L9: Pancreatitis Flashcards

Question

A pancreatic pseudocyst is best seen on _____

Answer 1

CT abdomen

Answer 2

Palpable mass in the mid-epigastric area in 10% of patients with acute pancreatitis +/- Symptoms→ Abdominal pain, Early satiety, N/V

Answer 3

Can spontaneously resolve or continue to enlarge Complicated by rupture, hemorrhage, or infection Treatment→ Surgery vs. drainage→ Indicated if symptomatic or infected

Answer 4

Interstitial edematous acute pancreatitis

Answer 5

Necrotizing acute pancreatitis

Answer 6

Mild→ no organ failure, no local or systemic complications Moderate→ transient organ failure <48 hours, no local or systemic complications Severe→ organ failure>48 hours, 1+ local complication(s), 1+ systemic complication(s)

Answer 7

SIRS | It's present on admission and persists >48 hours

Answer 8

Characteristics: >55 yrs old, obesity, altered mental status and comorbidities Labs: BUN>20mg/dL or rising, hematocrit > 44% or rising, increased creatinine Radiographic findings: many or large extrapancreatic fluid collections, pleural effusions, pulmonary infiltrates

Answer 9

Acute Physiology and Chronic Health Examination) Mild→ Decreasing values in first 48 hrs Severe→ Increasing values in first 48 hrs More complex and cumbersome Does not differentiate between interstitial and necrotizing

Answer 10

``` Initial signs Age > 55 WBC > 16, 000 Glucose > 200 mg/ml AST > 250 IU/L LDH > 350 IU/L ``` ``` Delayed signs (next 48 hrs) HCT drop > 10% BUN ↑ > 5 mg/dl Calcium < 8 mg/dl pO2 < 60 mmHg Serum albumin < 3.2 mg/dl Fluid sequestration 4-5 L ``` Mortality Score < 3 = 0-3% Score > 3 = 11-15% Score > 6 = 40%

Answer 11

1st 2 weeks: SIRS/organ failure | After 2 weeks: Sepsis, other complications

Answer 12

Treat the underlying cause: Gallstone pancreatitis 1. ERCP if CBD stone 2. Elective cholecystectomy Alcoholic pancreatitis→ Abstinence from alcohol Hypertriglyceridemia 1. Dietary modification 2. Lipid lowering medications Drug induced→ Discontinue offending medication

Answer 13

``` alcohol induced disease (most) cystic fibrosis hereditary idiopathic smoking 5-20% with acute pancreatitis develop chronic disease ```

Answer 14

Exocrine Insufficiency→ malabsorption: : 1. Steatorrhea: ↑ excretion of fecal fat, Greasy, foul smelling stool 2. Weight loss: Fear of eating, Malabsorption Endocrine Insufficiency→ Diabetes: 1. Polydipsia, polyuria, polyphagia 2. Insulin dependent 3. Brittle DM→ alpha and beta cells affected

Answer 15

Classic triad of chronic pancreatitis

Answer 16

Amylase + lipase→ “normal” or slightly increased Bilirubin + alkaline phosphatase→ +/-mildly elevated ↑ Glucose Secretin stimulation test: Cumbersome, expensive, not used often Abnormal if 60% of exocrine function lost Fecal Fat testing

Answer 17

Fecal Fat testing 1. 72 hour quantitative fecal fat preferred over qualitative testing of a spot sample (Gold Standard) 2. Fecal Elastase (test of choice for steatorrhea)

Answer 18

``` Chronic pain Pseudocyst Abscess formation Fistula formation Pancreatic Ascites Mesenteric venous thrombosis ```

Answer 19

Abdominal Xray→ scattered calcifications (30%) Abdominal CT→ calcifications, ductal dilations, pseudocysts MRCP→ pancreatic + biliary ducts imaging, gaining popularity ERCP→ “chain-of-lakes” appearance is gold standard. More invasive→ used less often

Answer 20

Behavior modification→ ETOH abstinence, smoking cessation, small low fat meals Early identification of complications Treatment of complications • Diabetes management • Malabsorption management→ Pancreatic enzyme supplements ``` Pain relief→ +/- Amitriptyline or SSRI Interventional Pain Specialist → referral • Opioids - long acting better control • Nerve Blocks • Celiac plexus – Ethanol or steroids ``` Endoscopic procedures • Dilation or Stenting Resection

Answer 21

ERCP of chronic pancreatitis | *Gold standard*

Answer 22

M>F, >45 years Etiology: Abnormal glucose metabolism, Insulin resistance, Obesity, Chronic pancreatitis Risk: smoking, high body mass, sedentary, non-hereditary chronic pancreatitis, pancreatic cysts, +/- ETOH + age

Answer 23

*It's NOT a clinical diagnosis* def use labs and imaging

Answer 24

epigastric pain, jaundice, weight loss asthenia (fatigue/weakness), N/A, back pain, dark urine, steatorrhea, hepatomegaly, RUQ/epigastric mass, ascites Exam: Abdominal pain + Palpable gallbladder→ courvoisier sign, nontender. Jaundice/ icterus

Answer 25

Jaundice or epigastric pain

Answer 26

``` Assay of serum aminotransferases Alkaline phosphatase Bilirubin Serum lipase – if epigastric pain (indicates acute pancreatitis) *CA 19-9* Tumor marker used in pancreatic cancer Sens/spec – 80-90% Elevations relative to tumor size ```

Answer 27

Exocrine pancreatic cancer | (vs endocrine is 5%)

Answer 28

Exocrine pancreatic cancer

Answer 29

Most common type of exocrine pancreatic cancer Most involve head, few are resectable Most present with locally advanced or metastatic disease *very poor prognosis*

Answer 30

Only potential cure is resection Whipple procedure: pancreaticoduodenectomy Biliary Obstruction • Biliary stent • Decompress bile duct Gastric obstruction: (N/V, anorexia) • Decompress stomach • Surgical palliation Pain • Narcotics • Chemotherapy vs. Radiation

Answer 31

MRCP or ERCP

Answer 32

if jaundiced→ Detects biliary tract/CBD dilation, Level of obstruction, Mass Epigastric pain + weight loss without jaundice→ lacks sensitivity for small tumors <3 cm, can’t clearly ID necrosis, so use CT

Answer 33

Preferred for suspected pancreatic cancer with epigastric pain and weight loss, but NO jaundice

Answer 34

if mass seen on ultrasound→ confirms mass, asses extent of disease 1. Mass appears typical, resectability assessed, + pt is fit for major surgery→ no further testing 2. In doubt→ additional testing

Answer 35

choledocholithiasis remains in differential biliary decompression required double duct sign

Answer 36

ERCP is contraindicated

Answer 37

EUS | No biopsy is needed if it's a resectable disease with typical imaging, they'll do it when they excise the tumor

Answer 38

Contrast Enhanced Helical CT