L9: Pancreatitis Flashcards
Endocrine and endocrine pancreatic cells
Endocrine: islet of langerhans
Excorine: acinar cells
Biggest causes of Acute pancreatitis
Gallstones
Chronic alcohol abuse
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Men get acute pancreatitis from _____ and women get it from ____
Men: alcohol
Women: gallstones
Acute pancreatitis presentation
Acute onset, after eating
Midepigastric → radiates to back
Constant, steady boring pain, severe
Aggravators: lying supine, food, alcohol
Relievers: sitting and leaning forward with knees flexed
N/V/A, abdominal distension/swelling
Diaphoresis, hematemesis, SOB
Acute pancreatitis exam
Tachycardia, Tachypnea, Fever, Hypotension
Guarding, decreased bowel sounds
+/- Jaundice, pallor, diaphoresis
Clues to the origin of acute pancreatitis
Severe necrotizing pancreatitis→ Cullen’s sign, Grey-Turner’s sign, panniculitis (erythematous nodules)
Ileus→ Abdominal distention, hypoactive bowels
Choledocholithiasis or edema pancreatic head→ Scleral icterus
Alcoholic abuse→ Hepatomegaly
Hyperlipidemia→ Xanthomas
Mumps→ Parotid swelling
General labs for acute pancreatitis
BC – Elevated WBC
CMP
Creatinine
Glucose→ hyperglycemia or hypoglycemia
Calcium - hypocalcemia
Elevated Bilirubin
LFTs→ ALT→ Alanine aminotransferase (ALT)
>150 U/L in the first 48hrs of symptom onset→ >85% PPV of gallstone pancreatitis
CRP→ 150 mg/dL at 48 hrs→ severe pancreatitis
Urine trypsinogen-2 dipstick test
Rapid, noninvasive, High sensitivity + specificity
Pancreatic enzyme labs for acute pancreatitis
Amylase→ Rises in 6-12 hrs, peaks 48 hrs, normalizes in 3-5 days. (20% have normal level)
Lipase→ Rises in 4-8 hrs, peaks 24 hrs, normalizes in 8-14 days. More specific to pancreatic injury
Who gets genetic testing for acute pancreatitis
Onset <35 or strong family history
Make sure they get genetic counseling before and after testing
Criteria for diagnosis of acute pancreatitis
2 of the following:
- Clinical presentation
Acute persistent, severe, epigastric pain
Often radiating to the back - Elevated serum lipase or amylase
3X or greater than normal - Consistent imaging findings
CT with contrast, MRI or US
Acute pancreatitis management
Inpatient , NPO until pain + N/V controlled +/- NG tube
IV opioid analgesia, antiemetics
Aggressive hydration: fluid resuscitation with crystalloids→ reduced morbidity + mortality, prevents necrosis
Infective necrosis→ Imipenem
Monitor: Vitals, I+Os, Labs
Aggressive hydration +/- Imipenem
The mainstay of tx for acute pancreatitis
Fluids prevent necrosis
Imipenem has good pancreas penetration in cases of infective necrosis (give if you see Cullen’s sign, gray-turner’s sign, or panniculitis)
Complications of acute pancreatitis
decreasing urinary output rising creatinine respiratory failure increased pain fever leukocytosis
Early ______ is not recommended for acute pancreatitis because ______
Early CT
most cases are uncomplicated, or complications don’t occur until 3 days after onset. IV contrast may worsen.
Imaging indicated for suspected pancreatitis, and what might be seen
Abdominal ultrasound
Gallstones, posterior shadowing
Abdominal xray for acute pancreatitis
Gallstones
sentinel loop
CT of the abdomen will show ______ in acute pancreatitis
Enlargement of pancreas
Severity of disease/complications: inflammation, calcification, pseudocyst, necrosis, abscess, hemorrhage.
Initial testing for recurrent pancreatitis, risk of malignancy, or unclear cause
EUS
Evaluate pancreatic duct abnormalities, tumors involving ampulla, pancreatic cancer, microlithiasis (gallbladder or common bile duct), early chronic pancreatitis
Test for recurrent pancreatitis with neoplasm or stricture, or if EUS shows abnormal findings
ERCP
Visualize biliary + pancreatic ductal anatomy (dilation), “clubbing of side branches”, obtain cytology or biopsy. Therapeutic stone removal, stent insertion.
