McGowan - Approach to Pancreatic Pt Flashcards
What should be the main differential considerations for RUQ and epigastric abdominal pain?
- gallbladder disease
- hepatitis
- pancreatitis (acute and chronic)
- peptic ulcer disease
What causes acute pancreatitis?
Cellular injury from:
- activation of protein kinases
- inflammatory mediators
- activation of digestive enzymes in pancreas (specifically trypsinogen activating to trypsin, result in autodigestion of pancreas and peri-pancreatic tissue)
What can happen to the pancreas in acute pancreatitis?
Saponification - interaction of cations w/FFAs released by activated lipase on trigylcerides in fat cells – can lead to hypocalcemia
What are causes of acute pancreatitis?
- GALLSTONES IN BILIARY TRACT (gallstones greater or equal to 5mm)
- HEAVY ALCOHOL USE
Others:
- hypertrigylceridemia
- trauma
- medications
- ERCP
- Autoimmune
- CTFR gene mutation
- idiopathic
What symptoms might a patient with acute pancreatitis present with?
- epigastric abdominal pain that is constant and bores straight through to the back
- RUQ pain/dyspepsia
- N/V, abdominal distension
What might a physical on a patient with acute pancreatitis show?
- distress
- Cullen or Grey Turner sign (bleeding around pancreas from damaged vessels)
- ARDS
- Chvostek and Trosseau signs for hypocalcemia!
What are the essential diagnostic criteria for acute pancreatitis? (labs-wise) How many do you need to have?
Need at least 2 of the 3:
- Epigastric pain
- lipase (and amylase) 2x the UNL
- CT changes consistent with pancreatitis
What would radiography show for acute pancreatitis?
- possibly calcified gallstones on x-ray
- ‘sentinel loop’ - segment of air-filled small intestine (mostly in LUQ)
- ‘Colon cutoff sign’ - gas filled segment of transverse colon ending at the area of pancreatic inflammation
What radiography is most helpful for diagnosing acute pancreatitis?
- plain radiography (x-ray)
- Rapid-bolus IV contrast-enhanced CT – should be avoided when serum Cr > 1.5 mg/dl, is of particular value AFTER 3 DAYS of severe acute pancreatitis
- MRI can be used if can’t do CT
What criteria do you use to score the severity of acute pancreatitis?
- Ranson criteria
- Bedside Index for Severity in Acute Pancreatitis (BISAP)
- Acute Physiology and Chronic Health Evaluation (APACHE II) – not just for pancreatitis
What does the BISAP score look for?
- BUN > 25 mg/dl
- Impaired mental status
- SIRS (systemic inflammatory response syndrome)
- Age > 60
- Pleural effusion
What is the APACHE II criteria used for?
It’s an ICU scoring system that predicts hospital mortality
> 8 = higher mortality
How do you treat acute pancreatitis? (both mild and severe)
for mild:
- usually resolves on its own without complications
- do lots of IV fluid resuscitation
- pancreas rest - NPO, bed rest
- pain control
for severe:
- consult surgery for possible treatment of complications
- put on hemodynamic monitoring in ICU
- give calcium gluconate IV for hypocalcemia w/tetany
- give FFP for coagulopathy, serum albumin for albuminopathy
What are possible complications of acute pancreatitis?
- intravascular volume depletion from fluids leaking into the pancreatic bed (3rd space)
- pre-renal azotemia or acute tubular necrosis
- fluid collections (pleural effusions)
- necrosis - if becomes infection, may need debridement (high mortality)\
- pseudocysts
- ARDS
- pancreatic ascites
- chronic pancreatitis (happens in 10% pts)
What are Ranson’s criteria?
- age over 55
- WBC > 16 x 10^3/mcL (> 16 x 10^9/L)
- blood glucose >200 mg/dL
- serum lactate dehydrogenase > 350 units/L
- aspartate aminotransferase > 250 units/L
With Ranson’s criteria, developing what in the first 48 hours indicates worsening prognosis?
- hematocrit drop of more than 10 points
- BUN rise > 5 mg/dL
- arterial PO2 of < 60 mm Hg
- serum calcium of < 8 mg/dL
- base deficit over 4 mEq/L
- estimated fluid sequestration of >6 L
What is the mortality rate associated with the number of Ranson’s criteria?
0-2 = 1% 3-4 = 16% 5-6 = 40% 7-8 = 100%
Why is lipase preferred over amylase when measuring pancreatitis?
Because amylase may be elevated in other conditions, while lipase is less often elevated
What is chronic pancreatitis?
A self-perpetuating disease characterized by chronic pain or recurrent episodes of acute pancreatitis - is characterized by irreversible damage to the pancreas
- eventually proceeds to pancreatic insufficiency (causing malabsorption) or endocrine insufficiency (causing diabetes mellitus)
What are the most common causes of chronic pancreatitis?
- ALCOHOLISM!! (most freq cause of clinically apparent chronic pancreatitis)
- sentinel acute pancreatitis event (SAPE)
What would you see in a history of a patient with chronic hepatitis?
- chronic or intermittent epigastric pain (cardinal sx)
- steatorrhea
- unintentional weight loss
- anorexia, N/V, constipation, flatulence, malabsorption, fatigue
What would you see on labs for chronic pancreatitis?
- decreased fecal elastase (< 100 mcg/g)
- glucose/HbA1C elevated (80% develop DM after 25 years of chronic pancreatitis)
- elevated IgG4 in autoimmune pancreatitis
What would you see on imaging for chronic pancreatitis?
- calcifications (pancreaticolithiasis)
- CT may show calcifications not seen on plain film, also ‘tumefactive chronic pancreatitis’ - concern for pancreatic cancer
- can do EUS to bx pancreas
Chronic pancreatitis mnemonic?
TIGAR-O
- Toxic metabolic (alcohol causes lots of cases)
- Idiopathic (early onset, ~23 or late ~62)
- Genetic (CF)
- Autoimmune (celiac, hypergammaglobulinemia)
- Recurrent (develops in 36% of pts w/recurrent acute pancreatitis)
- Obstructive (stricture, stone, tumor)
