Pancreas - Week 9 Flashcards
What imaging is best for diagnosing acute pancreatitis?
- CT scan is best diagnostic
> With contrast for pancreatic necrosis
Can also do
- X-ray
- Abdominal US
> See if cause is gallstones
- MRI
- MRCP
- ERCP
What are the possible complications of acute pancreatitis?
- Necrotizing pancreatitis
- Pseudocysts
- Infection
- Renal failure
- Pulmonary conditions
> Atelectasis, pleural effusion, pneumonia, ARDS - Metabolic disturbances
> Hypocalcemia, hypomagnesemia, hyperglycemia - GI bleeds
- Cardiogenic shock
- Pancreatic encephalopathy
- Fistula formation
Which lab values are indicative of acute pancreatitis?
- Elevated serum amylase
> Levels 3x normal are considered diagnostic - Elevated serum lipase
- Elevated urine amylase (may remain elevated for 7-10 days after serum is normal)
- Possibly hyperglycemia
- 25% have hypocalcemia
- Bilirubin, alk phos, ALT, AST increased for 4-7 days (from gallstone pancreatitis)
- Leukocytosis
- Elevated HCT
- ESR > 30 mm/hr
- CRP
> Levels over 10 mg/dL strongly indicates severe pancreatitis
How quickly does serum amylase elevate, and how long does it stay elevated?
- Rises within 2-12 hours of onset
- Stays elevated for 3-5 days
What ND treatments are appropriate for acute pancreatitis?
Hydrotherapy
- Castor oil infused with Larrea tridentata applied over abdomen for 30 minutes 2-3x/day
> No heat in acutes
Botanicals
- Belladonna tincture 8-10 gtts q 2-4 hours
> Toxic - use caution
- Salvia miltiorrhiza
- Calendula officinalis
- Curcuma (may activate for some pts)
- Yarnell's Acute Pancreatitis Formula
Other
- Avoid solid foods (for 48 hours or until pain diminished)
- Avoid alcohol
- No fatty foods for 3-6 days after light food tolerated
- Fish oil (9-12g) once fatty foods tolerated
- Vitamin C 1000mg TID
- NAC
What are the uses and limitations of chymotrypsin testing?
Uses
- Low levels may indicate pancreatic insufficiency or hypochlorhydria
Limitations
- May be falsely elevated with supplementation of pancreatic enzymes (plant or pancreatin)
- Falsely low levels may occur with stool transit time >96 hours
What are the uses and limitations of elastase-1 testing?
Uses
- Levels lower than 200 indicate an exocrine insufficiency
- Correlations between low levels and chronic pancreatitis and cancer have been reported
- Accurate even with pancreatic enzyme supplementation**
- Is less invasive and expensive
Limitations
- Liquid stool could falsely elevate levels
What is the etiology of pancreatic insufficiency?
- Over-eating
- Low fiber diets
- High sugar diets
- Excess refined carbohydrates (includes alcohol)
- Excessive caffeine
- Lack of raw food in the diet
- Deficiency of zinc, manganese, magnesium
- Deficiency of protein, B6
- H. pylori or Giardia infections
- SIBO
- Hypothyroidism, hypoadrenalism
- Poor food hygiene (not eating with family, not chewing, drinking while eating)
- Diabetes
- Chronic hepatitis
What is the role of Celiac disease in pancreatic insufficiency?
- 20% or more of Celiac patients have EPI
- Patients who continue to have diarrhea after going gf are more likely to have pancreatic insufficiency
- D/t villous atrophy and loss of S cells and I cells
What is the role of Cow Milk Enteropathy in pancreatic insufficiency?
- Similar correlation as with Celiac patients
> Often go together
What is the etiology of chronic pancreatitis?
- Excessive alcohol consumption (60-70% of all cases)
- Idiopathic (30%)
- Obstruction of the flow of pancreatic juice (<10%)
- Volatile hydrocarbon exposure?
- Hereditary pancreatitis
- Cystic fibrosis
- Hyperlipidemia
- Hypercalcemia d/t hyperparathyroidism
- Protein calorie malnutrition (rare in US)
- Some medications
- Acquired obstructions
- Autoimmune pancreatitis
What is the gold standard testing to diagnose chronic pancreatitis?
- Direct tests?
> Most sensitive (can detect at its earliest stage)
> Invasive, labor intensive, and expensive
> Pancreatic juice with ERCP - Elastase-1?
What are dietary considerations in chronic pancreatitis?
- Pescatarian or lean-protein Mediterranean diets
> More fish, less beef
> Avoid shellfish - Increase vitamin-rich foods (especially fat solubles)
- Increase fruits, vegetables, nuts, legumes
- Increase water intake (min. 64oz)
- Increase olive oil, coconut oil (medium chain FA)
- Increase fish oil
Avoid
- Refined carbs
- Sugar
- Trans fats/saturated fats
- Nutrient-poor foods
- All alcohol and tobacco!
- Spicy foods
- Dairy
What therapies are useful for chronic pancreatitis?
Supplements
- Pancreatic enzymes (before meals and at bedtime)
- Selenium 500-1000 mcg QD
- Magnesium 250-500 mg QD (to tolerance)
- Fish oil 3-6g QD (to tolerance)
- Vitamin A 50000-100000 IU QD
- Vitamin B complex, B6, B12 (IM and oral)
- Vitamin C 1-2g BID
- Vitamin D3 2000-5000 IU QD
- Vitamin E 800-1200 IU QD
- Vitamin K 80-120 mg QD
Enzyme Replacement Therapy
- Can reduce pain in 75% of pts
- Lipase is most important
- Doesn’t alter course; considered palliative
Hydrotherapy
- Alternating hot/cold compresses to abdomen 3min/30s
- Constitutional
- Vinegar pack
- Castor oil pack with heat (can add chaparral)
Botanicals
- Mild-moderate spasmolytics
> Viburnum opulus
> Dioscorea villosa
> Valeriana officinalis
- Stronger analgesics (low-dose)
> Atropa belladonna
> Gelsemium sempervirens
> Pulsatilla spp.
- Antifibrotics
> Centella asiatica
> Silybum marianum
> Scutellaria baicalensis
> Colchium autumnale
- Chionanthus virginica (obstruction of bile ducts)
- Achillea millefolium (as compress)
- Aconitum napellus (toxic)
- Bryonia alba (toxic)
- Inula helenium
- Matricaria chamomile
Homeopathy
Physical Manipulations
Why is pancreatic cancer so often missed?
- Initial symptoms are often nonspecific and subtle in onset
> Anorexia, malaise, nausea, fatigue, midepigastric or back pain - Often forms first in the tail with few symptoms
- Anxiety and depression may be the most prominent presenting symptom
