ICL 12.3: Acute Chronic Pancreatitis Including Pancreatic Insufficiency Flashcards
what is the pancreas?
the pancreas is a soft, elongated, flattened gland that is 12 to 20 cm in length
the adult gland weighs between 70 and 110 g
what is acute pancreatitis? which cells are effected?
it’s not one organ inflammation! it can be systemic which is why it’s so important to deal with it quickly and effectively
it’s an inflammatory process arising in the exocrine pancreas with variable involvement of peripancreatic tissues and other organ systems
severity can be mild to severe with multi-organ failure and high rates of morbidity and mortality
the inflammation is usually effecting the parenchyma of the pancreas; specifically the acinar cells –> with chronic pancreatitis, the acinar and islet Langerhans cells can be effected!
what is the pathophysiology of acute pancreatitis?
- parenchyma is effected; specifically acinar cells
- duct itself can be blocked like with stones
- defective intracellular transport
so basically there’s insult to the pancreas whether that be stones, alcohol, drugs, trauma etc. that causes injury to the acinar cells –> this leads to local inflammation,> this leads to systemic inflammatory response syndrome (SIRS) –> multiple organ dusfunction syndrome (MODS)
the inflammation can be systemic because the inflammatory chemokines can be spread throughout the whole body via capillaries and veins
how do you diagnose acute pancreatitis?
you need 2/3 of these criteria:
- abdominal pain consistent with the disease
- serum amylase and/or lipase > 3 times the upper limit of normal
- abnormal imaging (CT or MRI) showing characteristic findings of pancreatitis
pain is also usually in the upper abdomen, rebound tenderness, no guarding
what kind of abdominal pain do you see with acute pancreatitis?
- upper abdominal pain, increases over several hours
- pain is persistent & moderate to severe
- radiates to the back in 50% cases
- 5-10% cases are painless
- 90% cases have nausea and vomiting
- guarding and tenderness (may be less than expected) & abdominal rigidity unusual
- bowel sounds diminished to absent
- abdominal ecchymosis <1%, poor prognosis
what are the 2 signs of acute pancreatitis?
- Cullen’s sign
bruising around the belly button
- Grey Turner’s sign
bruising at the flank
what serum amylase changes do you see with acute pancreatitis?
may be normal in alcohol-induced AP and ↑TG because there isn’t a lot of viable tissues and they’re fibrotic
but it may also be HIGH in patients without pancreatitis:
- macroamylasemia
- low GFR
- diseases of the salivary glands
- acute appendicitis
- cholecystitis
- intestinal obstruction or ischemia
- peptic ulcer
- gynecological diseases
what serum lipase changes do you see with acute pancreatitis?
more specific, remains elevated longer
elevated in:
1. renal disease
- appendicitis
- cholecystitis
- ectopic pregnancy
should you get a CT scan/MRI in acute pancreatitis?
routine use is unwarranted because of high radiation and the contrast can even further irritate the pancreas
only do it if there’s an unclear diagnosis or failing to improve in 48-72 hours
but CT scans/MRIs can make an official diagnosis and show how severe it is and detect complications
contrast won’t be taken up by pancreas the pancreas won’t be white in acute pancreatitis because there’s a lot of edema
what is the progression of acute pancreatitis?
day 1 = interstitial pancreatitis –> inflammation in the pancreas but not that bad
day 3 = necrotizing pancreatitis –> higher infection, tissue isn’t viable, potential systemic complications
day 7 = infected necrosis –> clinical deterioration, gas in collection, gram stain/culture
you DONT give antibiotics with acute pancreatitis; you only do it if they have signs of infection aka infected necrosis
what are the local vs systemic manifestations of acute pancreatitis?
LOCAL
1. pancreatic ischemia
- pancreatic necrosis
- peripancreatic fluid collection
SYSTEMIC
1. systemic circulation failure
- organ failure
what are the causes of acute pancreatitis?
- alcohol*
- biliary stones*
- other: “GET SMASHED”
- idiopathic
what is the mneuominc for causes of acute pancreatitis?
GET SMASHED
Ⓖall stones*
Ⓔthanol*
Ⓣrauma*
Ⓢurgical (post-operative), scorpion sting
Ⓜumps and cosackie (viruses), malignancy
Ⓐutoimmune
ⓈPINK-1, PRSS1 mutation
Ⓗypertriglyceridemia, hypercalcemia, hypothermia
ⒺRCP
Ⓓrugs = corticosteroids thiazides, valproate, azathioprine, estrogen, sulfonamides, tetracycline, 6-MP, anti-HIV drugs
who gets biliary pancreatitis?
aka gallstone pancreatitis
more common in women than men
small stones are more common than large because they can get through the cystic duct
what are the clinical indications someone has biliary pancreatitis?
