pancreatic diseases Flashcards
case 1: hx gallstones 1 day hx of sev. epigastric pain radiates to mid-upper back N/V, diaphoretic, have a fever T=100.7F P=108 RR=18 BP=100/48 questions?
GERD, ulcers, taking PPIs? better/worse with food? peritoneal signs (radiation to back) MI
ask if similar presentation to past gallstone attacks
Acute Pancreatitis
Most cases are related to the biliary tract (often a passed gallstone) or heavy alcohol intake
Generally there is some insult to the ampulla of Vater causing obstruction and reflux of bile into the pancreatic ducts causing damage and inflammation to the cells of the pancreas
other considerations for acute pancreatitis
ERCP procedure itself can cause pancreatitis
Medications, viruses, autoimmune, high cholesterol also are considerations
acute pancreatitis acronym
GET SMASHED
gallstones
etOH
trauma
steroids mumps autoimmune scorpion venom hypothermia hyperlipidemia ERCP drugs: azathioprine, thiazides, na valproate, tetracycline
pancreatitis clinical findings
Most pts have epigastric abdominal pain
Often abrupt onset, radiates to the back, worse when laying flat
Better when laying in the fetal position or leaning forward
N/V, often fever, may have mild jaundice, tender abdomen
Possible history of a heavy meal or heavy alcohol consumption prior to the attack
pancreatitis labs
Elevations in amylase and lipase (more specific)
Generally 3x the upper limits of normal within 24 hours of symptoms
Return to normal is variable
Lipase remains elevated longer than amylase and is slightly more accurate for the diagnosis of acute pancreatitis
Elevated WBC count (can be pure inflammation)
Hyperglycemia (pancreas isn’t functioning properly) (may become DM)
Hyperbilirubinemia and/or elevated LFTs may be present as well
High crea is associated with progression to pancreatic necrosis
?? can independently be associated with a greater mortality rate
Presence of a systemic inflammatory response syndrome (SIRS) or sepsis
?? is widely used to determine the severity of acute alcoholic pancreatitis
Ranson’s criteria
Sensitivity of predicting a severe course as accurate as 60-80% based on these criteria
each factor worth a point
more than 3 positives: pancreatitis is likely
less than 3: pancreatitis unlikely
the greater, higher mortality: 4-6: 50% mortality
close to all positive: almost 100% mortality
Ranson’s criteria
Blood glucose > 200 mg/dL Age in years > 55 years Serum LDH > 350 IU/L Serum AST > 250 IU/L White blood cell count > 16000 cells/mm3 Within 48 hours: Serum calcium less than 8.0 mg/dL Hematocrit fall > 10% Oxygen: PaO2 below 60mmHg BUN rise more than 5 mg/dL base deficit more than 4 mEq/L Sequestration of fluids > 6 L
mnemonic GALAW AND CHOBBS: Glucose, Age, LDH, AST and Whites; Calcium, Hematocrit, Oxygen, BUN, Base, Sequestration.
-the more risk factors you have to more severe of a case it is
if increase in score: increase in morbidity/mortality
pancreatitis imaging
Plain radiographs may show calcified gallstones
A “sentinel loop”
Segment of air-filled small intestine usually in the LUQ
“Colon cutoff sign”:
Gas-filled segment of transverse colon abruptly ending at the area of pancreatic inflammation
pancreatitis U/S
can be helpful for identifying gallstones/cholecystitis but generally not helpful for pancreatitis given overlying bowel gas
CT can help to identify an ??
enlarged or inflamed pancreas
Can also show necrosis, pseudocyst, or other complications
Pancreatitis EponymsPresent in 1-2% of cases…
Cullen’s sign
Grey Turner’s sign
may present together
imply pancreatic necrosis, higher risk of death
need volume resuscitation
Mild pancreatitis tx
most will subside over a few days
Bowel rest, bed rest, pain control
Fluid resuscitation
Classically meperidine has been given for pain preferentially over morphine due to risk of?
