DSA 1: Approach to Pancreatic Pt Flashcards
What part of the abd will pancreas problems present
RUQ
Epigastric
what is the pathophysiology of acute pancreatitis
Cellular injury from - activation of digestive enzymes in pancreas - trypsinogen to trypsin results in autodigestion of pancreas and peri-pancreatic tissue
Saponification- interaxn of cations w/ FFA released by action of activated lipase on triglyceride in fat cells –> hypocalcemia
What is the etiology of acute pancreatitis
biliary tract - gallstones (=<5 mm)
heavy alc use
hypertriglyceride, trauma, meds, ERCP, AI, infxns, CFTR, idiopathic
What is the Hx/PE of acute pancreatitis
Hx: epigastric abd pain - constant boring pain straight through the back
RUQ pain/dyspepsia, GB dz etiology
never smoke/active lifestyle - decrease risk ; h/o GB dz- increase risk
PE: cullen or grey turner sign; ARDS (difficulty breathing, crackles); chvostek and trousseau signs for hypocalcemia
What are diagnostic criteria and lab criteria for acute pancreatitis
atleast 2 of 3: epigastric pain, lipase (& amylase) 3 x the ULN, CT changes consistents w/ pancreatitis
CBC (increase WBC, Hct)
CMP/BMP (hyperglycemia; hyperbilirubinemia; increase BUN, alkaline phosphatases, creatinine, ALT; hypoCa2+ saponification)
UA: proteniuria, granular casts in urine, glycosuria
increase CRP
What are diagnositic radiography criteria of acute pancreatitis
x-ray: sentineal loop (LUQ-air filled SI); colon cutoff sign (gas filled segment of transverse colon abrupting ending at the area of pancreatitic inflam)
US: not helpful
CT w/ rapid-bolus IV contrast - after aggressive vol resuscitation after 3 days of severe pancreatitis - find area of necrosis, avoid when Cr > 1.5 mg/dL; IV contrast may increase compllications of pancreatitis & AKI
PCT: specifically focus on an organ and it’s perfusion (pancreas in this case)
how do you determine the severity of acute pancreatitis
prognostic indicators for SAP (severe acute pancreatitis):
Ranson criteria
Bedside index for severity in acute pancreatitis - BUN >25 mg/dL, impaired mental status, SIRS, age > 60 & pleural effusion
APACHE II- > 8 = higher mortality
how do you treat/manage acute pancreatitis
treat the cause
Mild: fluid resuscitation (lots) - 1st thing (IV); pancreas rest - NPO, bed rest, NG suction for ileus
severe: early surgical consult, hemodynamic monitoring in ICU, Ca2+-gluconate IV for hypoCa2+ w/ tetany, fresh frozen plasma (FFP) for coagulopathy, albumin infusion for hypoalbuminemia
What are the compllications for acute pancreatitis
Leak of fluid in pancreatic bed (3rd spacing)
pre-renal azotemia
fluid collections (pleural effusion)
necrosis - w/ or w/o infxn (emphysematous pancreatitis)
pseudocysts
ARDS
what is a (+) cullen’s sign
ecchymosis of umbilicus from retroperitoneium fluid & bleeding
in acute pancreatitis
what is a (+) grey turner sign
ecchymosis of flank from fluid and blood in retriperitoneium
seen in acute pancreatitis
What are ranson criteria
assess severity of acute pancreatitis
GA-LAW = glucose > 200, age >55, LDH > 350, AST >250, WBC > 16,000
C & HOBBS (after 48 hrs admission) = Ca2+ < 8, HCT >10%, PaO2 <60 mmHg, base deficit >4, BUN increase > 5, sequestration of fluid > 6L
What is BISAP Score
Bun > 25
Impaired mental status
SIRS > 2-4 present
Age > 60
Pleural effusion
=acute pancreatitis
What is APACHE
acute pancreatitis > 8 means severe pancreatitis & 18% mortality
helps to determine diagnostics and Tx
What is a sentineal loop or localized ileus a sign for
acute pancreatitis
=single dilated loop of small bowel in LUQ
signals presence of adjacent irritative or inflam process
what is it called when there is infected pancreatic necrosis w/ secondary gas formation
how do you treat this
emphysematous pancreatitis
can form from C. perfringens, E. aerogenes, E. faecalis
Tx = surgical debridement & ABx (imepenem/meropenem)
what is chvostek and trousseau signs for hypoCa2+
