3 causes of chronic pancreatitis 1. ___ 2. ___ 3. Autoimmune

1. Alcohol/Tobacco use 2. Cystic Fibrosis

Pancreas Flashcards by Stephanie Escobar

pt px w/ epigastric pain radiating to back
elevated lipase/amylase
what imaging do you get first?

U/S

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In Pancreatitis an Elevated __ is the worst prognosis

BUN

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Common causes of acute pancreatitis:
(3)
Hypercalcemia
Post-\_\_\_\_
Scorpion stings
Infections (CMV)
Drugs (valproate, thiazides)

Alcohol use
Gallstones
Hyper Triglyceridemia
Post- ERCP

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Diagnosis of Acute Pancreatitis requires 2 of the following
1. \_\_
2. \_\_
3. On u/s enlarged pancreas 
On abdominal x-ray:
Sentinel loop sign
Colon cut off sign

Acute epigastric pain radiating to the back

2. Amylase or Lipase 3x> normal

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ALT > ___ suggests gallstone pancreatitis

150

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__ is characterized by intermittent epigastric pain that radiates to the back and worsens after meals.
+/- steatorrhea
+/- h/o Diabetes

Chronic pancreatitis

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Chronic pancreatitis

Imaging demonstrates pancreatic atrophy and __, in some cases.

calcifications

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Management of chronic pancreatitis

Pancreatic enzyme supplementation

(lipase, protease, amylase)
is used to treat both exocrine insufficiency and pain

(smoking/etoh cessation)

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3 causes of chronic pancreatitis

___
___
Autoimmune

Alcohol/Tobacco use

2. Cystic Fibrosis

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___ is a rare complication of chronic pancreatitis that results from damage to the pancreatic duct, leading to leakage of pancreatic juice into the peritoneal space.

Pancreatic ascites

Like ascites from other causes, sxs include abdominal distension, dyspnea, and early satiety

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Pt presents with epigastric TTP & early satiety
Physical exam significant for shifting dullness & fluid wave.
Serum albumin is low at 3.4 mg/dL.
Paracentesis reveals serosanguinous fluid showing high
levels of total protein & amylase.
Diagnosis

Pancreatic ascites

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___ is the most common complication after ERCP

Acute pancreatitis

Order Amylase & Lipase levels first

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Pancreatic ___ is an encapsulated area (composed of enzyme-rich fluid, tissue, and debris) that causes an inflammatory response.

pseudocyst

Diagnosis is confirmed by abdominal imaging

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For pts w/ pancreatic pseudocyst & minimal or no symptoms and without complications __ management is preferred.

expectant

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This procedure is typically reserved for patients w/ pancreatic pseudocyst & significant symptoms:
(abdominal pain, vomiting),
infected pseudocyst,
or evidence of pseudoaneurysm.

Endoscopic drainage

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Initial management in pts with acute pancreatitis presenting with epigastric pain and vomiting includes
(4)

NPO
IVF
NGT
Analgesia (NSAIDS; Opioids)

Early oral feeding (w/in 24 hrs) as tolerated or Enteral tube (nasogastric or nasojejunal)
If s/t gallstones → ERCP (within < 24 hours indicated if concurrent cholangitis) → cholecystectomy

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Pancreatic ___ can be 2/2 Acute Pancreatitis or abdominal trauma

It can eventually progress to ___ or ___

abscess
pancreatic pseudocyst
chronic pancreatitis

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Edematous pancreatitis commonly occurs 2/2 alcohol use or post ___

Laryngeal interventions

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Type of pancreatitis that presents with:

↑ HCT
↓ HCT

Edematous

2. Hemorrhagic

Pancreatic abscess or necrosis seen on CT

What is the first and second step in management?

First: ABxs
Second: Drain (percutaneous/open)

Pancreatic ___ can be 2/2 Acute Pancreatitis or abdominal trauma.

It presents weeks after acute pancreatitis, deep mass, early satiety, and abdominal pain.

Pseudocyst

In Pancreatic Pseudocysts
Get U/S or CT

If ≤6cm & ≤6 weeks old → ____

If >6cm & >6 weeks old → ____

Observe

Percutaneous drainage

Chronic Pancreatitis commonly 2/2 multiple pancreatic episodes.