Imaging indicated if risk of malignancy, or if a stone in the common bile duct isn’t visible on CT or US
MRCP
Lower risk of nephrotoxicity, Increased characterization, view of biliary + pancreatic ducts, Fluid collections. Necrosis, Abscess, Pseudocyst
I GET SMASHED mnemonic for causes of acute pancratitis
Idiopathic
Gallstones
Ethanol
Trauma
Steroids Mumps Autoimmune Scorpion/Snakes Hyperlipidemia/Hypercalcemia ERCP Drugs
Medications associated with acute pancreatitis
Acetaminophen Amiodarone Cannabis Carbamazepine Chlorothiazide/HCTZ Codeine Dexamethasone Enalapril Estrogens Erythromycin Furosemide Losartan Methimazole Metronidazole Pravastatin/Simvastatin Procainamide Tetracycline Trimethoprim-sulfamethoxazole Tuberculosis antibiotics
Complications of pancreatitis
1. Local complications: Peripancreatic fluid collection Pancreatic pseudocyst→ see right Necrosis Gastric outlet dysfunction Splenic and portal vein thrombosis 2. Systemic Inflammatory Response Syndrome (SIRS) → present on admission, persists >48 hours 3. Organ failure: Cardiovascular, Respiratory, Renal
Early CT isn’t indicated for acute pancreatitis, but you for sure have to get one for these patients:
> 72 hours of symptom onset + suspect complications:
Persistent or recurrent abdominal pain
Increased in pancreatic enzyme level after initial decrease
New or worsening organ dysfunction
Sepsis→ fever and increased WBC
A pancreatic pseudocyst is best seen on _____
CT abdomen
Pancreatic pseudocyst
Palpable mass in the mid-epigastric area in 10% of patients with acute pancreatitis
+/- Symptoms→ Abdominal pain, Early satiety, N/V
Pancreatic pseudocyst prognosis and management
Can spontaneously resolve or continue to enlarge
Complicated by rupture, hemorrhage, or infection
Treatment→ Surgery vs. drainage→ Indicated if symptomatic or infected
Acute inflammation of the pancreatic parenchyma and peripancreatic tissues without necrosis
Interstitial edematous acute pancreatitis
Inflammation associated with pancreatic parenchymal necrosis and/or peripancreatic necrosis
Necrotizing acute pancreatitis
Classification of severity of acute pancreatitis
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)
A simple and accurate predictor of acute pancreatitis disease severity
SIRS
It’s present on admission and persists >48 hours
Initial findings that indicate severe pancreatitis
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
APACHE score (acute pancreatitis)
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
Ranson Criteria
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%
Causes of death from acute pancreatitis
1st 2 weeks: SIRS/organ failure
After 2 weeks: Sepsis, other complications
Preventing recurrence of acute pancreatitis
Treat the underlying cause:
Gallstone pancreatitis
- ERCP if CBD stone
- Elective cholecystectomy
Alcoholic pancreatitis→ Abstinence from alcohol
Hypertriglyceridemia
1. Dietary modification
2. Lipid lowering medications
Drug induced→ Discontinue offending medication
Etiology of chronic pancreatitis
alcohol induced disease (most) cystic fibrosis hereditary idiopathic smoking 5-20% with acute pancreatitis develop chronic disease
Chronic presentation presents similarly to repeated episodes of acute pancreatitis (early) or continuous inflammation, and can include be one of 2 main presentations:
Exocrine Insufficiency→ malabsorption: :
- Steatorrhea: ↑ excretion of fecal fat, Greasy, foul smelling stool
- Weight loss: Fear of eating, Malabsorption
Endocrine Insufficiency→ Diabetes:
- Polydipsia, polyuria, polyphagia
- Insulin dependent
- Brittle DM→ alpha and beta cells affected
Diabetes+Steatorrhea+Calcification
Classic triad of chronic pancreatitis
Labs for chronic pancreatitis
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
Test of choice for steatorrhea and gold standard for quantitative fecal fat
Fecal Fat testing
- 72 hour quantitative fecal fat preferred over qualitative testing of a spot sample (Gold Standard)
- Fecal Elastase (test of choice for steatorrhea)
Complications of chronic pancreatitis
Chronic pain Pseudocyst Abscess formation Fistula formation Pancreatic Ascites Mesenteric venous thrombosis
Which pancreatitis has a higher mortality?
Acute
Imaging for chronic pancreatitis
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
Management of chronic pancreatitis
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
Chain of Lakes
ERCP of chronic pancreatitis
Gold standard
Who gets pancreatic cancer
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
How do you diagnose pancreatic cancer
It’s NOT a clinical diagnosis def use labs and imaging
Pancreatic cancer presentation
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
When to look for cholestasis
Jaundice or epigastric pain
Pancreatic cancer labs
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
Most common type of pancreatic cancer
Exocrine pancreatic cancer
(vs endocrine is 5%)
All tumors related to the pancreatic ductal and acinar cells and their stem cells
Exocrine pancreatic cancer
Ductal adenocarcinoma of the pancreas
Most common type of exocrine pancreatic cancer
Most involve head, few are resectable
Most present with locally advanced or metastatic disease
very poor prognosis
Management of pancreatic cacner
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
Imaging for choledocholithiais
MRCP or ERCP
Abdominal ultrasound for pancreatic cancer
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
Triple Phase Thin Sliced Enhanced Helical CT of Abdomen with 3D reconstruction
Preferred for suspected pancreatic cancer with epigastric pain and weight loss, but NO jaundice
Do an abdominal CT if _______. It shows ______
if mass seen on ultrasound→ confirms mass, asses extent of disease
- Mass appears typical, resectability assessed, + pt is fit for major surgery→ no further testing
- In doubt→ additional testing
ERCP is therapeutic in cases of pancreatic cancer if:
choledocholithiasis remains in differential
biliary decompression required
double duct sign
Use MRCP for pancreatic cancer if
ERCP is contraindicated
Best for tissue diagnosis of pancreatic cancer
EUS
No biopsy is needed if it’s a resectable disease with typical imaging, they’ll do it when they excise the tumor
Test of choice for staging and resection eligibility of pancreatic cancer. FNA.
Contrast Enhanced Helical CT