Chvostek: twitching of Ms innervated by facial N; refers to an abnormal rxn to the stimulation of facial N
Trousseau: (+) when ionized Ca2+ is 1.75-2.25 mmol/L; hand adopts a characterisitic posturewhen the sphygmomanometer. cuff is inflated above the sBP w/i 3 mins
(can be seen in acute pancreatitis)
what is ARDS
and what can be seen on imaging
=bilateral fluffly inflitrate
normal cardiac size
tracheostomy tube
L subclavian central line going inside the R atrium
ECG wires
why is lipase preferred over amylase when testing for acute pancreatitis
amylase can be elevated for many other reasons - high intestinal obstruction, gastroenteritis, mumps, ectopic preg, opioids, after abd surgery
lipase could be elevated in some of these but is still considered more accurate of a measurement for pancreatic source
what is the etiology of chronic pancreatitis
alcoholism = MCC of clinically apparent chronic pancreatitis
irreversible damage to pancreas
self perpetuating- characterized by chronic pain/recurrent episodes of acute pancreatitis & pancreatic exocrine/endocrine insufficiency (malabs/DM, respectively)
what is the Hx/PE of chronic pancreatitis
epigastric pain, steatorrhea [chronic fatty diarrhea], unintentional wt loss, abnormal pancreatic imaging
Anorexia, N/V, constipation, flatulence, and malabs, fatigue
Pain is cardinal symptom
Attacks =only a few hrs or as long as 2 weeks;
Steatorrhea (bulky, foul, fatty stools) may occur late in the course; Malabs- aka EPI (Exocrine Pancreas Insufficiency)
what are diagnostic findings of chronic pancreatitis
decreased fecal elastase (<100 mcg/gram)
glucose/HbA1c (80% develop DM after 25 yr of chronic pancreatitis)
AI pancreatitis - elevated IgG4
x-ray - calcifications
CT: calcifications; tumefactive chronic pancreatitis = concern for pancreatic CA
EUS: Bx tissue
What is the mneumonic used for chronic pancreatitis causes
TIGAR-O
Toxic metabolic: alcoholic (45-80%)
Idiopathic (early onset - 23 yo OR late - 62 yo)- smoking = RF
Genetic (<30) - CFTR- CF
AI- celiac dz, hypergammaglobuminemia (IgG4)
Recurrent: develops in 36% of pt w/ recurrent acute pancreatitis
Obstructive: stricture, stone or tumore
What is the Tx for chronic pancreatitis
supportive, pain control
pancreatic enzyme supplementation: alcohol is forbidden, avoid opoids if possible, supplements w/ high lipase activity for statorrhea)
Tx associated DM
what are complications of chronic pancreatitis
and what is the prognosis
brittle DM (develop DM w/i 25 yr)
pancreatic insufficiency - steatorrhea, malnutrition
pancreatic CA- main cuase of death
what is pancreatic insufficiency
seen in chronic pancreatitis, CF or pancreatic CA
significant steatorrhea - due to malabs of triglycerides
–> wt. loss, gaseous distention & flatulence, large, greasy, foul-smelling diarrhea
exocrine- detection of decreased fecal chymotrypsin, pancreatic fecal elastase, secretin stimulation test, 40% B12 malabs
endocrine- 80% develop DM after 25 yrs
what are pancreatic function tests
fecal elastase (<100 mcg/gram stool)
trypsinogen, pancreatic malabs, CCK/secretin
what are Hx/PE of pancreatic CA
how do you treat this
=adenoCA
painless jaundice, pain is mid-epigastric pain - hurts the most at night (lying flat on back and relieved w/ bending forward
trousseau sign of malignancy = repeated attacks of multiple venous thrombosis at different and changing sites due to procoagulant factors (aka migratory thrombophlebitis)
courvoisier sign, CA 19-9 >100 U/mL = highly specific for malignancy
jaundice commonly complicates tumors of the head, due to biliary obstruction
- surgical resection; chemotherapy
What are RFs for pancreatic CA
smoking, obesity, male, african american
>65 yo, DM, chronic pancreatitis, liver cirrhosis (alc), FHx
associated w/ MEN 1
What are the associations of MEN Type 1
>= 2:
Parathyroid: hyperCa2+, increase PTH
Pancreas: gastrinoma (ZE syndrome) & insulinoma
Pituitary: acromegaly/cushing dz
