B5.065 Pancreatitis

Question 1

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

clinical presentation of acute pancreatitis

Answer 2

1. symptoms, such as epigastric pain, consistent with disease
2. serum amylase or lipase > 3x normal limit
3. radiologic imaging consistent with the diagnosis, usually using CT or MRI

Question 3

epidemiology of acute pancreatitis

Answer 3

17 per 100,000
2-3% mortality
median age depends on etiology

Question 4

common etiologies of acute pancreatitis

Answer 4

alcohol
biliary tract
drugs
ERCP
trauma
AIDs
vasculitis

Question 5

most common signs and symptoms associated w acute pancreatitis

Answer 5

severe epigastric pain, often radiating throughout back
nausea and emesis
fatigue and malaise
fever and chills

Question 6

less common, ominous signs associated with acute pancreatitis

Answer 6

Grey-Turner’s sign: hemorrhagic discoloration of the flanks

Cullen’s sign: hemorrhagic discoloration of the umbilicus

Question 7

pathophys of duct obstruction pancreatitis

Answer 7

duct obstruction > interstitial edema > impaired blood flow > ischemia > acinar cell injury

Question 8

pathophys of acinar cell injury pancreatitis

Answer 8

alcohol/drugs/trauma/ischemia > release of intracellular proenzymes and lysosomal hydrolases > activation of enzymes > acinar cell injury

Question 9

pathophys of defective intracellular transport pancreatitis

Answer 9

metabolic injury > delivery of proenzymes to lysosomal compartment > intracellular activation of enzymes > acinar cell injury

Question 10

actions of activated enzymes

Answer 10

interstitial inflammation and edema
proteolysis
fat necrosis
hemorrhage

Question 11

possible clinical outcomes of acute pancreatitis

Answer 11

90-95% mild, no organ failure
5-10% severe necrotizing, organ failure > 60% sterile and 40% infected
of infected necrosis, 15-25% mortality

Question 12

lab tests done for acute pancreatitis

Answer 12

1. serum amylase
2. serum lipase
3. serum trypsinogen
4. urine amylase
5. serum glucose
6. serum bilirubin and lk phos
7. serum calcium
8. CBC
9. BUN, Cr

Question 13

expected value of serum amylase

Answer 13

2-3x normal in 2-12 hours

returns to normal in 3-4 days

Question 14

expected value of serum lipase

Answer 14

rises and remains elevated for 7-14 days

Question 15

expected value of serum trypsinogen

Answer 15

elevated with acute

decreased with chronic

Question 16

expected value of serum calcium

Answer 16

hypocalcemia with acute

can contribute to globules of saponified fat in abdomen

Question 17

radiologic and diagnostic studies for acute pancreatitis

Answer 17

CT
MRI/MRCP
US
ERCP
fine needle aspiration (FNA)

Question 18

what types of diagnostic features can be identified on CT?

Answer 18

normal vs. edematous vs necrotizing pancreatitis

Question 19

appearance of edematous pancreatitis on CT

Answer 19

enlarged and homogenously enhancing pancreatic gland

less well demarcated than normal pancreas on CT

Question 20

appearance of necrotizing pancreatitis on CT

Answer 20

poorly defined

heterogeneous areas of unperfused tissue

Question 21

what is Ranson’s criteria?

Answer 21

classification of acute pancreatitis disease severity
made up of lab values at admission and at 48 hrs out
predictor of mortality

Question 22

2012 Atlanta classification of acute pancreatitis

Answer 22

2 phases: early (1st week), late (> 1 week)
3 severities: mild (no organ failure), moderate (organ failure < 48 hr), severe (organ failure > 48 hr)
2 types: edematous, necrotizing

Question 23

classification of interstitial edematous pancreatitis fluid collections

Answer 23

< 4 weeks after onset : acute peripancreatic fluid collection (APFC)
>4 weeks after onset: pseudocyst

Question 24

how is a pseudocyst different from APFC

Answer 24

thickened wall

more distinguishable formation

Question 25

classification of necrotizing pancreatitis fluid collections

Answer 25

< 4 weeks after onset: acute necrotic collection (ANC) >4 weeks after onset: walled off necrosis (WON) any collection can be sterile or infected

Question 26

patterns of necrosis

Answer 26

parenchymal alone peripancreatic alone combines (most common)

Question 27

treatment of acute interstitial edematous pancreatitis

Answer 27

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

Question 28

additional treatment of biliary pancreatitis

Answer 28

laparoscopic cholecystectomy indicated once pain has resolved (during same hospitalization)

Question 29

why is fluid resuscitation necessary in acute pancreatitis

Answer 29

can cause fluid shift in abdomen leading to intravascular volume depletion

Question 30

additional treatment of pseudocyst

Answer 30

drainage to resolve fluid accumulation

Question 31

management of an asymptomatic pseudocyst

Answer 31

usually < 6 cm is asymptomatic follow up in 6-8 weeks stable: < 4cm follow up, > 4 cm elective therapy

Question 32

management of symptomatic pseudocyst

Answer 32

depending on location and size > FNAB/drainage | if recurs > operation

Question 33

why are pancreatic enzymes sometimes not elevated despite damage?

Answer 33

too damaged for raised enzymes, not producing them | "hamburger meat"

Question 34

appearance of infection on CT

Answer 34

black spots on pancreas due to gas (produced by bacteria)

Question 35

how does the pancreas acquire infection

Answer 35

translocation of gut flora into pancreas when there is damage

Question 36

generalized treatment protocol for necrotizing pancreatitis

Answer 36

admission to ICU for hemodynamic monitoring aggressive volume resuscitation correction of metabolic/electrolyte abnormalities broad spectrum antibiotics early enteral nutrition organ system support CT guided FNA for gram stain/culture

Question 37

treatment of infected necrosis

Answer 37

clinically stable: continue antibiotics and observe delayed minimally invasive surgical, endoscopic or radiologic debridement clinically unstable: prompt surgical debridement

Question 38

predominant bacteria infecting the pancreas

Answer 38

``` E.coli pseudomonas enterobacter proteus bacteroides ```

Question 39

favored antibiotics for treatment of acute pancreatitis

Answer 39

tissue penetrating | Imipenem, Meropenem

Question 40

why is early enteral nutrition favored for all types of pancreatitis

Answer 40

maintain gut health | prevents migration of bacteria