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GI II Test 2 > McGowan - Approach to Pancreatic Pt > Flashcards

McGowan - Approach to Pancreatic Pt Flashcards

1
Q

What should be the main differential considerations for RUQ and epigastric abdominal pain?

A
  • gallbladder disease
  • hepatitis
  • pancreatitis (acute and chronic)
  • peptic ulcer disease
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2
Q

What causes acute pancreatitis?

A

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)
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3
Q

What can happen to the pancreas in acute pancreatitis?

A

Saponification - interaction of cations w/FFAs released by activated lipase on trigylcerides in fat cells – can lead to hypocalcemia

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4
Q

What are causes of acute pancreatitis?

A
  • GALLSTONES IN BILIARY TRACT (gallstones greater or equal to 5mm)
  • HEAVY ALCOHOL USE

Others:

  • hypertrigylceridemia
  • trauma
  • medications
  • ERCP
  • Autoimmune
  • CTFR gene mutation
  • idiopathic
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5
Q

What symptoms might a patient with acute pancreatitis present with?

A
  • epigastric abdominal pain that is constant and bores straight through to the back
  • RUQ pain/dyspepsia
  • N/V, abdominal distension
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6
Q

What might a physical on a patient with acute pancreatitis show?

A
  • distress
  • Cullen or Grey Turner sign (bleeding around pancreas from damaged vessels)
  • ARDS
  • Chvostek and Trosseau signs for hypocalcemia!
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7
Q

What are the essential diagnostic criteria for acute pancreatitis? (labs-wise) How many do you need to have?

A

Need at least 2 of the 3:

  • Epigastric pain
  • lipase (and amylase) 2x the UNL
  • CT changes consistent with pancreatitis
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8
Q

What would radiography show for acute pancreatitis?

A
  • 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
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9
Q

What radiography is most helpful for diagnosing acute pancreatitis?

A
  • 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
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10
Q

What criteria do you use to score the severity of acute pancreatitis?

A
  • Ranson criteria
  • Bedside Index for Severity in Acute Pancreatitis (BISAP)
  • Acute Physiology and Chronic Health Evaluation (APACHE II) – not just for pancreatitis
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11
Q

What does the BISAP score look for?

A
  • BUN > 25 mg/dl
  • Impaired mental status
  • SIRS (systemic inflammatory response syndrome)
  • Age > 60
  • Pleural effusion
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12
Q

What is the APACHE II criteria used for?

A

It’s an ICU scoring system that predicts hospital mortality

> 8 = higher mortality

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13
Q

How do you treat acute pancreatitis? (both mild and severe)

A

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
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14
Q

What are possible complications of acute pancreatitis?

A
  • 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)
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15
Q

What are Ranson’s criteria?

A
  • 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
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16
Q

With Ranson’s criteria, developing what in the first 48 hours indicates worsening prognosis?

A
  • 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
17
Q

What is the mortality rate associated with the number of Ranson’s criteria?

A 
0-2 = 1% 
3-4 = 16%
5-6 = 40%
7-8 = 100%
18
Q

Why is lipase preferred over amylase when measuring pancreatitis?

A

Because amylase may be elevated in other conditions, while lipase is less often elevated

19
Q

What is chronic pancreatitis?

A

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)
20
Q

What are the most common causes of chronic pancreatitis?

A
  • ALCOHOLISM!! (most freq cause of clinically apparent chronic pancreatitis)
  • sentinel acute pancreatitis event (SAPE)
21
Q

What would you see in a history of a patient with chronic hepatitis?

A
  • chronic or intermittent epigastric pain (cardinal sx)
  • steatorrhea
  • unintentional weight loss
  • anorexia, N/V, constipation, flatulence, malabsorption, fatigue
22
Q

What would you see on labs for chronic pancreatitis?

A
  • decreased fecal elastase (< 100 mcg/g)
  • glucose/HbA1C elevated (80% develop DM after 25 years of chronic pancreatitis)
  • elevated IgG4 in autoimmune pancreatitis
23
Q

What would you see on imaging for chronic pancreatitis?

A
  • 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
24
Q

Chronic pancreatitis mnemonic?

A

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)
25
Q

How do you treat chronic pancreatitis?

A
  • supportive
  • pain control
  • pancreatic enzyme supplementation
  • low fat diet, NO ALCOHOL, avoid opiods if possible
  • treat diabetes
26
Q

Complications of chronic pancreatitis?

A
  • opioid addiction (cuz pain)
  • brittle diabetes mellitus
  • pancreatic insufficiency
  • pancreatic cancer
  • bile duct stricture
  • pancreatic pseudocyst or abcess
27
Q

What is the prognosis of pancreatic cancer?

A
  • chronic pain, usually leads to disability, reduced life expectancy

Pancreatic CA is main cause of death

28
Q

What is pancreatic insufficiency caused by?

A

chronic pancreatitis
cystic fibrosis
pancreatic cancer

29
Q

What symptoms are associated with pancreatic insufficiency?

A
  • significant steatorrhea (from fat malabsorption) resulting in wt loss, abdominal distension and flatulence
30
Q

What are lab signs of pancreatic insufficiency

A
  • fecal elastase (is low in insufficiency)
  • trypsinogen (low in insufficiency)
  • pancreatic malabsorption
  • stimulation tests (cholecystokinin/secretin)
31
Q

How is exocrine pancreatic insufficiency diagnosed?

A
  • through secretin stimulation tests
  • detection of decreased fecal chymotrypsin
  • decreased pancreatic fecal elastase
  • is confirmed by response to therapy with pancreatic enzyme supplements
32
Q

When do you see endocrine pancreatic insufficiency?

A

when pts have chronic pancreatitis for 25 years - causes diabetes mellitus

GI II Test 2 (7 decks)

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