Case- Pancreatitis Flashcards
What signs to look for in suspected pancreatitis?
Epigastric tenderness to palpation Voluntary guarding Can be hypotensive Cullen Sign Grey-Turner sign
Which test is more sensitive for pancreatitis in pts w/ETOH pancreatitis & Hypertriglyceridemia: Amylase or Lipase?
Lipase
Which test remains elevated longer? (8-14d) Amylase or Lipase?
Lipase
Which test is more specific for acute Pancreatitis? Amylase or lipase?
Lipase
Elevations of Lipase in Acute Pancreatitis?
3x > ULN
What are the normal levels of Amylase & Lipase?
Amylase:35-118
Lipase: 0-160
Two imaging modalities for Dx Acute Pancreatitis
Abdominal CT w/Contrast
Abdominal U/S
Dx of acute pancreatitis requires 2/3 of what?
- Acute onset of persistent, severe, epigastric pain often radiating to the back
- Elevation in serum lipase OR amylase 3x or greater than the ULN
- Characteristic findings of acute pancreatitis on imaging
Dx of acute pancreatitis requires 2/3 of what?
- Acute onset of persistent, severe, epigastric pain often radiating to the back
- Elevation in serum lipase OR amylase 3x or greater than the ULN
- Characteristic findings of acute pancreatitis on imaging
4 Common etiologies for pancreatitis?
Most common?
-Gallstones (MC 40-70%)
-ETOH
(uncommon if not a heavy drinker for >5yrs)
-Hyperlipidemia
(serum TG >1000)
-Post-ERCP
Mild Pancreatitis
No organ failure, no local/systemic complications
What are the local complications of Acute Pancreatitis
- Acute peripancreatic fluid collection
- Pancreatic pseudocyst
- Necrosis
What are the sytstemic complications of Acute Pancreatitis
Examples of systemic complications are exacerbations of underlying comorbidities
Moderate Pancreatitis
No organ failure
or
transient organ failure is <48 hours
and/or local complications
Severe Pancreatitis
Persistent organ failure
(>48 hours)
involving 1+ organs
Edematous Pancreatitis vs Necrotizing Pancreatitis
Most cases of acute pancreatitis are:
acute interstitial edematous pancreatitis
20% will become necrotizing pancreatitis.
Necrotizing pancreatitis has worse outcomes,
can also become secondarily infected (with bacteria or fungus)
Scoring systems for severity/risk of pancreatitis. Accuracy?
Ranson’s criteria, APACHE II score, SIRS score, BISAP score, harmless acute pancreatitis score, CT severity index
None have great accuracy.
Initial management of Acute Pancreatitis
LR or NS?
Aggressive fluids for the first 24-48 hours!
LR!
Benefits of aggressive LR & fluid replacement in acute pancreatitis?
LR:
reduces incidence of SIRS,
reduction in hospital stay
ICU admissions
- Fluid replacement is associated with reduction in M&M.
- Fluid resuscitation also helps with pain control (hypovolemia can worsen ischemia & pain)
Clues to knowing you have adequately resuscitated the patient? (5)
- normalization of HR
- Normalization of BP,
- Increase urine output,
- reduction in H&H
- Reduction in BUN
Pain control?
Opioids (IV)
Hydromorpine or Fentanyl
ABX?
not recommened
Nutrition?
NPO during work up
Management for Gallstones
ERCP early on (<24 hours) if they have gallstone pancreatitis + cholangitis.
Cholecystectomy after recovery in all pts with gallstone pancreatitis
Management of Hypertriglyceridemia
severe restriction of dietary fat. Consider plasmapheresis.
Rx admin to decrease TG if plasmaparesis unavailable
IV insulin administration
Long term Tx for management of Hypertriglyceridemia
lipid management w/ Rx therapy
+ dietary modification
+ weight loss
T/F: Patients with acute pancreatitis are at risk for developing prediabetes and diabetes after their first episode of acute pancreatitis.
True
T/F: WBC often elevated in Acute Pancreatitis
True
Nutrition if:
moderate to severe pancreatitis and oral feeding not tolerated
enteral feeding
(nasogastric tube)
if they can’t tolerate oral feeding by day 5.
Nutrition if:
patient doesn’t have an ileus, nausea, or vomiting
resume oral intake within 24 hours if tolerated.
Start with:
- low residue
- low fat
- soft diet
- advance cautiously as tolerated.
Acute Pancreatitis management if etiology is gallstones?
cholecystectomy
ERCP
T/F: If Pancreatitis is from ETOH it can be recurrent?
True
Heavy drinking is how many drinks for men/women per week?
7 Women
14 Men
T/F: Acute Pancreatitis presents better with laying down & worse when sitting up?
False.
Opposite.
Revised Atlanta criteria for mild, moderate and severe pancreatitis?
I GET SMASHED
Acronym for Acute Pancreatitis
I- idiopathic
G- GALLSTONES (40-70%)
E- ETOH
T- Trauma
S-steroids M-mumps A- autoimmune S-Scorpion sting H-Hypertriglyceremia E- ERCP D- Drugs- SULFA
*also pregnancy, pancreatic cancer, genetic mutations,
What can a CT with show for pancreatitis by gallstones
Diffuse pancreatic enlargement with edema and Perihepatic fat stranding
What can inadequate hydration lead to in acute pancreatitis?
-hypotension
-ATN
-reduction in other organ perfusion
(possibly leading to necrosis)
-Ischemia
-Pain