- elevated LFTs
2. biliary dilation
what is the best test to diagnose biliary pancreatitis?
ultrasound to find the stone!
how do gallstones cause pancreatitis?
there are 2 theories for how it happens:
- there’s a common channel; the pancreatic duct and bile duct join each other and make a common duct that feeds into the duodenum
if there’s a gallstone in the bile duct then the bile will reflux into the pancreas and cause pancreatitis
- obstructed pancreatic duct doesn’t allow for draining of pancreatic enzymes which then get autolytically activated and start to degrade the pancreas
how does alcohol cause pancreatitis?
- stimulation of CCK and secretin release in small bowel
- abnormal blood flow and secretion
- toxic metabolites
- sensitization to CCK
- sphincter of Oddi spasm
how does hypertriglyceridemia induce acute pancreatitis?
a serum triglyceride more than 1,000 mg/dL when fasting it can cause acute pancreatitis
these patients will usually have acute recurrent episodes of pancreatitis
amylase could be “normal” because the triglycerides are so high it makes the amylase levels look low
which drugs induce acute pancreatitis?
- azathioprine and 6-mercaptopurine*
- sulfonamide
- pentamidine
- valproic acid
- thiazides
- estrogen
how do acute pancreatitis cause by pancreatic tumors present?
if the patient is over 40 years old, smokes, has had a lot of weight loss, glucose intolerance and there are elevated cholestatic enzymes
so 60 year old patients will come in with no previous alcohol or gallstone problems but they have new onset pancreatitis and you checked medication list and triglycerides and everything, check for cancer with endoscopy after acute episode is over…
what are the lab results in acute pancreatitis?
- serum amylase and lipase:↑) by3Xupper limit of NL
- LFTs**: ↑ALT > 150 IU/L (X 3-5 times NL) (ALT>AST) is diagnostic of gall stone pancreatitis), ↑T. Bilirubin, Alk phos
- renal function tests:BUN**/Creatinine
- CBC
Leukocytosis with shift to left (Inflammation or SIRS)
↑HCt(means hemoconcentration due to fluid sequestration)*
↓HCt(dehydration or hemorrhage)
- blood biochemistry:
serum glucose:may↑ due to insulin producing Beta-cell dysfunction
serum calcium:↓(due tohypoalbuminemiaor fat necrosis) or ↑(if hypercalcemia is etiology)
lipid profile:to rule out hypertriglyceridemia
- ABG: to monitor oxygenation andacid-base status
- other:CRP, Trypsin, Trypsinogen-2, LDH, Phospholipase A
what are the most important values to look at in lab analysis of acute pancreatitis?
- BUN levels
BUN level is the most valuable single routine laboratory test for predicting mortality in acute pancreatitis
- Hct
admission’s Hct >44 that do not decrease in 24 hours is predictor of necrotizing pancreatitis
if these are both elevated give lots of fluids!!
what imagining studies do you do to try to figure out what’s causing the acute pancreatitis?
- ultrasound
sensitive for cholelithiasis or choledocholethiasis
- MRCP** best test
- EUS
- ERCP
- IOC
- CT/MRI
how do you manage acute pancreatitis?
- early diagnosis and assessing Severity
- early aggressive hydration in acute pancreatitis
- pain medications
- nutrition
- antibiotics
- management of acute gallstone pancreatitis
- diagnosis & Treatment of local complications
what is the BISAP score?
it’s used to asses acute pancreatitis
- BUN
- impaired mental status
- SIRS
- age
- pleural effusion
each one is 1 point; 0-2 points is lower mortality and 3+ is higher mortality
what is the best fluid to give with acute pancreatitis?
Ringer’s lactate
you can give normal saline if you don’t have that; dont give D5!
acute pancreatitis patients need fluids because of the vomiting, reduced oral intake, 3rd spacing of fluids, increased respiratory losses and diaphoresis
do you give antibiotics in acute pancreatitis?
NO
you only give it if there’s proof of extra-pancreatic infection!!!
what nutrition do you give for acute pancreatitis?
start with low fat diet and avoid PPN aka feeding through the vein because it’ll cause gut atrophy and transfer of bacteria to the pancreas
what is ERCP? what is its role in acute pancreatitis?
ERCP = endoscopic retrograde cholangiopancreatography
urgent ERCP is done in patients with acute pancreatitis AND acute cholangitis
elective ERCP is done in patients with acute pancreatitis and retained stone in CBD but without cholangitis
cholecystectomy is performed during the same hospitalization for gallstone pancreatitis in most cases – so if someone comes in with acute pancreatitis without a stone in the bile duct, once they’re better you remove the gallbladder while they’re in the hospital still, DON’T send them home with their gallbladder!! if they have acute pancreatitis and a stone, then you have to do a cholecystectomy AND an ERCP to remove the stone from the duct
what are the complications of acute pancreatitis?
EARLY
1. DIC
- shock
- multiorgan failure
LATE
1. pseudocyst
- pancreatic infections/sepsis/hemorrhage
