Diseases of the Pancreas Flashcards
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What is the pneumonic to remember the etiologies of pancreatic disease?
- I - idiopathic
- G - gallstones (other obstructive lesions)*, genetic (Cystic Fibrosis)
- E - ethanol
- T - trauma
- S - steroids
- M - mumps (& other viruses, CMV, EBV)
- A - autoimmune (SLE, plyarthritis nodosa)
- S - scorpion sting (Tityus trinitatis)
- H - hypercalcemia, hypertriglyceridemia
- E - ERCP (5-10% of patients)
- D - drugs (thiazides, sulfonamides, ACE-1, NSAIDS, azathioprine)
What are signs and symptoms of acute pancreatitis?
- Severe epigastric abdominal pain
- SUDDEN onset
- radiates to back
- nausea & vomiting
- weakness
- tachycardia
- +/- fever
- +/- hypotension or shock
Diagnosis of acute pancreatitis requires 2 of what 3 signs?
- Acute onset abdominal pain characteristic of panreatitis
- severe, persistent for hours to days, epigastic, radiates to back
- serum lipase or amylase levels 3-5x upper limit of normal
- amylase (2-12 hrs)
- sensitivity decreases with time from onset of symptoms
- lipase 4-8 hrs
- increased sensitiity in alcohol-induved pancreatitis
- more specific and sensitive than amylase
- amylase (2-12 hrs)
- characteristic radiographic findings on CT (with contrast), MRI or transabdominal ultrasound
- ultrasound has higher sensitivity for detecting gallstones
In addition to amylase & lipase, what other lab value can be helpful in diagnosing pancreatitis?
How is it useful?
- ALT
- 12-24 hrs
- associated with gallstone pancreatitis
- 3-fold increase or greater in presence of acute pancreatitis
Once pacreatitis is suspected, what steps are used in the evaluation?
- RUQ ultrasound
- rule out gallstones
- not good for common duct stones
- endoscopic US
- useful in obses patients
- ERCP & MRCP
- AXR - “sentinel loop” or small bowel ileus
- CT of abdomen
- stranding
- abscess
- fluid collections
- hemorrhae
- necrosis
- pseudocyst
- MRI - if contrast allergy or bad kidneys
Denote the level of panceratitis indicated by the provided images & the features indicated by the white arrows
What is the most important thing you can do for a patient with suspected pancreatitis?
- Determine the severity
- dynamic CT assesses pancreatic necrosis
- pancreatic necrosis (20-30% of acute pancreatitis)
- other organ failure
- cardiovascular
- pulmonary: decreased O2
- renal insufficiency
- metabolic abnormality (hypocalcemia)
- altered metal status
Describe how you would determine if a patient had mild acute, moderately severe or severe pancreatitis?
- mild acute
- no local of systemic complications
- no organ failure
- usually resolve within 1 week
- moderately severe pancreatitis
- involves local or systemic complication
- necrosis or transient organ failure (less thn 48 hrs)
- involves local or systemic complication
- severe
- SIRS (systemic inflammatory response system)
- elevated heart rate (above 90 bpm)
- elevated respiratory rate (above 20 breaths/min)
- temp (above 38 or below 36 C)
- elevated/low leukocytes (abover 12/below 4)
- persistent organ failure
- one or more local complications
- mortality rate as high as 50%
- SIRS (systemic inflammatory response system)
What are the different scoring systems for pancreatitis?
- Ranson criteria
- admission
- age >55
- WBC >16,000
- glucose >200
- LDH >350
- AST >250
- first 48 monitor
- arterial pressure
- fluid sequestration
- increase in BUN
- base deficit
- serum calcium
- hematocrit drop
- admission
- APACHE II
- age
- AaDO2 or PaO2
- temperature (rectal)
- mean arterial pressure
- pH arterial
- heart rate
- respiratory rate
- sodium (serum)
- potassium (serum)
- creatinine
- hematocrit
- white blood cell count
- glasgow coma scale
- Bedside index for severity of acute pancreatitis
- Each is given 1 point
- BUN > 25 mg/dL
- impairment of mental status w/ glasgow coma score <15
- 2+ SIRS cirteria
- age ?60
- pleural effusion
- Each is given 1 point
What are the important components for pancreatitis management?
- fluid resuscitation
- pain mamagement
- antinausea medications
- antibiotics not routine
- use if evidence of extrapancreatic infxn
- restart feeding when N/V controlled and symptoms improve
- enteral feeding if oral not tolerated
- naso-jejunal tube preferred b/c will go past where pancreas dumps enzymes into the duodenum
What is the most likely diagnosis?