(Now thought to be an acceptable alternative and is often preferred)
Slowly resume p.o. diet when pain free (after “gut rest”), bowel sounds are present, and labs are improving
can go home when eating again
Severe pancreatitis tx
Large amounts of IVF resuscitation due to volume loss in necrotizing disease
Treatment of sepsis and evolving multi-organ dysfunction
Calcium replacement if hypocalcemic
Enteral feeding via nasojejunostomy preferred
Parenteral nutrition (TPN) in those with ileus
?? considered the drug of choice for necrotizing pancreatitis involving more than 30% of the pancreas
Carbapenems (imipenem)
Antifungals a consideration as well (yeast is in gut, higher risk for candida if on TPN, higher blood glucose)
pancreatitis complications: Intravascular volume depletion due to leakage of fluids in the pancreatic bed and ileus can cause ??
acute renal insufficiency/ATN
Could last 1-2 weeks and in some cases patients require hemodialysis
pancreatitis complications: Pancreatic necrosis and fluid collections (pseudocysts)
can be acute or chronic and can be sterile or infected
This complication occurs in 5-10% of cases and is a frequent predictor of mortality
An infected pseudocyst can form a pancreatic abscess
Often associated with splenic vein thrombosis and L sided pleural effusions as well
about 50% mortality, not good candidate for sx, can only effectively drain thru tubes
other possible pancreatitis complications
Fistula formation, erosion into a blood vessel, chronic pancreatic insufficiency and permanent diabetes
slide 18
pseudocyst on right
tx of pancreatitis complications
Surgery should follow all severe cases especially with nercocosis/pseudocyst:
Some mild cases with stones may need a cholecystectomy or cholecystotomy
Necrosectomy may improve survival but patient must be good candidates:
If possible delay until patient is stable and necrosis has organized
Internal or external drainage of pseudocysts a consideration as well:
Risk for infection, fistula formation
Mortality: 25% and if there is multiorgan failure present, 50%
case 2: chronic alcohol use presents to the ER with a c/o intermittent epigastric pain, weight loss, and diarrhea
labs/imaging
Patient has mild elevation in amylase and lipase
Serum alkaline phosphatase and bilirubin are slightly elevated
Patient uses the restroom and returns to tell you his stool looked “oily”
CT scan demonstrated diffuse pancreatic calcifications (chronic!) and some ductal dilation
slide 23
chronic pancreatitis: calcifications
chronic pancreatitis Characterized by ??
persistent or intermittent epigastric pain, steatorrhea, weight loss, and up to 30% of affected patients have calcifications of their pancreas on CT
nearly 80% chronic pancreatitis due to
chronic alcoholism
BUT The risk of pancreatitis in heavy drinkers is only 5-10%
Smoking can accelerate this risk
Mnemonic for predisposing factors of chronic pancreatitis:
T – toxic metabolic I – idiopathic G – genetic A – autoimmune R – recurrent and severe acute pancreatitis O - obstructive
?? which increases levels of serum calcium can lead to increased calcium deposition in the pancreas and be a cause
Hyperparathyroidism
Elevated levels of IgG and certain autoantibodies can be the hallmarks of autoimmune pancreatitis
autoimmune pancreatitis
Between 10-30% of all cases of chronic pancreatitis are ??
80% of adults develop ?? within 25 years after the onset of chronic pancreatitis
idiopathic
diabetes
CP presentation
epigastric and LUQ pain
Anorexia N/V, constipation acutely (steatorrhea is a later finding)
Abdominal exam may reveal LUQ tenderness over the pancreas
Attacks can last a few hours or possibly 2+ weeks
?? is the most sensitive test and can show dilated ducts, intraductal stones, strictures, pseudocyst development
ERCP
medical management of chronic pancreatitis
Low fat diet
Abstinence from all alcohol
Use NSAIDs, tramadol, acetaminophen (avoid opioids)
Steatorrhea is treated with pancreatic supplements at mealtimes:
Viokace, Creon, Ultresa, Zenpep, Pancreaze, Peptyze
Autoimmune pancreatitis is treated with ??
steroids
Prednisone 40mg/d for 1-2mo followed by a taper
CP Surgical Treatment
If there is underlying biliary tract disease, surgical treatment is advised
Must reestablish free flow of bile into the duodenum
Possible endoscopic drainage of pancreatic pseudocysts
Distal bile duct obstruction can be relieved with stenting
considered as a last resort ??
In severe cases, subtotal or total pancreatectomy is considered as a last resort
Results in diabetes mellitus and pancreatic insufficiency
Prognosis is best in patients with ??
recurrent acute pancreatitis caused by stones or sphincter of Oddi stenosis which can be remedied
Endoscopic Pseudocyst Drainage
listen 28 min
slide 29
creating a fistula to drain into the gut
ramsey criteria
each factor worth 1 pt (look up)