Management includes:

Insulin
Pancreatic Enzyme replacement
+/- MRCP (drain pancreatic duct)

In hemorrhagic pancreatitis obtain daily ___ and start the patient on ___

CT scans

Abxs

Gallstone Pancreatitis presents with sxs of cholangitis and elevated amylase/lipase. Obtain U/S Initial management includes (3) followed by ___

NPO, NGT, IVFs Cholecystectomy (+/-) ERCP or sphincterotomy

Skin changes (rare) Cullen sign: periumbilical ecchymosis and discoloration Grey Turner sign: flank ecchymosis with discoloration Fox sign: ecchymosis over the inguinal ligament suggest what diagnosis

Acute Pancreatitis

_____ in the first 12–24 hours has the greatest impact on the clinical outcome of patients with acute pancreatitis.

IVF resuscitation

___ are not recommended in acute pancreatitis, and should only be used in pts with evidence of infected necrosis.

Prophylactic antibiotics

Bowel rest is no longer routinely recommended for acute pancreatitis. ___ nutrition should be initiated as early as tolerated. Ideally within 24 hrs.

Enteral (via oral or enteral tube/NGT)

Urgent __ is not indicated in acute gallstone pancreatitis unless acute cholangitis is present.

ERCP *Cholecystectomy in all pts to prevent recurrence

What lung manifestation can occur in acute pancreatitis?

Pleural effusion and/or ARDS

In Chronic Pancreatitis ↓ ___ confirms steatorrhea is due to pancreatic lipase insufficiency

Fecal elastase-1

Analgesics used for pancreatitis include NSAIDs & Opioids (fentanyl or ___) for severe pain

hydromorphone

Necrotizing pancreatitis necrosis of pancreatic tissue Clinical features: Fever, persistent tachycardia, or insufficient symptomatic ___ over several days Treatment Can usually be managed conservatively Encourage enteral nutrition if feasible.

improvement | Necrostomy is severe

Infected necrotizing pancreatitis Bacterial superinfection of necrotic pancreatic parenchyma Clinical features: persistent or worsening leukocytosis, bacteremia, & inflammatory markers CT abdomen: gas or fluid around/in the pancreas Treatment:

Antibiotics Drain is clinical deterioration or no improvements w/Abxs

A STEP-wise approach to diagnosing chronic pancreatitis may include: Survey, Tomography/imaging, Endoscopic imaging, and Pancreatic function testing.

Abdominal CT (with and without contrast) or MRCP/MRI

Pancreatic enzyme levels are often normal in ____ and cannot be used to confirm or rule out the diagnosis.

chronic pancreatitis *Acute pancreatitis always causes significant enzyme elevation.

Complication of chronic pancreatitis Encapsulated collection of pancreatic fluid that develops 4 weeks after an acute attack of pancreatitis +/- Features: Painless abdominal mass Gastric outlet obstruction (early satiety, NB emesis, abd pain)

Pancreatic pseudocysts *Splenic vein thrombosis is another cx

Courvoisier sign: enlarged, nontender gallbladder and painless jaundice & Trousseau syndrome: superficial thrombophlebitis suggests what pancreatic cause?

pancreatic cancer * MCC: ductal adenocarcinoma (95%) * Lymphatic & Hematogenous spread

Double-duct sign | Increasing size of ___ tumor may block bile drainage in the CBD & pancreatic duct leading to dilatation of both.

pancreatic head

Pancreatic head carcinoma treatment:

Pancreaticoduodenectomy (Whipple procedure) *Resection of the pancreatic head, distal stomach (antrum/pylorus), duodenum, proximal jejunum, gallbladder, CBD, lymphadenectomy, and reconstruction via Roux-en-Y.

Pancreatic body and tail carcinoma treatment:

Resection of the pancreatic body & tail with splenectomy *In some cases, Duodenum is resected also

Palliative approach to pancreatic cancer: 1. Pain management: opioids 2. _____: for symptomatic metastasis, especially to the brain and bones 3. _____: when pain management fails

2. Radiotherapy | 3. Celiac ganglion/plexus block

2 indications for Whipple's Procedure | Pancreaticoduodenectomy

1. Periampullary tumors | 2. Chronic pancreatitis

[Procedure] is recommended in patients with gallstone pancreatitis who have cholangitis, visible common bile duct dilation/obstruction, or increasing liver enzyme levels.

Endoscopic retrograde cholangiopancreatography (ERCP) *Allows for cannulation and sphincterotomy to relieve the obstruction.

A pancreaticopleural fistula (between the pancreatic duct and the pleural space) resulting in an amylase-rich exudative pleural effusion occurs most commonly as a result of _____.

acute or chronic pancreatitis Management includes bowel rest to promote fistula closure +/- ERCP

Imaging study performed in all patients with suspected gallstone-induced pancreatitis.

Abd U/S