B5.065 - Big Case Pancreatitis

Question 1

atlanta symposium definition of acute pancreatitis

Answer 1

an acute inflammatory process of the pancreas with variable involvement of other regional tissues or remote organ systems

Question 2

acute pancreatitis criteria

Answer 2

2 of: 1.) sx like epigastric pain, consistent with the disease 2.) a serum amylase or lipase greater than 3x upper limit of normal 3.) radiologic imaging consistent w/ dx usually using CT or MRI

Question 3

epidemiology of pancreatitis

Answer 3

2-3% overall mortality more in fem, alcoholics

Question 4

signs and sx of pancreatitis

Answer 4

severe epigatric pain, radiating thru back nausea, emesis fatigue, malaise fever, chills

Question 5

less common signs of pancreatitis which suggest severe disease

Answer 5

grey turner sign: hemorrhagic discoloration of flanks cullens sign: hemorrhagic discoloration of umbilicus

Question 6

causes of pancreatitis

Answer 6

duct obstruction acinar cell injury defective intracellular transport all leading to activated enzymes

Question 7

clinical outcomes of pancreatitis

Answer 7

most (95%) have mild or no organ failure 5% have severe necrotizing organ failure

Question 8

lab tests for dx of disease in acute

Answer 8

1. serum amylase 2-3x normal 2. serum lipase high 7-14 d 3. serum trypsinogen elevated 4. urine amylase rises 5. serum glucose transient elev 6. serum bili and alk phos may be increasedw with compression of bild duct 7. hypocaclcemia

Question 9

lab tests for dx of disease in chronic

Answer 9

1. decreased trypsinogen 2. hypercalcemia in chronic

Question 10

radiologic diagnostic studies for pancreatitis

Answer 10

CT MRI/MRCP US Endoscopic US ERCP FNA

Question 11

what is ransons criteria

Answer 11

classification of disease severity

Question 12

what are ransons criteria at admission

Answer 12

1. age >55 2. WBC >16 3. glu >200 4. AST >250 5. LDH >350

Question 13

ransons criteria at 48 hrs out

Answer 13

1. Ca <8 2. HCT fall >10% 3. PO2 <60 4. BUN increases >5 5. base deficit >4 6. sequestration of fluids >6L

Question 14

ranson criteria met and mortality rate

Answer 14

0-2 - 2% 0-3 15% 5-6 - 40% 7-8 - 100%

Question 15

atlanta classification of pancreatitis

Answer 15

2 phases (early, late) severity (mild, mod, severe) 2 types (odematous, necrotizing)

Question 16

classification of fluid collections for pancreatitis

Answer 16

Question 17

Answer 17

a. pancreatic necrosis
b. peri pancreatic necrosis
c. combined peri pancreatic necrosis

Question 18

criteria for APFC

Answer 18

<4 weeks

in interstitial pancreatitis

homogenous fluid density

no fully definable wall

adjacent to pancreas

confined by normal fascial planes

Question 19

criteria for pseudocyst

Answer 19

>4 weeks

in interstitial pancreatitis

homogenous fluid density

well defined wall

adjacent to pancreas

no non liquid component

Question 20

ANC criteria

Answer 20

<4 weeks

in necrotizing pancreatitis

heterogenous collection

non fully definable wall

intra or extrapancreatic

Question 21

walled off necrosis criteria

Answer 21

>4 weeks

in necrotizing pancreatitis

heterogenous collection

well defined wall

intra or extrapancreatic

Question 22

treatment for acute pancreatitis interstitial edematous

Answer 22

early enteral nutrition, fluid resuscitation, correction of metabolic electrolyte abnormalities and pain control

Question 23

tx for biliary pancreatitis

Answer 23

laparoscopic cholecystectomy indicated once pain resolved

Question 24

Answer 24

pancreatic pseudocyst

Question 25

tx for pancreatic pseudocyst

Answer 25

early enteral nutrition, fludi resuscitation, correction of metabolic electrolyte abnormalities, pain control and drainage of pseudocyst

Question 26

tx for symptomatic pancreatic pseudocyst

Answer 26

depending on location and sizde FNAB/drainage

if big cyst gastrotomy

Question 27

tx for asymptomatic pancreatic pseudocyst

Answer 27

follow up in 6-8 wks

if stable <4cm follow up

if >4 cm elective therapy or FNAB/drainage

Question 28

Answer 28

necrotizing pancreatitis

Question 29

treatment of necrotizing pancreatitis

Answer 29

admission to ICU for hemodynamic monitoring

aggressive volume resuscitation

correction of metabolic/electrolyte abnormalities

broad spec IV abx

early enteral nutrition

organ system support- renal replacement therapy

CT guided FNA for gram stain/culture

Question 30

treatment of infected necrotizing pancreatitis

Answer 30

bact spectrum primarily gram neg and anaerobic (E. coli, pseudomonas, enterobacter, proteus, bactroides)

flora probably from gut

early prophylactic abx therapy and enteral nutrition favor a shift to gram positive pathogens from otehr nosocomial sources

imipenem and meropenem favored (tissue penetrating)

Question 31

Answer 31

normal CT

note: always do it with IV contrast

Question 32

Answer 32

pancreas well perfused and isodense but its too big and edematous (not well demarcated)

edematous interstitial pancreatitis

Question 33

Answer 33

acute necrotizing pancreatitis

pancreas not well defined and inhomogenous of unperfused tissue suggesting parapancreatic soft tissue that is necrotic

within pancreas there is varying desnity and a parapancreatic fluid density

Question 34

Answer 34

infected necrotizing pancreatitis

most infection comes from gut mucosa

this is why maintaining gut health is key to treating inftected pancreatitis

Question 36

Answer 36

necrotizing pancreatitis with superimposed infection

Question 37

Answer 37

catheter based drainage of necrotizing pancreatitis