GI

Question 1

Pancrease essentials:

Answer 1

located behind stomach
pancreatic enzymes released during digestion

Lipase: break down fat

Amlyase : break down starches into sugar

Protease : break down protien

Pancreatic hormones:
insulin , glucagon, or amylin

Question 2

pancreatic injury

Answer 2

premature release of pancreatic enzymes
increased amounts of lipase and amlyase

Question 3

Pancreatitis most common of GI in patinents

Answer 3

most common nonsurgical condition for geriatric
mortality is 40% above the age of 70

Hospitalizations:
200 fold after the age of 65
88% higher among blacks

Question 4

pancreatitis 3 phases

Answer 4

initial phase: enzyme activation and acinar cell injury

second phase: cytokine activation resulting in inflammatory reaction

third phase; leads to clinical findings

Question 5

Acute pancreatitis etiology

Answer 5

gallstones 80-90% of cause

alcohol use: 80-90% of cause due to acinar cellular that damage pancreatic ducts from alcohol

hypertriglyceridemia

ERCP procedure

Drugs

Trauma

Post op

Question 6

acute pancreatitis phases

Answer 6

The revised Atlanta criteria:
Defines phases of pancreatitis
outlines severity
clarifies imaging definitions

Question 7

early and late phase of pancreatitis

Answer 7

Early : < 2weeks
last 1-2 weeks
severity defines by clinical (sirs)
organ failure occurs if left untreated

Late phase:
protracted illness
persistent organ failure

Question 8

pancreatitis clinical findings:

Answer 8

abdominal pain , N/V , Fever and tachycardia

elevated amylase and lipase

3 x or more above normal
lipase elevated 7-14 days
amylase elevated 3-4 days

Leukocytosis : 15-20,000

hemoconcentration
hematocrit > 44%
severe disease process ( ie pancreatic necrosis)

Azotemia;
significant risk factor for mortality

Hyperglycemia
accompany transient jaundice

hyperbilirbuernea

eleved serum AST and ALT
Considering gallbladder or inflammation in the pancreatic head

Question 9

diagnosis 2 out of 3 criteria

Answer 9

1: epigastric abominal pain

2: > 3fold elevation in lipase or amylase

3: confirmed findings on imaging

Question 10

classification of pancretitis for coding

Answer 10

mild: without complications
subsides 3-7 days

moderate: transient organ failure
resolves < 48 hours

severe : persistent organ failure > 48 hours

Question 11

imaging of pancretitis

Answer 11

Two types :

Interstitial :
90-95% of admission
diffuse gland enlargement
contrast enhancement
mild infalmmation or pancreatic stranding

Necrotizing:
5-10% of admissions
lack of pancreatic parenchymal enhancement by IV contrast
peri pancreatic necrosis
greater risk of mortality

organ failure and mortality associated with necrosis
median prevalence of 54%
mortality is 3-10 % with single organ
mortality is 47% with multi-system failure

Question 12

Acute pancreatitis severity

Answer 12

BISAP:
Bun > 25
imparied mental status
SIRS
Age: > 60
Pleural effusion
> 3 or more admit to ICU

Question 13

pancreatitis treatment

Answer 13

fluid rescuscesstion
200-250 ml hour
LR is superior to NSS

Targets:
HCT and BUN q 8-12 hours indicated sufficient fluids

NPO:
mild cases: start CLD and advance slowly to low-fat
initiate when there is no abdominal pain

Severe cases:
2-3 days after admission
enteral nutrition rather than TPN

Question 14

necrotizing pancreatitis treatment

Answer 14

multi-disciplinary approach
two types:

Sterile necrosis:
conservative management

Signs of infection :
leukocytosis, fever, or organ failure
perc aspiration
gram stain and cluture

no role for abx prophlactic
broad spectrum abx if sepsis
discontinue if gram stain neg

repeated FNA with gram stain and culture
5-7 days

follow up with CT /MRI
monitor for complication

Step-up approach:

percutaneous or endoscopy drain first
necrosectomy if needed

pancreatic debridement
for definitive management of infected necrosis