- Acute pancreatitis
- duodenal ulcer
- acute intestinal infarct
- ischemic colitis
-
Acute pancreatitis
- sever epigastric pain
- not too long
- radiates to back
- associated with vomiting
- a little tachycardic
- WBC elevated
- amylase not elevated– don’t have lipase
- but with that triglyceride level and that level of pain , it is probably pancreatitis
Symptoms associated with hypocalcimea?
What can mask increased amylase?
What is the first thing you should rule out if you suspect pancreatitis?
- Hypercalcemia may cause muscle crampys
- hypertriglyceridemia masks increased amylase
- must differentiate from diabetic
- take a peek of the glucose
What is the name of the signs & why are they associated with pancreatits?
- Grey Turner sign
- echimosis on the flanks (right or left)
- Cullen’s sign
- echimosis aroundthe bellybutton
- Can see them in anything that may cause bleeding/blood pooling
When do pancreatic pseudocysts appear?
Why are they concerning?
- usually 4 weeks after acute episode
- consider if delayed recurrence of pain w/ another elevation of amylase
- concerns
- infection
- rupture
- hemorrhage
- obstruction adjacent structures
- no symptoms, no change – just watch
- symptomatic, rapidly enlarging - decompress
When do you see abscess show up as a complication of pancreatitis?
Concerns?
Next steps if you suspect?
- late complication (>4 weeks) or severe acute pancreatitis
- concerns
- fever
- shock
- multi-system organ failure
- CT scan with needle aspiration
When someone comes in with abdominal pain, nausea, vominting, what differential diagnosis should you consider?
- acute pancreatitis
- acute cholecystitis – RUQ, pain after eat
- salpingitis– iflamation reproductive female tract
- perforated ulcer
- diabetic ketoacidosis
- ectopic pregnancy
What is the probable cause for acute pancreatitis?
- Inflammatory response from acute pancreatitis perisists
- distortion of normal parenchyma results in loss of acinar (exocrine) and islet cell (endocrine) function
- maybe some genetic predisposition
- Causes
- toxic/metabolic causes (alcohol, tobacco, hyperclacemia, hypertriglyceridemia)
- genetic
- recurrent and severe acute panreatitis
- vascular disease/ischemia
- obstructive
- posttraumatic
- autoimmune
- idiopathic
Clinical presentation of patients with chronic pancretitis?
- abdominal pain (85% of patients) presnting symptoms
- pancreatic enzyme levels might not increase during attacks
- exoctine/endocrine insufficiency may occur
What is the classic triad for diagnosing chronic pancreatitis?
- structural and metabolic changes
- classic triad
- pancreatic calcifications
- diabetes
- steatorrhea
What testing can you do to work up a patient you suspect to have chronic pancreatitis?
- function
- direct
- stimulation with secretagogues
- indirect
- fecal fat
- fecal elastase (exocrine function)
- serum trypsin
- direct
- structure - will see calcifications
- X-ray – abdomen
- CT – abdomen with contrast
- ERCP, MRCP
- EUS
How is chronic pancreatitis treated?
- NO treatment to CURE
- savoid alcohol and tobacco
- severe, acute pain is treated same as acute pancreatitis
- need to evaluate for complications
- pseudocyst, pancreatic duct stones, malignancy
- pain management
- NSAIDS, tramadol, gabapentinoids, narcotics
- Pancreatic enzymes for steatorrhea
- Nerve plexus blocks
- Sx offers best long-term results
What are the risk factors for pancreatic adenocarcinomas?
Presentation?
- Risk factors
- smoking
- chronic pancreatitis
- diebetes mellitus
- family history
- 5th leading cause of cancer death in the U.S.
- Presentation
- Symptoms
- jaundice (obstructing common bile duct)
- abdominal or back pain
- weight loss
- most located at head of pancreas
- elevated at Ca19-9
- advanced disease: poor survival
- if mass: CT-guided biopsy, or needle biopsy at EUS
- Symptoms
Once pancreatic cancer has been detected, what are the next steps if there are no metastasis?
if metastisis or local vascular invasion?
- No metastasis
- consider evaluation for surgery
- most still not respectable
- metastasis or local vascular invasion
- ERCP + Stent = palliation
- Germcitabine (chemotherapy)
- reductress pain
- improves quality of life
