Clinical DSA 1: Pancreas Flashcards
Etiology of acute pancreatitis
Activation of digestive enzymes within the pancreas => autodigestion
Causes of acute pancreatitis
Main 2 are cholelithiasis and heavy alcohol use
Others:
Hypertriglyceridemia (lipid panel shows trigs >1000mg/dL)
Trauma: injury or surgery (don’t fuck with the pancreas)
Medications
ERCP (don’t fuck with the pancreas)
The following PE findings are associated with what diagnosis?
Epigastric pain that radiates straight through to the back
Cullen sign (periumbilical ecchymosis)
Grey Turner sign (flank ecchymosis)
Pulm stuff (crackles, difficulty breathing, ARDS)
Chovstek/Trousseau Signs (hypocalcemia)
Acute pancreatitis
The following lab findings are suggestive of what diagnosis?
Lipase elevated 3x upper limit of normal
CBC: leukocytosis and elevated Hct
CMP: Increased blood glucose, bilirubin, BUN, creatinine, ALT, Alk phos; hypocalcemia
INR: increased
Lipid panel: hypertriglyceridemia (>1000)
CRP: elevated
Acute pancreatitis
Diagnostic criteria for acute pancreatitis
At least 2/3 of the following
- Epigastric pain
- Lipase 3x upper normal
- CT changes consistent with pancreatitis
First imaging study ordered when suspecting acute pancreatitis
1st: CT abdomen WITHOUT contrast
Many with acute pancreatitis may have kidney disease, which can be exacerbated by IV contrast
When working up acute pancreatitis, in what situation should a CT with IV contrast be avoided?
In patients with serum creatinine >1.5 mg/dL
*don’t give IV contrast to pts with bad kidney fx
Abdominal x ray findings in acute pancreatitis (2)
Sentinel loop (air filled air segment in SI)
Colon cutoff sign (gas filled segment of transverse colon ending at pancreas)
Major complications that may arise from acute pancreatitis
Intravascular volume depletion => pre-renal azotemia (acute tubular necrosis)
ARDS
Treatment/Management for acute pancreatitis (severe/unstable)
1st: Aggressive IV fluid resuscitation (can increase pain and lead to ARDS, but absolutely needs to be done), use vasopressors too if not sufficient
- Calcium gluconate for hypocalcemia w/tetany
- FFP for coagulopathy
- Albumin infusions for hypoalbuminemia
Treatment/Management for acute pancreatitis (stable)
Treat underlying cause
i.e alcohol cessation, remove gallstones
Severe acute pancreatitis prognostic indicators:
APACHE II
used to evaluate ICU patients, not just for pancreatitis
Score >8 = higher mortality
Severe acute pancreatitis prognostic indicators:
Bedside Index for Severity in Acute Pancreatitis (BISAP)
B = BUN > 25 I = Impaired mental status S = SIRS (systemic inflammatory response synd) A = Age >60 P = Pleural effusion
BISAP score interpretation
Scale 0-5
0-1 = <1% chance of mortality 5 = 27% chance of mortality
Characterized by irreversible damage to the pancreas
Chronic pancreatitis
Causes of chronic pancreatitis (TIGAR-O)
TIGAR-O
Toxic/Metabolic (alcohol) Idiopathic Genetic Autoimmune Recurrent (develops from recurrent acute pancreatitis) Obstructive (stone/tumor)
The following lab findings are suggestive of what diagnosis?
Lipase/Amylase: normal
Fecal fat: elevated (pancreatic insufficiency)
Fecal chymotrypsin: decreased (pancreatic insufficiency)
Fecal elastase: decreased <100 mcg/g (pancreatic insufficiency)
Chronic pancreatitis
Abdominal x ray finding in chronic pancreatitis
Calcifications throughout pancreas
CT may show pancreatic calcifications not seen on x ray, suggestive of pancreatic cancer
Treatment/Management for chronic pancreatitis
Supportive
- Pain control
- Pancreatic enzyme supplementation
- Low fat diet with NO alcohol
- Corticosteroids for autoimmune
Major complications of chronic pancreatitis (3)
Diabetes mellitus (most will develop)
Pancreatic insufficiency
Pancreatic cancer (most common cause of death)
The following patient history is associated with what diagnosis?
Painless jaundice
New onset diabetes mellitus in older person
Trousseau sign of malignancy (migratory thrombophlebitus)
Courvoiser sign (nontender, palpable gallbladder from underlying mass)
Pancreatic cancer (adenocarcinoma)
