancreatitis

Answer 8

common, and not necessarily worrisome. Infection seen in 2-4%, eps. if the pt also has pancreatic necrosis. On CT, fluid may seem simple or complex. Unless there is an expanding fluid collection or a known infection, just observe.

Question 9

Psuedocysts: definition and complications

Answer 9

localized fluid collection that presents 4 wks after the onset of disease. collections aren’t lined by epithelium.
complications: pain, obstruction, infection, erosion, bleeding, rupture, pseudoaneurysm (erosion into a artery that may present as pain or GI bleeding).

Question 10

Pseudocyst: dx and tx

Answer 10

Dx: CT
if asymptomatic, observe for 6-12 mo
If still not gone, you may either drain it or continue to followit.
If symptomatic, rapidly enlarging, or causing a complication, drain. (I think endoscopic drainage is best?)

Question 11

Ascites: definiction and dx

Answer 11

communication btw duct or pseudocyst and the peritoneal cavity. causes pancreatic fluid in the abdomen.

Question 12

pancreatic ascites: tx

Answer 12

endoscopically placed stents, continuous infusion of somatostatin, surgical drainage/resection

Question 13

pancreatic necrosis

Answer 13

if greater than 50%, very very poor prognosis. give antibiotic prophylaxis in pts with severe pancreatitis and extensive necrosis. visualized with CT scan with IV contrast.consider cefuroxime and imipenem

Question 14

How might GI bleeds arise from acute pancreatitis?

Answer 14

pseudoaneurysm or pseudocyst erosion into a hollow viscus

Question 15

pancreatic infection: early. definition, tx, clinical presentation

Answer 15

may be early or late. early infection occurs 1-2 wks post devo of acute pancreatitis. high likelihood of sepsis. sx: incr. abdominal tenderness, high fever, leukocytosis, and bacteremia. requires prompt debridement.

Question 16

pancreatic infection: late. definitin, tx, clinical presentation

Answer 16

ate infection: may not occur for months. infectious spread limited d/t fibrosis. abdominal pain with sepsis but no evidence of acute pancreatitis. look with CT and do CT guided aspirations. Gram stain the contents. usually polymicrobial w/ poor prognosis, though monomicrobial infections are easier to treat. polymicrobial needs surgery; monomicrobial can be treated with percutaneous catheters.